Datasets:

dmacres

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mimiciii-hospitalcourse-meta

like 3

[ { "category": "Nursing/other", "chartdate": "2120-01-12 00:00:00.000", "description": "Report", "row_id": 1397355, "text": "NPN 1900-0700\n\nNEURO: AWAKE AND ALERT. ANSWERS QUESTIONS INCONSISTANTLY ,BUT APPROPRIATE WHEN ANSWERS.HAS FACIAL AND EXTREMETY TREMORS (PARKINSONIAN LIKE IN NATURE)\n\nRESP: PT WAS EXTUBATED AT 10PM W/O INCIDENT, HE IS CURRENTLY ON 4 LITERS NC, AND SHOVEL MASK.HIS LUNG SOUNDS ARE DIMINISHED AND HE HAS OCC BASALAR CRACKLES. HIS SAT IS CURRENTLY 97%.\n\nC/V: SR , HYPERTENSIVE. 3 DOSES OF 5 MG IV LOPRESSOR(WHICH HAD LITTLE EFFECT) ALONG W/ 100MG PO DOSE. HE ALSO (2) 10 MG DOSES OF HYDRALIZINE WHICH BROUGHT HIS BP DOWN TO 140-150'S .HE IS ALSO ON CAPTIPRIL TID.\n\nF/E/N: + 2 BILAT PEDAL EDEMA, UO 40-50CC/HR, INCT OF LGE SIZED SOFT BROWN STOOL.AM LABS PENDING\n\nSKIN: BUTTOCK AND RECTAL AREA EXCORIATED.DUODERM ON SACRUM INTACT. CLEANSED AREA AND APPLIED BARRIER CREAM.\n\nPLAN : CONT AB TX, MONITOR HEMODYNAMICS, NEB TX PRN.\n" }, { "category": "Nursing/other", "chartdate": "2120-01-12 00:00:00.000", "description": "Report", "row_id": 1397356, "text": "resp care note:\n\npt was extubated between 10 - 11 last night. SpO2 decreased to low 90's about A.M. , pt was given neb rx and presently is doing better.\n" }, { "category": "Nursing/other", "chartdate": "2120-01-12 00:00:00.000", "description": "Report", "row_id": 1397357, "text": "altered resp status\nd: pt alert and oriented x3. mae's and follow simple commands.\n\n\nresp: o2 at 4l/m nc with o2 sats> 94%. coarse bs and diminished at the bases. continue to administer nebs as ordered.\n\ncv: hr 80's nsr without ectopy and sbp 120-160's. lopressor and captopril doses have been increased and will continue to follow hemodynamics. electrolytes repleted and will follow electrolytes as ordered.\n\ngi: pt's diet advanced to pureed/ and appetite fair. abd soft and nontender with pos bowel sounds on auscultation. incontinent x2 of lg amts of green loose stool. following blood sugars q 6 hrs and will tx with ssi as needed.\n\ngu: foley cath in place with adequate hourly uo. bun and creat wnr. pt with 3-4+pitting edema.follow fluid balance closely.\n\nintegumentary: peri and sacral area excoriated and skin barrier ointment and nystation powder applied. r heel blister open and now has wet to dry drsgs to be done . duoderm ot coccyx area in place.\n\nid: afebrile and pt receiving imipenem and cipro for antibiotic coverage. follow fever curve. pt on droplet precautions until final results of nasopharyngeal aspirates come back.\n\nsocial: pt's wife called this am but have not heard from her this pm. pt is a full code and will continue with present medical management.\n\n" }, { "category": "ECG", "chartdate": "2120-01-10 00:00:00.000", "description": "Report", "row_id": 307762, "text": "Sinus rhythm, rate 100. Normal tracing. Compared to the previous tracing\nof the sinus rate is faster and T waves are now upright in\nleads V3-V4.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2128-05-24 00:00:00.000", "description": "ART EXT (REST ONLY)", "row_id": 1187770, "text": " 12:49 PM\n ART EXT (REST ONLY) Clip # \n Reason: LEFT FOOT ULCERS\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with left lower extremity ulcerations\n REASON FOR THIS EXAMINATION:\n ABI/PVR\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 66-year-old gentleman with left lower extremity ulcerations.\n\n TECHNIQUE: Evaluation of the arterial system in the bilateral lower\n extremities was performed with Doppler signal, pulse volume recordings and\n segmental limb pressure measurements.\n\n FINDINGS: Triphasic Doppler waveforms were seen at the right femoral artery.\n However, monophasic Doppler waveforms were seen at the right popliteal,\n posterior tibial and dorsalis pedis arteries.\n\n On the left side, triphasic Doppler waveforms were seen at the femoral and\n popliteal arteries. However, monophasic Doppler waveforms were seen at the\n left posterior tibial and dorsalis pedis arteries.\n\n The bilateral ABIs could not be obtained due to non-compressible arteries.\n\n Pulse volume recordings showed markedly decreased amplitudes at the right\n metatarsal level.\n\n COMPARISON: None available.\n\n IMPRESSION: Mild-to-moderate bilateral outflow arterial disease in the lower\n extremities.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-05-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1188025, "text": " 9:31 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 42cm SL R basilic PICC placed ? tip - \n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with new R PICC - existing R IJ & L pacer\n REASON FOR THIS EXAMINATION:\n 42cm SL R basilic PICC placed ? tip - \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post PICC placement, assess position.\n\n COMPARISON: Chest radiograph from at 5:51 a.m.\n\n FINDINGS: The right PICC ends in the mid to high right atrium. The right IJ\n large bore catheter ends in the uppermost portion of the SVC. The left\n pacemaker/ICD and right ventricular lead are unchanged in position. Mild\n pulmonary edema has improved. Mild cardiomegaly is unchanged. The\n mediastinal contours are unchanged. The left lung base is excluded from this\n radiograph. There is no right pleural effusion. No pneumothorax is seen.\n There is unchanged retrocardiac atelectasis.\n\n IMPRESSION:\n\n 1. Right PICC ends in the mid to high right atrium. Recommend withdrawing by\n 4 cm for appropriate positioning in the low SVC. This finding was\n communicated to IV nurse, , by at 9:45 a.m. via\n telephone on the day of the study.\n\n 2. Improving mild pulmonary edema.\n\n 3. Unchanged mild cardiomegaly.\n\n 4. Unchanged retrocardiac atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2128-05-20 00:00:00.000", "description": "CT UP EXT W/O C", "row_id": 1187368, "text": " 4:45 PM\n CT UP EXT W/O C Clip # \n Reason: ? fluid collection, ?etiology shoulder pain\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with pain and erythema x10 day L shoulder, concern for septic\n joint, Ortho would like CT prior to tap.\n REASON FOR THIS EXAMINATION:\n ? fluid collection, ?etiology shoulder pain\n CONTRAINDICATIONS for IV CONTRAST:\n CR 1.8\n ______________________________________________________________________________\n WET READ: 7:35 PM\n Left subcutaneous/intramuscular gas and fliuid collection within and adjacent\n to left trapezius. Extensive adjacent inflammatory stranding. Suspicious for\n abscess with cellulitis. No evidence of adjacent osseous erosion. Small left\n glenohumeral effusion. Pacemaker in left anterior chest wall noted but is\n remote from inflammation which is predominantly above left shoulder joint.\n Probable enlarged lymph nodes medial to acromion.\n IMPRESSION: Left trapezius and adjacent subcutaneous abscess with cellulitis.\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE LEFT SHOULDER, \n\n STUDY INDICATION: 66-year-old man with pain in the left shoulder region for\n 10 days in the left shoulder, concern for septic joint. Query fluid\n collection. Query etiology shoulder pain.\n\n TECHNIQUE: Non-contrast CT scan of left shoulder with multiplanar\n reconstructions with soft tissue and bone reformats.\n\n No previous for comparison.\n\n FINDINGS: Bone alignment is normal. No fracture or bone lesion.\n\n There is an area of abnormal fluid and gas in the subcutaneous tissues of the\n left shoulder superiorly, measuring 3.7 x 9.6 cm in transverse diameter and\n 1.6 cm in depth. There is no distinct wall and the margins of this area are\n quite ill-defined. The abnormality remains superficial to the trapezius\n muscle and does not appear extend into the acromioclavicular joint. This is\n consistent with soft tissue infection with gas forming organisms.\n\n There is a small amount of fluid in the subacromial-subdeltoid bursa without\n gas, most probably unrelated to the area of soft tissue abnormality. No\n distinct fluid collection amenable to percutaneous drainage.\n\n There are mild-to-moderate degenerative changes involving the\n acromioclavicular joint without joint effusion. There is also\n mild-to-moderate osteoarthritis of the glenohumeral joint with a small joint\n effusion.\n\n Increased number of round subcentimeter nodes is seen in the left base of the\n (Over)\n\n 4:45 PM\n CT UP EXT W/O C Clip # \n Reason: ? fluid collection, ?etiology shoulder pain\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n neck.\n\n Visualized portion of the left lung and mediastinum are unremarkable.\n\n A left transsubclavian pacemaker is seen in place.\n\n IMPRESSION: Gas-containing subcutaneous infection superficial to the left\n trapezius muscle. No sign of septic arthritis. No abscess amenable to\n percutaneous drainage.\n\n The scan results were discussed with Dr. from medicine (pager\n ) at 9 a.m., .\n\n" }, { "category": "Radiology", "chartdate": "2128-05-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1187842, "text": " 12:17 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line position and ptx\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with cecal volovulus\n REASON FOR THIS EXAMINATION:\n line position and ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: For line position, to assess for pneumothorax.\n\n FINDINGS: In comparison with study of , there is an endotracheal tube\n with its tip approximately 6 cm above the carina. Right IJ sheath is in place\n with no evidence of pneumothorax. Nasogastric tube extends at least to the\n mid body of the stomach where it crosses the lower margin of the image. Pacer\n device remains in place.\n\n Continued substantial enlargement of the cardiac silhouette with evidence of\n elevated pulmonary venous pressure. Opacification at the left base most\n likely reflects a combination of lower lobe volume loss and pleural effusion.\n\n Of incidental note is extensive calcification in the left carotid artery.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1188004, "text": " 5:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pulmonary edema\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p exlap for cecal volvulus\n REASON FOR THIS EXAMINATION:\n assess for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Volvulus, assessment for pulmonary edema.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is unchanged evidence\n of moderate pulmonary edema. Unchanged moderate cardiomegaly with\n retrocardiac atelectasis. No pleural effusions. No focal parenchymal opacity\n suggesting pneumonia.\n\n In the interval, the nasogastric tube and the endotracheal tube have been\n removed. The right venous introduction sheath is unchanged. Unchanged\n position and course of the pacemaker devices.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-05-21 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1187445, "text": " 11:10 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: Abscess, osteo?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66yo M CHF p/w shoulder pain, SOB, found to be fluid overloaded and bacteremia\n of uncertain origin, now on broad spectrum abx, found to have shoulder abscess,\n L foot osteo, complaining of back and R hip pain\n REASON FOR THIS EXAMINATION:\n Abscess, osteo?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of shoulder pain and abscess. Patient with bacteremia.\n Complaining of back pain. Rule out osteomyelitis.\n\n COMPARISON: No prior studies are available for comparison.\n\n MDCT-acquired images of the cervical spine were obtained without\n administration of intravenous contrast. Coronal and sagittal reformatted\n images were reviewed.\n\n FINDINGS: There is no malalignment. The craniocervical junction is\n unremarkable.\n\n There are multilevel degenerative changes throughout the cervical spine\n without concerning lesion for infection or malignancy.\n\n There is calcification of the posterior longitudinal ligament at the level of\n C6-C7 which causes moderate to severe spinal canal stenosis at this level.\n There is no concerning epidural or paravertebral soft tissue abnormality.\n There are no pathologically enlarged cervical lymph nodes.\n\n Partially imaged upper chest demonstrates emphysematous changes and biapical\n atelectasis. A 11 x 4-mm left upper lobe spiculated opacity and a 9 x 2 mm\n pleural-based right apical opacity cannot be fully characterized in this study\n and may represent lung lesions or infectious process.\n\n There is a subcentimeter hypodensity in the right thyroid lobe.\n\n Bilateral calcified atherosclerosis are noted in the internal carotid arteries\n and vertebral arteries. The aortic arch is calcified.\n\n IMPRESSION:\n\n 1. Multilevel degenerative changes throughout the cervical spine without\n concerning lesion for infection or malignancy. MRI is more sensitive for\n discitis/osteomyelitis evaluation.\n\n 2. Right thyroid hypodensity is not fully characterized in this study. A\n dedicated US can be performed for better evaluation, if clinically indicated.\n\n (Over)\n\n 11:10 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: Abscess, osteo?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Bilateral lung opacities cannot be fully characterized in this study, and\n may represent infection or pulmonary lesions.\n\n" }, { "category": "Radiology", "chartdate": "2128-05-21 00:00:00.000", "description": "CT T-SPINE W/O CONTRAST", "row_id": 1187446, "text": " 11:10 AM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: abscess, osteo?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66yo M CHF p/w shoulder pain, SOB, found to be fluid overloaded and bacteremia\n of uncertain origin, now on broad spectrum abx, found to have shoulder abscess,\n L foot osteo, complaining of back and R hip pain\n REASON FOR THIS EXAMINATION:\n abscess, osteo?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with shoulder abscess. Concerning for osteomyelitis.\n\n COMPARISON: No prior.\n\n TECHNIQUE: MDCT-acquired images of the thoracic spine were obtained without\n administration of intravenous contrast. Coronal and sagittal reformatted\n images were reviewed.\n\n FINDINGS:\n\n There are multilevel degenerative changes throughout the thoracic spine\n without osseous or soft tissue lesion concerning for malignancy. The\n alignment is well preserved. The vertebral body height and intervertebral\n disc spaces are preserved.\n\n There is calcification of the posterior longitudinal ligament at the level of\n C6-7 with central disc protrusion causing moderate/severe spinal canal\n stenosis.\n\n Partially imaged lungs demonstrate emphysematous changes with paraseptal\n bullae at the right base. Ground-glass opacities are noted in the lower\n lungs. An 11 mm spiculated opacity in the left apex and a 7-mm right pleural\n based opacity at the right apex are not well characterized in this study and\n may represent infection. There is bilateral small pleural effusion.\n\n The ascending aorta is mildly dilated measuring up to 4 mm (3:61). There is\n diffuse calcified atherosclerosis at the ascending aorta, aortic arch and\n descending aorta. Calcified atherosclerosis is also noted in the coronary\n arteries. Defibrillator/pacemaker leads are noted with the tips not imaged.\n The left atrium is markedly enlarged.\n\n IMPRESSION:\n\n 1. Multilevel degenerative changes throughout the thoracic spine with no\n osseous or soft tissue lesion concerning for infection. Note is made that MRI\n is more sensitive for evaluation of discitis and osteomyelitis.\n\n 2. Emphysematous changes with bilateral ground-glass ill-defined lung\n opacities and bilateral small pleural effusion. A dedicated chest CT may be\n (Over)\n\n 11:10 AM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: abscess, osteo?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n considered for better evaluation, if clinically indicated.\n\n" }, { "category": "Radiology", "chartdate": "2128-05-21 00:00:00.000", "description": "CT L-SPINE W/O CONTRAST", "row_id": 1187447, "text": " 11:10 AM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: epidural, osteo?**Please include entire sacrum in cuts, and\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66yo M CHF p/w shoulder pain, SOB, found to be fluid overloaded and bacteremia\n of uncertain origin, now on broad spectrum abx, found to have shoulder abscess,\n L foot osteo, complaining of back and R hip pain\n REASON FOR THIS EXAMINATION:\n epidural, osteo?**Please include entire sacrum in cuts, and hip, or notify HO\n if need separate order for CT hip**\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of bacteremia, now with back pain. Concerning for\n osteomyelitis.\n\n COMPARISON: No prior studies available for comparison at the .\n\n TECHNIQUE: MDCT-acquired images of the lumbar spine were obtained without\n administration of intravenous contrast. Coronal and sagittal reformatted\n images were reviewed.\n\n FINDINGS: There are multilevel degenerative changes throughout the lumbar\n spine without concerning lesion for infection or malignancy. There is no\n destruction of endplates. No soft tissue abnormalities are noted. There is\n posterior disc bulge at L3-L4, without significant spinal canal stenosis.\n\n At L4-L5 and L5-S1, there is posterior disc bulge, posterior osteophyte\n formation and facet hypertrophy with mild spinal canal stenosis.\n\n Partially imaged abdominal structures demonstrate diffuse calcified\n atherosclerosis at the abdominal aorta and its major branches including both\n iliacs without aneurysm formation or significant stenosis.\n\n There is extrarenal pelvis on the left with significant hydronephrosis and\n hydroureter with no definite cause identified. The distal ureter courses in\n normal caliber inferiorly. There is colonic diverticulosis without evidence\n of diverticulitis.\n\n 5.8 cm hyperdensity in the deep pelvis (4:87) cannot be fully characterized in\n this non-contrast study, and may represent cluster of small bowel loops.\n\n Cholelithiasis is without evidence of cholecystitis.\n\n IMPRESSION:\n\n 1. Multilevel degenerative changes throughout the lumbar spine are more\n prominent at L4 through S1. No concerning osseous or soft tissue lesions are\n noted, but MRI is more sensitive for evaluation of discitis and osteomyelitis.\n\n 2. Left hydronephrosis and hydroureter with no specific cause identified. In\n (Over)\n\n 11:10 AM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: epidural, osteo?**Please include entire sacrum in cuts, and\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the setting of continued clinical concern, a dedicated CTU protocol can be\n performed for better characterization, which will provide additional\n evaluation of the small bowel.\n\n 3. Cholelithiasis without cholecystitis.\n\n 4. Diverticulosis without diverticulitis.\n\n" }, { "category": "Radiology", "chartdate": "2128-05-21 00:00:00.000", "description": "R CT LOW EXT W/O C RIGHT", "row_id": 1187448, "text": " 11:11 AM\n CT LOW EXT W/O C RIGHT Clip # \n Reason: pls eval sacrum and right hip for abscess, drainable fluid c\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66yo M CHF p/w shoulder pain, SOB, found to be fluid overloaded and bacteremia\n of uncertain origin, now on broad spectrum abx, found to have shoulder abscess,\n L foot osteo, complaining of back and R hip pain\n REASON FOR THIS EXAMINATION:\n pls eval sacrum and right hip for abscess, drainable fluid collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the right hip .\n\n COMPARISON: Radiographs, .\n\n TECHNIQUE: 5-mm and 3 mm small field of view axial images of the right hip\n were obtained. 3-mm coronal and sagittal reformatted images were obtained.\n Please note, the indication states evaluate sacrum, no images of the sacrum\n were provided.\n\n INDICATION: Please evaluate sacrum and right hip for abscess, drainable fluid\n collection.\n\n FINDINGS: Mild osteopenia, which limits the evaluation for fractures. No\n fracture is identified. No dislocation. Degenerative changes of the right\n hip with mild acetabular sclerosis and acetabular and femoral head small\n osteophytes. There is no evidence for periostitis, cortical disruption, or\n focal cortical thickening on the small field of view images.\n\n On the soft tissue windows, no abnormal masses or fluid collections\n identified. The visualized muscles demonstrate grossly normal CT appearance.\n Atherosclerotic vascular calcifications.\n\n IMPRESSION:\n 1. No drainable fluid collection identified on the small field of view\n images. No CT evidence for infection.\n 2. No hip joint effusion seen on this CT.\n 3. Mild degenerative changes of the right hip.\n\n" }, { "category": "Radiology", "chartdate": "2128-05-24 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1187799, "text": " 3:58 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: assess for any causes to explain RLQ pain\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with RLQ pain, firm, with guarding, admitted with MRSA\n bacteremia\n REASON FOR THIS EXAMINATION:\n assess for any causes to explain RLQ pain\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n WET READ: MLHh MON 5:59 PM\n Cecal volvulus w/ dil to 10 cm, mesenteric edema, possible pneumatosis\n indicating ischemia. No free air.\n Severe atherosclerosis.\n Emphysema. Bilat effusions. LV calcs = prior MI.\n Hepatosplenomegaly w/ liver irregularity, correlate for cirrhosis.\n L UPJ obstruction/atrophy.\n WET READ VERSION #1 MLHh MON 4:31 PM\n Cecal volvulus w/ dil to 10 cm, mesenteric edema. No free air.\n Severe atherosclerosis.\n Emphysema. Bilat effusions. LV calcs = prior MI.\n Hepatosplenomgealy. L UPJ obstruction/atrophy.\n WET READ VERSION #2 MLHh MON 4:51 PM\n Cecal volvulus w/ dil to 10 cm, mesenteric edema, possible pneumatosis\n indicating ischemia. No free air.\n Severe atherosclerosis.\n Emphysema. Bilat effusions. LV calcs = prior MI.\n Hepatosplenomgealy. L UPJ obstruction/atrophy.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old male with MRSA bacteremia, congestive heart failure,\n and right lower quadrant pain and guarding.\n\n No prior examinations for comparison.\n\n TECHNIQUE: Helical MDCT images were acquired from the lung bases through the\n greater trochanters without intravenous contrast, due to the patient's\n elevated creatinine of 1.3. Oral contrast was administered. 5-mm axial,\n coronal, and sagittal multiplanar reformats were generated.\n\n FINDINGS: Evaluation is suboptimal due to absence of intravenous contrast.\n\n Bilateral small simple pleural effusions are present, left greater than right,\n with associated compressive atelectasis. A 5.7 x 4.1 cm bulla is noted at the\n right lung base. Right ventricular pacemaker/defibrillator courses in\n expected position. Dense calcifications are also noted in the thoracic aorta,\n mitral annulus, and left ventricular myocardium, compatible with prior\n myocardial infarction. The heart is normal in size. There is no pericardial\n effusion.\n\n (Over)\n\n 3:58 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: assess for any causes to explain RLQ pain\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ABDOMEN: There is diffuse fatty infiltration of the liver. The liver appears\n mildly heterogeneous, with an irregular contour, suggestive of underlying\n cirrhosis. Scattered punctate hyperdensities likely represent calcified\n granulomas. The gallbladder is partially distended, without calcified stones,\n wall edema, fat stranding, or pericholecystic fluid. There is mild fatty\n infiltration of the pancreas. There is no intra- or extra-hepatic biliary\n ductal dilatation. The spleen is mildly enlarged at 14.4 cm.\n\n The adrenals are normal. There is moderate-to-severe left hydronephrosis,\n tapering to the level of the renal pelvis, suggestive of ureteropelvic\n junction obstruction. The right collecting system is normal. Both kidneys\n are slightly atrophic, without evidence of stones.\n\n Note is made of a small fat-containing umbilical hernia.\n\n PELVIS: A Foley catheter is present within a partially collapsed bladder.\n Prostate and seminal vesicles are unremarkable. Note is made of small\n bilateral inguinal hernias, containing nonobstructed loop of small bowel on\n the right, and fat on the left.\n\n GASTROINTESTINAL: The stomach is distended with oral contrast. Enteric\n contrast has progressed to the level of mid-ileal loops in the pelvis. The\n terminal ileum is rotated and displaced into the left abdomen, with focal\n high-grade stricture and tethering of mesenteric vessels (301B:30 and 2:47).\n There is no significant proximal bowel dilation, indicating early or\n intermittent bowel pathology.\n\n The cecum is axially torsed by approximately 180 degrees and anteriorly\n folded, with relative transition points at the terminal ileum and ascending\n colon. There is distention of the intervening cecum to 10 cm, with mild\n surrounding fat stranding and mesenteric edema. Locules of gas in the\n dependent portion of the cecum (301:26-29, 2:45-56) are concerning, though not\n diagnostic, for pneumatosis. There is no extraluminal air to suggest bowel\n perforation. No portal or mesenteric venous gas is present.\n\n The distal colon and rectum are distended with retained fecal material and\n air, ruling out high-grade obstruction.\n\n Dense calcifications are noted throughout the abdominal aorta and iliac\n arteries, with mild celiac and left renal, moderate-to-severe superior\n mesenteric and right renal, and moderate inferior mesenteric artery stenosis.\n Scattered mesenteric and retroperitoneal lymph nodes are present, not\n pathologically enlarged.\n\n The bones are diffusely demineralized, with multilevel degenerative changes.\n Moderate diffuse disc bulges are present at L3-4 through L5-S1, with abutment\n (Over)\n\n 3:58 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: assess for any causes to explain RLQ pain\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of the thecal sac outline. Please note that CT cannot visualize intrathecal\n detail. Moderate facet hypertrophy and ligamentum flavum thickening are also\n present at multiple levels. There is diffuse fatty atrophy of the paraspinal\n and thoracoabdominal wall musculature. Diffuse soft tissue edema is present.\n\n IMPRESSION:\n\n 1. Cecal volvulus, with findings suggestive of early or intermittent\n obstruction. Surrounding mesenteric edema and possible pneumatosis concerning\n for ischemia. This was called to Dr. on at 4:30 p.m.\n\n 2. Diffuse atherosclerosis and sequelae of remote myocardial infarction.\n\n 3. Small bilateral pleural effusions.\n\n 4. Hepatosplenomegaly, with possible cirrhosis. Please correlate clinically.\n\n 5. Chronic left UPJ obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2128-05-18 00:00:00.000", "description": "LP SHOULDER 2-3 VIEWS NON TRAUMA LEFT PORT", "row_id": 1187022, "text": " 9:09 AM\n SHOULDER VIEWS NON TRAUMA LEFT PORT Clip # \n Reason: bony abnormality, soft tissue swelling;\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with L shoulder pain, joint erythema\n REASON FOR THIS EXAMINATION:\n bony abnormality, soft tissue swelling;\n ______________________________________________________________________________\n FINAL REPORT\n LEFT SHOULDER, \n\n CLINICAL INFORMATION: Bony abnormalities. Soft tissue swelling.\n\n FINDINGS:\n\n Three views of the left shoulder demonstrates moderate osteoarthritis of the\n acromioclavicular joint. There is soft tissue swelling about the\n acromioclavicular joint and soft tissues of the shoulder of unclear etiology.\n There is mild glenohumeral osteoarthritis. In addition, there are foci of\n calcification in the vicinity of the supraspinatus tendon, consistent with\n calcific tendinopathy. Visualized left upper lung zone is clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-05-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1187032, "text": " 9:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: focal signs of infection, fluid overload\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with CHF, shortness of breath, remaining hypotensive, difficult\n to eval fluid status\n REASON FOR THIS EXAMINATION:\n focal signs of infection, fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of CHF, shortness of breath, remaining hypotensive.\n Evaluate for signs of infection or fluid overload.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: A left pacemaker/ICD and associated right ventricular lead are\n unchanged in position. Mild cardiomegaly is unchanged. Haziness of the hila,\n diffuse interstitial opacities, and Kerley B lines reflect mild pulmonary\n edema, not significantly changed compared to the prior exam. There are no\n pleural effusions. No pneumothorax is seen. The mediastinal contours are\n normal.\n\n IMPRESSION:\n\n 1. Unchanged mild pulmonary edema.\n\n 2. Unchanged mild cardiomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2128-05-19 00:00:00.000", "description": "RP HIP UNILAT MIN 2 VIEWS RIGHT PORT", "row_id": 1187194, "text": " 11:56 AM\n HIP UNILAT MIN 2 VIEWS RIGHT PORT Clip # \n Reason: signs of osteo, other infection\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with R hip pain, bacteremia\n REASON FOR THIS EXAMINATION:\n signs of osteo, other infection\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Two views of the right hip, portable .\n\n COMPARISON: None.\n\n INDICATION: Signs of osteomyelitis, other infection.\n\n ADDITIONAL INFORMATION: Right hip pain, bacteremia.\n\n FINDINGS: Limited evaluation due to technique and body habitus. Difficult to\n evaluate for fracture, however, no definite fracture identified. No\n dislocation. A linear ossific/calcific density projects over the hip,\n possibly representing posterior heterotopic ossification. No significant\n degenerative change. No bony destruction, cortical thickening, or\n periostitis.\n\n IMPRESSION: No radiographic evidence for osteomyelitis. If there is\n continued concern, recommend MRI. In addition, if there is concern for septic\n arthritis, recommend aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2128-05-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1186980, "text": " 6:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o fluid overload\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with ? sepsis. hxc chf, s/p fluid bolus now with congested\n cough\n REASON FOR THIS EXAMINATION:\n r/o fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, two semi-erect AP portable views.\n\n CLINICAL INFORMATION: 66-year-old male with history of sepsis, history of\n CHF, status post fall, with congested cough.\n\n COMPARISON: None.\n\n FINDINGS: A single-lead left-sided AICD is seen with lead extending to the\n expected position of the right ventricle. No focal consolidation, pleural\n effusion, or pneumothorax is seen. While there may be minimal pulmonary\n vascular congestion, no overt pulmonary edema is seen. The cardiac silhouette\n is top normal to mildly enlarged. Aortic knob calcified. Degenerative\n changes are seen at both acromioclavicular joint and along the spine.\n\n IMPRESSION: Borderline to mild enlargement of the cardiac silhouette without\n overt pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2128-05-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1186981, "text": " 6:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with elevated INR, confusion\n REASON FOR THIS EXAMINATION:\n ? ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MLHh MON 7:43 PM\n No ICH. Chr atrophy and small vessel dz.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old male with elevated INR and confusion.\n\n No prior examinations for comparison.\n\n TECHNIQUE: Contiguous non-contrast axial images were obtained through the\n brain, and reconstructed at 5-mm intervals. 2-mm coronal and sagittal\n multiplanar reformats were also generated.\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect, or\n vascular territorial infarct. The ventricles and sulci are prominent,\n consistent with age-related involutional changes. Periventricular and\n subcortical white matter hypodensities reflect small vessel ischemic disease.\n Superimposed focal hypodensities in the bilateral centrum semiovale likely\n represent chronic lacunes. Dense calcifications are noted in the bilateral\n cavernous and supraclinoid portions of the internal carotid arteries, as well\n as the vertebral arteries.\n\n Minimal mucosal thickening is noted in multiple ethmoid air cells. The\n remaining paranasal sinuses and mastoid air cells are clear. Orbits and\n intraconal structures are preserved.\n\n IMPRESSION: No acute intracranial process. Chronic involutional changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-05-17 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1186982, "text": " 6:58 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ELEVATED LFTS ? GB, LIVER PATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with elevated LFTs\n REASON FOR THIS EXAMINATION:\n ? GB, liver path\n ______________________________________________________________________________\n WET READ: MLHh MON 8:34 PM\n Mildly heterog liver, no masses.\n GB partially collapsed, cirumfernetial wall thickening likely reactive.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old male with elevated LFTs.\n\n No prior examinations for comparison.\n\n RIGHT UPPER QUADRANT ULTRASOUND: Liver is normal in echogenicity, without\n focal lesions. There is normal hepatopetal flow in the portal vein. There is\n no intrahepatic biliary ductal dilatation. The common duct measures 3 mm.\n There is no free fluid.\n\n The gallbladder is partially collapsed, with apparent mild circumferential\n wall thickening that may be reactive or artifactual due to collapse. There is\n a probable 3 mm echogenic stone at the gallbladder neck. There is no\n gallbladder wall edema or pericholecystic fluid. Ultrasonographic sign\n was negative.\n\n The pancreatic body is normal, and the head and tail are not well visualized\n due to shadowing bowel gas.\n\n IMPRESSION: Cholelithiasis, without findings to suggest acute cholecystitis.\n\n" }, { "category": "Radiology", "chartdate": "2128-05-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1187138, "text": " 4:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pulmonary edema or PNA\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with sepsis and possible CHF\n REASON FOR THIS EXAMINATION:\n assess for pulmonary edema or PNA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Sepsis with possible chronic heart failure, evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is a minimal increase\n in density at the right lung base. To exclude the possibility of aspiration\n or early pneumonia, a repeat radiograph should be performed within the next 24\n hours. The referring physician, . was paged for notification at\n the time of dictation, 9:01 a.m., .\n\n Otherwise, there is no relevant change. Moderate cardiomegaly with minimal\n pulmonary edema. Unchanged position of the pacemaker generator.\n\n\n" }, { "category": "Echo", "chartdate": "2128-05-21 00:00:00.000", "description": "Report", "row_id": 91361, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 69\nWeight (lb): 196\nBSA (m2): 2.05 m2\nBP (mm Hg): 116/50\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 15:21\nTest: Portable TEE (Congenital)\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. PFO is present.\n\nLEFT VENTRICLE: Severely depressed LVEF.\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\n\nAORTA: No atheroma in aortic arch. Complex (>4mm) atheroma in the descending\nthoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve. No 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. 0.2 mg of IV\nglycopyrrolate was given as an antisialogogue prior to TEE probe insertion. No\nTEE related complications.\n\nConclusions:\nA patent foramen ovale is present. Overall left ventricular systolic function\nis severely depressed (LVEF= 30%). Mild right ventricular global free wall\nhypokinesis. There are complex (>4mm) atheroma in the descending thoracic\naorta. The aortic valve leaflets (3) are mildly thickened. No masses or\nvegetations are seen on the aortic valve. Trace aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. No mass or vegetation is seen\non the mitral valve. Moderate (2+) mitral regurgitation is seen. The tricuspid\nvalve leaflets are mildly thickened. No vegetation/mass is seen on the\npulmonic valve. The ICD wire is visualized in the RA and RV without\nvegetation.\n\nIMPRESSION: No valvular or ICD wire vegetations seen. Moderate eccentric\nmitral regurgitation. Patent foramen ovale.\n\n\n" }, { "category": "Echo", "chartdate": "2128-05-18 00:00:00.000", "description": "Report", "row_id": 91362, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Left ventricular function. Right ventricular function.\nHeight: (in) 69\nWeight (lb): 185\nBSA (m2): 2.00 m2\nBP (mm Hg): 90/70\nHR (bpm): 57\nStatus: Inpatient\nDate/Time: at 09:50\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Severely depressed\nLVEF. Estimated cardiac index is depressed (<2.0L/min/m2). No resting LVOT\ngradient.\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; septal apex - hypo; inferior apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV free wall thickness. Dilated RV cavity. Severe\nglobal RV free wall hypokinesis.\n\nAORTA: Mildy dilated aortic root. Focal calcifications in aortic root. Mildly\ndilated ascending aorta. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: ?# aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Aortic valve not well seen. Minimal AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Eccentric MR jet. Mild to moderate (+) MR. \nto the eccentric MR jet, its severity may be underestimated (Coanda effect).\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Very small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is severely\ndepressed (LVEF= 25 %) secondary to akinesis of the inferior septum, inferior\nfree wall, and posterior wall. The estimated cardiac index is depressed\n(<2.0L/min/m2). The right ventricular free wall thickness is normal. The right\nventricular cavity is dilated with severe global free wall hypokinesis. The\naortic root is mildly dilated at the sinus level. The ascending aorta is\nmildly dilated. The number of aortic valve leaflets cannot be determined. The\naortic valve leaflets are moderately thickened. The aortic valve is not well\nseen. There is a minimally increased gradient consistent with minimal aortic\nvalve stenosis. The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. An eccentric, posteriorly directed jet of mild to\nmoderate (+) mitral regurgitation is seen. Due to the eccentric nature of\nthe regurgitant jet, its severity may be significantly underestimated (Coanda\neffect). The tricuspid valve leaflets are mildly thickened. There is a very\nsmall pericardial effusion. There are no echocardiographic signs of tamponade.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-05-19 00:00:00.000", "description": "LP FOOT AP,LAT & OBL LEFT PORT", "row_id": 1187195, "text": " 11:56 AM\n FOOT AP,LAT & OBL LEFT PORT Clip # \n Reason: signs of osteo\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66yo M PMHx L hallux amputation, now bacteremic w wound dehiscence\n REASON FOR THIS EXAMINATION:\n signs of osteo\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Three portable views of the left foot .\n\n COMPARISON: None.\n\n INDICATION: Signs of osteomyelitis. Past medical history of left hallux\n amputation, now bacteremic with wound dehiscence.\n\n FINDINGS: Atherosclerotic vascular calcifications. Soft tissue swelling at\n the great toe. There may be a skin defect. There is a locule of subcutaneous\n emphysema. Prior great toe hallux amputation. Ossific fragments are seen\n within the surgical site, which may be post-surgical. There may be some\n cortical irregularity of the surgical margin, which may represent infection.\n No acute fractures or dislocations. Os naviculare. Plantar spur. Posterior\n calcaneal enthesopathy.\n\n IMPRESSION:\n 1. Soft tissue swelling with possible skin defect. Subcutaneous emphysema.\n 2. Irregular surgical margin from hallux amputation.\n These may represent infection. If there is clinical concern, recommend\n further evaluation with MRI.\n\n" }, { "category": "ECG", "chartdate": "2128-05-30 00:00:00.000", "description": "Report", "row_id": 257081, "text": "Atrial fibrillation with a controlled ventricular response. Ventricular\nectopy. There is a single paced beat. Non-specific ST-T wave changes.\nCompared to the previous tracing of ventricular ectopy and ventricular\npacing are new.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2128-05-29 00:00:00.000", "description": "Report", "row_id": 257082, "text": "Atrial fibrillation with a controlled ventricular response. Non-specific\nST-T wave changes. Compared to the previous tracing of fusion beats are\nno longer present.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2128-05-27 00:00:00.000", "description": "Report", "row_id": 257083, "text": "Atrial fibrillation with a probable ventricular paced beat with fusion\ncomplex. Modest intraventricular conduction delay may be incomplete\nleft bundle-branch block. ST-T wave abnormalities may be due to\nintraventricular conduction delay but are non-specific. Clinical correlation\nis suggested. Since the previous tracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2128-05-24 00:00:00.000", "description": "Report", "row_id": 257084, "text": "Atrial fibrillation. Modest intraventricular conduction delay - may be\nincomplete left bundle-branch block. ST-T wave abnormalities may be due\nto intraventricular conduction delay and are non-specific. Clinical\ncorrelation is suggested. Since the previous tracing of lateral\nprecordial lead ST-T wave changes appear slightly more prominent but there may\nbe no significant change.\n\n" }, { "category": "ECG", "chartdate": "2128-05-18 00:00:00.000", "description": "Report", "row_id": 257085, "text": "Atrial fibrillation with a ventricular paced beat. Borderline low QRS voltage.\nModest intraventricular conduction delay. ST-T wave abnormalities. Findings are\nnon-specific. Since the previous tracing of same date ventricular ectopy is\nabsent and further ST-T wave changes are seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2128-05-18 00:00:00.000", "description": "Report", "row_id": 257086, "text": "Atrial fibrillation with ventricular premature beats. Indeterminate axis. Low\nlimb lead QRS voltage. Modest intraventricular conduction delay. Findings are\nnon-specific. No previous tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2153-08-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1252573, "text": " 6:22 PM\n CHEST (PA & LAT) Clip # \n Reason: cardiomegaly?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 41F with tachycardia\n REASON FOR THIS EXAMINATION:\n cardiomegaly?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 41 female with tachycardia. Question cardiomegaly.\n\n COMPARISON: Chest x-ray from .\n\n FINDINGS:\n\n PA and lateral views of the chest. The lungs are clear. Cardiomediastinal\n silhouette is within normal limits. Osseous and soft tissue structures are\n unremarkable.\n\n IMPRESSION:\n\n No acute cardiopulmonary process\n\n\n" }, { "category": "ECG", "chartdate": "2153-08-30 00:00:00.000", "description": "Report", "row_id": 254305, "text": "Sinus tachycardia. Consider right atrial abnormality. ST-T wave abnormalities.\nSince the previous tracing of the rate is faster. Precordial T waves\nare more peaked.\n\n" }, { "category": "Radiology", "chartdate": "2153-08-31 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1252610, "text": " 2:40 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: right IJ placement\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with DKA, unable to get PIV.\n REASON FOR THIS EXAMINATION:\n right IJ placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 2:41 A.M. \n\n HISTORY: 41-year-old woman with DKA. Right IJ line placed.\n\n IMPRESSION:\n AP chest compared to :\n\n Tip of the new right internal jugular line ends in the region of the superior\n cavoatrial junction. Lungs clear. Heart size normal. No pneumothorax,\n pleural effusion or mediastinal widening.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2176-04-28 00:00:00.000", "description": "Report", "row_id": 2003565, "text": "NPN 1900-0700\n\n\n#1CV. HR 130-160s, BP 63/47, MAP 50. Loud murmur present.\nWell perfused. Plan to monitor CV status.\n\n#2Parenting. Dad in x2 overnight, infant asleep during\nvisits. Plan to continue to update and support parents.\n\n#3Dev. Pt. swaddled in OAC, temp. stable. Waking for cares,\nalert and active with cares. MAE. AFF. Plan to continue to\nsupport dev. needs.\n\n#4Nutrition. Wt. 3010gms, down 20gms. On BM20/E20adlib. Took\n70cc and 55cc first two cares tonight. Well coordinated with\npo feeds. Abd. soft, pink, active bowel sounds, no noted\nloops. Voiding with each care. Stool x1, green, guaic\nnegative. Plan to continue current feeding plan.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-04-28 00:00:00.000", "description": "Report", "row_id": 2003566, "text": "Neonatology\nDoing well. RA. No spells. Comfortable appearing. BP stable. Well eprfused. Mumru as before.\n\nWt 3010 dowqn 20 Tolerating feeds at ad lib with good intake.\nAbdomen benign.\n\nRepeat echo for am.\n\nBili 10.5. To be rechecked in am.\n\nContinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2176-04-28 00:00:00.000", "description": "Report", "row_id": 2003567, "text": "Nursing transfer note\n\n\nInfant admitted to NICU for elvaluation of cardiac\nmurmur. Pt noted to have valvular aortic stenosis per\ncardiac echo. Pt planned for balloon dilitation Monday\n at TCH. Infant to transfer to TCH today for\nmonitoring prior to procedure.\n\nInhfant in RA, RR 30-50s, LS clear/=, no retractions or WOB\nnoted. O2 sats >95%. No bradys/desats. Loud murmur\nauscultated. HR 120-150s. Infant pink/jaundiced, WP.\nPulses normal. Good cap refill. BP 67/56 (59). 4ext BP\ndone overnoc; WNL. BW 3150 CW 3010 (down 20g). Pt feeding\nadlib demand BM/E20. Infant BF well Q3-4H. Eager suck,\nwell coordinated. Abd exam benign, V/S heme negative.\nTemps stable OAC. A/a with cares, sleeps well btwn. Wakes\nfor feeds. PKU sent . Bili sent : 10.5/0.3\nHep B to be given prior to transfer TCH. Transfer consents\nobtained. Parents well updated by this RN, team, and\ncardiology at Hospital. Parents appear to be\ncoping well. Mom at times, Dad is great support. Mom\nd/c'd from post-partum unit today. Plan to stay with infant\novernoc at TCH.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-04-28 00:00:00.000", "description": "Report", "row_id": 2003568, "text": "Discharge Physical Exam\nAwake and alert. Jaundiced.\nHEENT: normal head. Intact palate. Bilaterla red reflexes. Neck supple.\nResp: Breath sounds clear and equal without retractions. Normal rate.\nCardiac: Normal S1S2. grade III/VI murmur at LLSB, normal pulses, well perfused. Cap refil 4 sec.\nAbd: Soft and rounded with active BS, no HSM or masses.\nGU: NOrmal male genitalia with descended testes, patent anus.\nSkellital: Normal, intact hips.\nNeuro: Normal exam with intact reflexes.\n" }, { "category": "Nursing/other", "chartdate": "2176-04-27 00:00:00.000", "description": "Report", "row_id": 2003560, "text": "#4 FEN\ns/o: wt up 25 gms to 3030 gms. BF and po feeding E20. Abd\nexam benign. A: Ad lib demand. P: cont to mtr\n#3 DEV\ns/o: waking and demanding q 3-4 hrs. temp stable in open\ncrib. Alert with care. A/P: cont dev supp care.\n#2 PARENT\ns/o: Parents in and actively participating in cares. Dad\nchanged diapers, took temp. A: invested parents. P: Cont\nsupport and education.\n#1 CV\ns/o: Murmur present. Pink in RA- clear BS. Sats high 90-100.\nA: known aortic stenosis. P: cardiology following.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-04-27 00:00:00.000", "description": "Report", "row_id": 2003561, "text": "NICU Nursing Note 2300-0700\n\nCardiovascular\nInfant noted to have loud murmur, AP 140's-150's, pulses\nnormal, quiet precordium, brisk capillary refill. BP stable\nwith mean of 54. No apnea or bradycardia.\n\nParenting\nNo contact with infant's parents this shift, thus far.\n\nDevelopment\nInfant awake and alert with care periods, waking on his own\nfor feeds. Temp. stable. Infant MAE, AFOF. Brings hands to\nface, sucks on pacifier. Infant swaddled in an open crib.\n\nNutrition\nInfant's wt. 3030gms. Feeding ad lib amounts, waking ~q4hrs\nto feed. Abdomen soft and nondistended, B.S.(+), no spits.\nVoiding and stooling q.s.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-04-27 00:00:00.000", "description": "Report", "row_id": 2003562, "text": "Attending Note\nDay of life 3 PMA 38 \nin room air RR 20-40 sat 97-100% no spells\nloud murmur from valvular aortic stenosis HR 140-150 BP 65/41 mean 54\nbrisk cap and normal pulses\nbili 10.5/0.3\nweight 3030 up 25 grams on ad lib demand feeds of E20 took in 58 cc/kg/day and breast feeding\nno spits\nin open crib\nalert and active\n\nImp-stable making progress\nwill continue to monitor cardiac status\nwill have a repeat ECHO on Monday\nwill consider transfer to Cardiology next week\nwill obtain consent for Hep B\n" }, { "category": "Nursing/other", "chartdate": "2176-04-27 00:00:00.000", "description": "Report", "row_id": 2003563, "text": "NPN 0700-1900\n\n\nCV: Loud murmur auscultated. HR 120-150s, Infant appears\npink/sl jaundiced, well perfused. Brisk cap refill, pulses\nnormal. BP 65/41 (54). Echo planned for Monday. 4 extr BP\nto be done this evening.\n\nPAR: Parents in to visit for cares today. Asking approp\nquestions. Updated by this RN. independant and involved in\npt cares. Mom planned for d/c tomorrow. Will continue to\nsupport and update as needed.\n\nDEV: Maintaining temps while swaddled in OAC. A/a with\ncares, sleeps well btwn. Loves pacifier, moves hands to\nface. , , AGA. Hep B consents to be signed.\n\nFEN: Pt feeding adlib demand, BM/E20. Pt BF well Q4H,\napprox 40-45min each. Feeds eager, well coordinated. Abd\nbenign. voiding QS, no stool thus far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-04-27 00:00:00.000", "description": "Report", "row_id": 2003564, "text": "NNP Physical Exam\nPE: pink, well perfused, mild jaundice, AFOF, breath sounds clear/equal with easy WOb, RRR, murmur audible throughout chest, +2 equal brachial and femoral pulses, abd soft, non distended, + bowel sounds, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2176-04-26 00:00:00.000", "description": "Report", "row_id": 2003554, "text": "Fellow note\nInformed the following health profesionals of Baby diagnosis and progress:\n1. Dr. , , covering & referring Ped. yesterday.\n2. Dr. \n3. Dr. : Pediatrician-Message left at his practice- for him to get back to me.\n" }, { "category": "Nursing/other", "chartdate": "2176-04-26 00:00:00.000", "description": "Report", "row_id": 2003555, "text": "Neonatology\nRemains in RA. No spells. RA sats 95-100. Murmur as before. No evidence of failure on exam.\n\nEcho yesterday showed valvar AS. PDA closed. ECho being repeated this am. Being followed by cardiology service. Await their review of repeat echo and recommendations.\n\nBreastfeeding well. Abdomen benign.\n\nContinue to observe. Monitor cvr status.\n" }, { "category": "Nursing/other", "chartdate": "2176-04-26 00:00:00.000", "description": "Report", "row_id": 2003556, "text": "Fellow note\nDr. (Pediatrician) called. I updated him on baby's diagnosis and progress.\n" }, { "category": "Nursing/other", "chartdate": "2176-04-26 00:00:00.000", "description": "Report", "row_id": 2003557, "text": "Nursing Progress Note\n\n3 Alteration in Development\n4 Alteration in Nutrition\n\n#1 CV__ O: HR 130s-150s; RR 30s-40s, O2 sats 95-100. No\ndesats, bradys. RA, comfortable resp, no GFR. Murmer is\nloud, good perfusion, pink. No edema. BP 70/46 mean 62.\nCardiac ECHO done- PND results A: Hx valvular aortic\nstenosis; stable P: Monitor vitals, sats, cardiac status.\nCheck on ECHO results and cadiology reccommendations\n\n#2 Parenting-- O: Both in today, updated re status and plan.\nWaiting for ECHO results. Reviewed temperature taking. Mom\nbreast feeding baby- going well. A: involved and concerned\nP: Cont to support and keep informed. Discharge teaching.\n\n#3 Development-- O: Alert and active with cares. Temp\nstable, swaddled, in crib. Sucking on pacifier. A: AGA P:\nCont to support development\n\n#4 Nutrition-- O: Ad lib demand feeds waking q3-4h. BF with\nmom- good and suck >10minutes. Abd exam benign. VQS,\nno stool. A: Adequate nutrition P: Cont to enc breast/bottle\n(E2o) ad lib & monitor tolerance and wt. PKU and Bili in am\n\nREVISIONS TO PATHWAY:\n\n 3 Alteration in Development; added\n Start date: \n 4 Alteration in Nutrition; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2176-04-26 00:00:00.000", "description": "Report", "row_id": 2003558, "text": "Medical Student Note\n\nPhysic Exam:\nGeneral Appearance: Pink, well perfused, reactive, breathing comfortable.\nHeent: Soft Fontanelles, Smooth Sutures, Nares patent, lips and palate intact. Neck w/o masses.\nChest: No retractions. Clear and equal Breath sound. Murmur systolic in troughout precordium. Peripheral pulses normal.\nAbdomen: soft, active bowels sounds.\nLimbs: Normal, good muscle tone, symmetrical movements.\nGenitalia: Male normal, testes in scrotum.\nNeuro exam: normal for gestational age.\n\n \nMedical Student.\n\nAgree with above exam.\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": "2176-04-26 00:00:00.000", "description": "Report", "row_id": 2003559, "text": "Nursing Addendum\nArea of skin around umbilical cord is reddened. Dry, no drainage, no swelling.\n" }, { "category": "Nursing/other", "chartdate": "2176-04-25 00:00:00.000", "description": "Report", "row_id": 2003548, "text": "Respiratory Care\nPt rec'd hyperoxia test as part of cardiac w/u. TcO2 >300mmHg while rec'ing 100% O2 via mask. MD notified.\n" }, { "category": "Nursing/other", "chartdate": "2176-04-25 00:00:00.000", "description": "Report", "row_id": 2003549, "text": "NURSING PROGRESS NOTE\nPT UP FOR CARDIAC EVAL. FOUR EXTREMITY BP STABLE. PT PINK, WELL PERFUSED. PULSES EQUAL / NON BOUNDING. PULSES WEAK IN RIGHT ARM. PT W/ LOUD MURMUR - HEARD THROUGHOUT CHEST. CHEST XRAY DONE. EKG DONE. HYPEROXY - PASSED 301. CARDIO TO CONSULT - PT TO RETURN TO NBN.\n" }, { "category": "Nursing/other", "chartdate": "2176-04-25 00:00:00.000", "description": "Report", "row_id": 2003550, "text": "Neonatology\nPatient is now 1 do term infant with murmur noted on exam in NN to have mumrur. SAent to NICU for evaluation\n\n3.15 kg product of term getsation born to 29 yo G2P0 woman whose Pregnancy was apparently uncomplicated. Did well at c-section for breech presentation.\n\nHas apparently been doing well in NN.\n\nOn exam pink active non-dysmorphic infant. Well saturated (100%) in RA. Skin w/o leisosn. Lungs clear. Cor nl s1s2 Grade 2-3/6 SEM at MLSb. No clicks or diastolic murmurs. Precordium normally active. Pulses sl diminished. Abdomen benign.\n\n\nCXR shows normal heart size. Small thymus. Situs solitus. Appears top have left sided arch.\n\nEKG normal to my review.\n\nPassed hyperoxia to > 300.\n\n4 Ext Bps normal.\n\n\nA- Otherwise well appearing term infant with murmur during early transitional period. EXam and initial testing is reassuring re: absence of critical cardiac disease.\n\nP Cardiology consult to see patient\n? echo now or prior to discharge.\nMother aware of status and plans.\nDr ill update pediatrician.\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-04-25 00:00:00.000", "description": "Report", "row_id": 2003551, "text": "nursing progress note\nPT ADMITTED TO NICU FOLLOWING ECHO. TO BE MONITORED PER CARDIOLOGGY. DAD IN TO VISIT, UPDATED BY NNP AT BEDSIDE - OPARENTS TO SPEAK W CARDIOLOGY IN ROOM.\n" }, { "category": "Nursing/other", "chartdate": "2176-04-25 00:00:00.000", "description": "Report", "row_id": 2003552, "text": "1 ALT IN CV STATUS\n2 ALT IN PARENTING\n\nREVISIONS TO PATHWAY:\n\n 1 ALT IN CV STATUS; added\n Start date: \n 2 ALT IN PARENTING; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2176-04-26 00:00:00.000", "description": "Report", "row_id": 2003553, "text": "NPN 1900-0700\n\n\n#1: O: Loud murmur audible. HR 150's-160's. Precordium is\nquiet, normal pulses and brisk capillary refill. BP 67/49\nwith a mean of 56. P: Continue to monitor.\n\n#2: O: Parents in at start of shift. Mom breastfed infant.\nWill be back in the morning to put infant to breast. A:\nLoving parents. P: Continue to support parents in the care\nof their infant.\n\n\n" }, { "category": "Echo", "chartdate": "2176-04-25 00:00:00.000", "description": "Report", "row_id": 81481, "text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease.\nStatus: Inpatient\nDate/Time: at 16:45\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 study. Report will be generated by .\n\n\n" }, { "category": "ECG", "chartdate": "2176-04-25 00:00:00.000", "description": "Report", "row_id": 201965, "text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2176-04-25 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 904732, "text": " 1:32 PM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: asymptomatic heart murmur\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with asymptomatic heart murmur\n REASON FOR THIS EXAMINATION:\n asymptomatic heart murmur\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Portable chest one view.\n\n DATE OF EXAMINATION: .\n\n TIME: 13:48.\n\n CLINICAL HISTORY: Infant with asymptomatic murmurs.\n\n COMPARISON: There is no prior examination available for comparison.\n\n FINDINGS: Lungs are clear bilaterally without focal pulmonary infiltrate,\n pleural effusion, or pneumothorax. Heart size and mediastinal contours are\n within normal limits. The visualized osseous structures are normal in\n appearance.\n\n IMPRESSION: Normal chest study.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2173-02-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 946925, "text": " 5:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusions\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66M s/p pancreatic debridement, intubation.\n REASON FOR THIS EXAMINATION:\n evaluate effusions\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST DATED .\n\n COMPARISON: Chest x-ray dated .\n\n INDICATION: 66-year-old male status post pancreatic debridement, intubation,\n evaluate effusions.\n\n FINDINGS: Single semiupright radiograph of the chest demonstrates an\n endotracheal tube unchanged in position. There has been interval removal of\n the NG tube. There is a left subclavian central line distal tip overlies the\n midline, likely in the left brachiocephalic vein. The lung volumes are low.\n Bibasilar airspace opacities are again demonstrated along with blunting of the\n costophrenic angles bilaterally, not significantly changed. There is no\n evidence of pneumothorax.\n\n IMPRESSION: Unchanged low lung volumes with small bilateral pleural effusions\n and bibasilar airspace disease, unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-03-17 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 949636, "text": " 8:45 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA NECK W/O CONTRAST\n Reason: MRI/MRA head and neckAssess left sided lesion\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with right sided weakness with unclear clinical picture.\n REASON FOR THIS EXAMINATION:\n MRI/MRA head and neckAssess left sided lesion\n ______________________________________________________________________________\n FINAL REPORT\n MR OF THE BRAIN\n\n INDICATION: 66-year-old male with right-sided weakness, unclear clinical\n picture. Please assess for left-sided lesion.\n\n COMPARISON: Multiple head CTs dating back to .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging including diffusion-\n weighted imaging.\n\n FINDINGS: No intracranial mass lesion, hydrocephalus, shift of normally\n midline structures, or acute minor or major vascular territorial infarct is\n apparent. Mild periventricular T2 hyperintensities are consistent with\n sequelae of chronic small vessel ischemic disease. Old lacunar infarcts are\n seen in the bilateral basal ganglia.\n\n There is a small retention cyst within the left sphenoid air cells. Mild\n mucosal sinus disease is present within the maxillary sinuses bilaterally.\n\n MRA OF THE CIRCLE OF :\n\n TECHNIQUE: 3D time of flight imaging with multiplanar reconstructions.\n\n FINDINGS: The major tributaries of the circle of are patent. There is\n a hypoplastic left A1 segment of the anterior cerebral artery. There is no\n area of significant stenosis or aneurysmal dilatation. Within the limits of\n coverage of this study, no sign of an arteriovenous malformation is apparent.\n\n MRA OF THE CAROTIDS AND VERTEBRAL ARTERIES\n\n TECHNIQUE: 2 and 3 dimensional time of flight imaging with multiplanar\n reconstructions.\n\n FINDINGS: No area of hemodynamically significant stenosis or ulceration is\n seen, particularly with reference to the common carotid bifurcations. The\n left vertebral artery is dominant.\n\n IMPRESSION:\n 1. No acute intracranial pathology, including no sign of intracranial mass or\n bleed.\n 2. Unremarkable MRA of the circle of and unremarkable MRA of the\n (Over)\n\n 8:45 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA NECK W/O CONTRAST\n Reason: MRI/MRA head and neckAssess left sided lesion\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n vertebral and carotid arteries.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-03-23 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 950604, "text": " 10:32 AM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n Reason: Surveillance CT. Assess pancreas. Please do thin cuts throug\n Admitting Diagnosis: SEVERE PANCREATITIS\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with h/o necrotizing pancreatitis s/p debridement. splenic v\n thrombosis on previous ct. Patient with open abd incision.\n REASON FOR THIS EXAMINATION:\n Surveillance CT. Assess pancreas. Please do thin cuts through pancreas.\n Contrast thru G-tube.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 66-year-old man with history of necrotizing pancreatitis,\n status post debridement. Splenic vein thrombosis on previous CT. Patient\n with open abdominal incision. Surveillance CT. Assess pancreas.\n\n Comparison made to prior studies, the most recent dated .\n\n CT ABDOMEN: At the right lung base there is air space consolidation most\n likely representing atelectasis, less likely pneumonia. Mild focal air space\n disease in the left lower lobe. There are coronary artery calcifications. No\n pleural or pericardial effusions.\n\n There are several subcentimeter hypoattenuating lesions in the liver that are\n too small to characterize, but most likely represent small cysts. No intra-\n or extra-hepatic biliary ductal dilatation. There is a 1.8-cm gallstone. Note\n is again made of a cholecystostomy catheter. Gastrostomy and jejunostomy\n tubes are again seen. Two pigtail drainage catheters are in place.\n\n The spleen, adrenal glands and kidneys are unremarkable. In the caudate lobe\n of the liver, there is a cystic structure that is essentially unchanged and\n most likely represents a pseudocyst. Several regions of the pancreas, most\n notably portions of the head, body, and tail are not enhancing, consistent\n with known pancreatic necrosis. There are portions of the body and tail of\n the pancreas that enhance appropriately, essentially unchanged. There are\n several intraperitoneal fluid collections, including in the region of the head\n and tail of the pancreas that are largely unchanged in size and appearance.\n\n CTA: The celiac, splenic and hepatic arteries are widely patent. The SMA is\n also widely patent. No evidence of pseudoaneurysms. There is focal narrowing\n of the splenic vein at the region of the portal confluence (sequence 3B, image\n #204).\n\n CT PELVIS: The urinary bladder is markedly distended and contains gas, likely\n from prior instrumentation. The rectum and sigmoid colon are unremarkable.\n\n No suspicious osseous lesions.\n\n Multiplanar reformatted images were useful in the delineation of the above\n findings.\n (Over)\n\n 10:32 AM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n Reason: Surveillance CT. Assess pancreas. Please do thin cuts throug\n Admitting Diagnosis: SEVERE PANCREATITIS\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Findings were discussed with surgery resident, Dr. , at the time\n the procedure was performed on .\n\n IMPRESSION:\n 1. Essentially stable appearance of multiple intra-abdominal fluid\n collections in this patient with necrotizing pancreatitis.\n 2. Unchanged focal attenuation of proximal splenic vein, which is patent. No\n evidence of pseudoaneurysm.\n 3. Essentially unchanged appearance to pancreas, with non-enhancing regions\n consistent with pancreatic necrosis.\n 4. Right lower lobe atelectasis.\n 5. Markedly distended urinary bladder.\n\n" }, { "category": "Radiology", "chartdate": "2173-03-16 00:00:00.000", "description": "B HAND, AP & LAT. VIEWS BILAT", "row_id": 949565, "text": " 7:39 PM\n HAND, AP & LAT. VIEWS BILAT Clip # \n Reason: Eval prior to Head MRI\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with hx of shrapnel injury. ***Please image B/L hands and\n arms***\n REASON FOR THIS EXAMINATION:\n Eval prior to Head MRI\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with history of shrapnel injury. Evaluate prior\n to head MRI.\n\n SINGLE VIEW OF EACH HAND: No radiopaque foreign bodies are seen.\n\n RIGHT HAND: Joint space narrowing and osteophyte formation are seen at the\n first carpometacarpal as well as the second and fifth DIP joints, likely\n representing osteoarthritic changes.\n\n LEFT HAND: Joint space narrowing and osteophyte formation is seen at the\n second and fifth DIP joints. Less severe joint space narrowing without\n osteophyte formation is seen in the reminder of the PIP and DIP joints. These\n findings are consistent with osteoarthritic changes.\n\n IMPRESSION: No evidence of metallic foreign bodies.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-03-12 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 948994, "text": " 1:02 PM\n CTA ABD W&W/O C & RECONS Clip # \n Reason: evaluate splenic vein thrombosis?\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with h/o necrotizing pancreatitis s/p debridement. splenic\n v thrombosis on previous ct. Please obtain CT-angiogram.\n REASON FOR THIS EXAMINATION:\n evaluate splenic vein thrombosis?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with history of necrotizing pancreatitis with\n possible vascular complication.\n\n Comparison is made to prior study done on .\n\n TECHNIQUE: Axial MDCT images are obtained from the lung bases to pelvic inlet\n after administration of 180 cc of Optiray intravenously. Oral contrast was\n also used. Sagittal and coronal reformatted images were obtained. Early\n arterial phase data were obtained for CT angiography.\n\n CT OF ABDOMEN WITH IV CONTRAST: The visualized portion of the lung bases does\n not demonstrate any pulmonary nodules. Mild atelectatic changes of right lung\n base are unchanged. No pleural effusion is seen. The visualized portions of\n the heart and great vessels are unremarkable.\n\n The patient is status post cholecystostomy, gastrostomy, jejunostomy, and two\n pigtail drainage catheters within the pancreatic bed. The spleen, kidneys,\n adrenal glands, loops of small and large bowel are unremarkable. Gallbladder\n contains a gallstone but there is no evidence of cholecystitis. A small\n pseudocyst that dissects into the caudate lobe of the liver is unchanged and\n measures 44 x 18 mm.\n\n The nonenhancing areas of pancreatic head and body are unchanged consistent\n with severe degree of pancreatic necrosis. Small portions of the body and\n tail of the pancreas are enhancing appropriately and are unchanged. Multiple\n areas of fluid collection within the pancreatic bed, anterior abdominal wall,\n and retroperitoneum are unchanged. The moderately attenuated areas of\n proximal portion of SMV and splenic vein within the pancreatic head and neck\n are unchanged. No evidence of thrombosis is seen within these vessels. The\n degree of attenuation of SMV and splenic vein is overestimated on axial\n section as venous-MIP images demonstrate mild degree of attenuation. No\n pseudoaneurysm is seen. No pancreatic hemorrhage is noted.\n\n CT ANGIOGRAM: The origin of the superior mesenteric artery and celiac artery\n and their branches are patent with no thrombosis or pseudoaneurysm.\n\n BONE WINDOWS: No concerning lytic or sclerotic lesions are noted.\n\n IMPRESSION:\n 1. Status post necrotizing pancreatitis with debridement and cholecystostomy,\n (Over)\n\n 1:02 PM\n CTA ABD W&W/O C & RECONS Clip # \n Reason: evaluate splenic vein thrombosis?\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n jejunostomy, gastrostomy, and placement of drainage catheter within the\n pancreatic bed.\n 2. Moderate degree of attenuation of proximal portion of splenic vein and\n superior mesenteric vein is unchanged. No thrombosis is noted. No\n pseudoaneurysm is seen.\n 3. Unchanged nonenhancing areas within the pancreatic head and the body\n consistent with pancreatic necrosis with no complication including gas\n collection.\n 4. Atelectatic changes of the right lower lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-03-18 00:00:00.000", "description": "R SHOULDER 2-3 VIEWS NON TRAUMA RIGHT", "row_id": 949927, "text": " 8:28 PM\n SHOULDER VIEWS NON TRAUMA RIGHT Clip # \n Reason: ? dislocation/injuries\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with Right shoulder pain and weakness\n REASON FOR THIS EXAMINATION:\n ? dislocation/injuries\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old male with right shoulder pain and weakness.\n\n FINDINGS: Three views of the right shoulder demonstrate no evidence of\n fracture or dislocation. There are severe degenerative changes of the\n acromioclavicular articulation. Inferiorly projecting osteophytes at the AC\n joint could cause impingement. There is no soft tissue abnormality. The\n visualized lung parenchyma is clear. A PICC catheter is noted with\n termination out of the field of view.\n\n IMPRESSION: No fracture or dislocation. Severe degenerative changes of the\n acromioclavicular joint.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-23 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 946287, "text": " 12:53 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o obsturction\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with w/ nec pancreatitis now with fevers and abdominal\n distension\n REASON FOR THIS EXAMINATION:\n r/o obsturction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL RADIOGRAPH\n\n INDICATION: 66-year-old man with pancreatitis, now with fevers and abdominal\n distention. Rule out obstruction.\n\n COMPARISON: .\n\n FINDINGS: Since prior exam, the Dobbhoff tube has been removed and an enteric\n feeding tube has been placed. The left costophrenic angle is mildly blunted\n consistent with pleural effusions. A nasogastric tube is again noted with its\n tip projecting over the stomach. The bowel gas pattern is unremarkable,\n without evidence of obstruction. The osseous structures are unremarkable.\n\n IMPRESSION: Nonobstructed bowel gas pattern. Interval removal of Dobbhoff\n tube with placement of an enteric feeding tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 946432, "text": " 11:00 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o ptx\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with w/ nec pancreatitis now with fevers and abdominal\n distension s/p intubation\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old male with necrotizing pancreatitis, status post\n reintubation.\n\n Comparison is made to prior film from earlier in the day at 9:30 a.m. and\n prior radiograph dated .\n\n SINGLE PORTABLE SUPINE AP CHEST RADIOGRAPH\n\n Since prior film, patient has been reintubated with tip of endotracheal tube\n approximately 5 cm from carina. There appears to be slight improvement to\n right lower and right middle lobe atelectasis with stable appearance to small\n bilateral pleural effusions. No evidence of pneumothorax or distinct\n parenchymal consolidation. New areas of disc-like atelectasis are identified\n projecting over the left base. Nasogastric tube is again identified to be\n within the GI tract; however, tip is not visualized.\n\n IMPRESSION:\n 1. Status post reintubation with no evidence of pneumothorax.\n\n 2. Improved right lower and right middle lobe atelectasis with new disc-like\n left lower atelectasis and stable bilateral pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-03-05 00:00:00.000", "description": "PR UNILAT UP EXT VEINS US PORT RIGHT", "row_id": 947870, "text": " 8:22 AM\n UNILAT UP EXT VEINS US PORT RIGHT Clip # \n Reason: RT ARM SWELLING EVAL FOR CLOT\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with increased arm swelling\n REASON FOR THIS EXAMINATION:\n eval for dvt\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old male with right upper extremity swelling and concern for\n DVT.\n\n RIGHT UPPER EXTREMITY ULTRASOUND: Grayscale and Doppler son of the\n right internal jugular, subclavian, axillary, brachial, cephalic, and basilic\n veins were performed. In a short segment of the distal right basilic vein,\n there is lack of color flow and abnormal compressibility. The proximal right\n basilic vein is patent with wall-to-wall flow and normal compressibility. The\n deep veins of the right upper extremity are patent with normal compressibility\n and wall-to-wall color flow.\n\n IMPRESSION: No evidence of deep venous thrombosis. Thrombus within a small\n segment of the distal superficial right basilic vein.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-03-10 00:00:00.000", "description": "PICC W/O PORT", "row_id": 948621, "text": " 9:27 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: NECROTIZING PANCREATITIS\n Admitting Diagnosis: SEVERE PANCREATITIS\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with necrotizing pancreatitis\n REASON FOR THIS EXAMINATION:\n Place\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: This 66-year-old man with necrotizing pancreatitis.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. ,\n the attending radiologist was present and supervising throughout the\n procedure.\n\n PROCEDURE AND FINDINGS: No suitable veins were visible, ultrasound was used\n to identify the right basilic vein, which was patent and compressible. The\n right arm of the patient was then prepped and draped in standard sterile\n fashion. Using local anesthesia, and a 21-gauge needle, access was gained\n into the right basilic vein under ultrasonographic guidance. Hard copies of\n the images were obtained before and after the venipuncture. A 0.018 guidewire\n was then advanced through the needle into the distal part of the SVC under\n fluoroscopic guidance. The needle was then exchanged for a 4.5 French\n micropuncture sheath. Based on markers and the guidewire, it was decided that\n a length of 40 cm would be suitable. The line was then trimmed to this length\n and advanced over the wire into the distal part of the SVC under fluoroscopic\n guidance and the wire and the peel-away sheath were then removed. The line\n was flushed, hep-locked and StatLocked. A final fluoroscopic image of the\n chest demonstrates tip of the catheter to be located in the distal part SVC.\n The patient tolerated the procedure well.\n\n IMPRESSION: Successful placement of a 40 cm long double lumen line placed via\n the right basilic vein with tip in the distal part of the SVC. The line is\n ready for use.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-24 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 946408, "text": " 9:09 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: cholelithiasis? cholecystitis?\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with nec pancreatitis and decreased urine output now w/ abnl\n LFTs and fevers\n REASON FOR THIS EXAMINATION:\n cholelithiasis? cholecystitis?\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Liver, gallbladder ultrasound.\n\n INDICATION: History of necrotizing pancreatitis with recurrent abnormal LFTs\n and fevers.\n\n COMPARISON: Comparison is made with the previous study from .\n\n FINDINGS: This was a technically difficult examination due to overlying bowel\n gas. The liver is normal in echotexture with no focal liver lesions\n identified. Within the gallbladder, there is increased echogenicity\n identified with posterior acoustic shadowing consistent with cholelithiasis. A\n second area of increased echogenicity is identified with some ring down\n artifacts. This does not move with positioning and appearances are consistent\n with a cholesterol polyp. The CBD is dilated at 15 mm, a new finding. The\n portal vein is patent with normal centripetal flow. The midline is obscured\n and the pancreas and aorta are not well visualized. The right kidney measures\n 12.5 cm in maximum length with normal renal cortical thickness. The left\n kidney is not well visualized and measures approximately 11 cm in maximum\n length. The spleen measures approximately 11 cm in maximum length.\n\n IMPRESSION:\n 1. Technically difficult examination due to overlying bowel gas.\n 2. Cholelithiasis without evidence of cholecystitis with newly dilated CBD at\n 15 mm.\n 3. Cholesterol polyp measuring approximately 5 mm.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-24 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 946409, "text": " 9:20 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with w/ nec pancreatitis now with fevers and abdominal\n distension\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of central venous line placement.\n\n Portable AP chest radiograph compared to .\n\n IMPRESSION: Left central venous line was inserted with its tip terminating at\n the level of mid SVC. There is no pneumothorax or apical hematoma.\n The NG tube and oral feeding tube are inserted terminating in the stomach and\n most likely in the third part of the duodenum accordingly. The lung volumes\n are additionally decreased with bilateral atelectasis and small pleural\n effusion. New linear opacity in the right lower lobe in continuation\n with RML atelectasis could represent either a worsening atelectasis or new\n consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2173-02-24 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 946459, "text": " 1:41 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval pancreatic process. po contrast only\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with necrotizing pancreatitis, high fever and white count\n\n REASON FOR THIS EXAMINATION:\n eval pancreatic process. po contrast only\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure--po contrast only\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 66-year-old man with necrotizing pancreatitis, high fever, and\n leukocytosis.\n\n COMPARISONS: Three days earlier.\n\n TECHNIQUE: Axial CT images of the abdomen and pelvis were obtained with oral\n contrast only. Intravenous contrast was not administered at the request of\n the referring service. Sagittal and coronal reconstructions were performed.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are marked coronary artery\n vascular calcifications. There is a persistent right basilar opacity, which\n may represent atelectasis, although the possibility of pneumonia or aspiration\n cannot be excluded. There are tiny associated bibasilar pleural effusions.\n\n The liver appears normal within the limitations of a non-contrast study. Again\n noted is a rim-calcified 13-mm stone within the gallbladder, which is non-\n distended and otherwise unremarkable. The spleen, adrenal glands are within\n normal limits, and the non-contrast appearance of the kidneys is unremarkable\n bilaterally. A weighted feeding tube terminates in the third portion of the\n duodenum. The stomach, small and large bowel are unremarkable without\n evidence of obstruction. Contrast reaches the rectum. There is no\n lymphadenopathy.\n\n There is a small amount of ascites of low density, but increased since the\n prior study. For the most part, the appearance of the pancreas is unchanged\n with a similar overall contour of the partially necrotic pancreas with\n multiple large associated fluid collections. This appearance was better\n characterized on a recent study with intravenous contrast, but is probably for\n the most part unchanged.\n\n The only change is the appearance of a new fluid collection along the\n gastrohepatic ligament, without a discernable wall, measuring 6.4 x 3.0 cm in\n axial dimensions, which layers along the caudate lobe.\n\n Diffuse mesenteric stranding and fascial thickening of the anterior pararenal\n fascia bilaterally is unchanged.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: There is a Foley catheter in the\n bladder. The patient is probably status post prostatectomy with surgical\n (Over)\n\n 1:41 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval pancreatic process. po contrast only\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n clips visualized in the pelvis. There is no lymphadenopathy. Diffuse edema is\n noted within the subcutaneous soft tissues.\n\n BONE WINDOWS: There are no suspicious lytic or blastic lesions.\n\n IMPRESSION:\n\n 1. Persistent right basilar opacity with air bronchograms, which may\n represent atelectasis, although pneumonia cannot be excluded.\n\n 2. New perihepatic fluid collection, perhaps a new pseudocyst, but otherwise\n the overall contour of multiple fluid collections associated with the\n partially necrotic pancreas do not appear significantly changed.\n\n 3. Increased ascites.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 946552, "text": " 8:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia? atetlectasis? interval change?\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66M s/p pancreatic debridement, intubation.\n\n REASON FOR THIS EXAMINATION:\n pneumonia? atetlectasis? interval change?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:22 A.M., \n\n HISTORY: Pancreatic debridement. Intubated.\n\n IMPRESSION: AP chest compared to and 31:\n\n ET tube is in standard placement. Tip of the left subclavian line is\n indistinct, but the line passes at least as far as the left brachiocephalic\n vein. Nasogastric tube passes into the stomach and out of view. Lung volumes\n remain very low with persistent small left pleural effusion and bibasilar\n atelectasis. Lung apices are clear. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 946514, "text": " 7:39 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please assess for ETT position.\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66M s/p pancreatic debridement, intubation.\n REASON FOR THIS EXAMINATION:\n Please assess for ETT position.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man status post pancreatic debridement, assess\n endotracheal tube placement.\n\n COMPARISON: 10:54 a.m. the same day.\n\n AP UPRIGHT CHEST: An endotracheal tube terminates 5.7 cm above the carina.\n There is a weighted feeding tube as well as a nasogastric tube both of whose\n tips overlie the left upper quadrant of the abdomen. There is a left\n subclavian central venous catheter with its tip in the left brachiocephalic\n vein. Lung volumes are quite low. There is persistent elevation of the right\n hemidiaphragm. Patchy retrocardiac left lower lobe opacity appears slightly\n worsened compared to earlier today with air bronchograms. There remains right\n basilar atelectasis. The left costophrenic angle has been excluded from the\n film.\n\n IMPRESSION: Endotracheal tube in satisfactory position. Left lower lobe\n retrocardiac opacity appears to have worsened and given air bronchograms is\n concerning for a developing pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2173-03-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 947187, "text": " 8:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for pulmonary process\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66M s/p pancreatic debridement, intubation now with fever.\n\n REASON FOR THIS EXAMINATION:\n Assess for pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post pancreatic debridement, intubated now with\n fever.\n\n CHEST: Low lung volumes remain. The position of the endotracheal tube and\n left subclavian line are unchanged. Bilateral effusions are present, probably\n marginally larger than on the prior chest x-ray of . Bibasilar\n opacities were again noted, slightly more marked on the left than the right.\n\n IMPRESSION: Probable increase in bilateral effusions and bibasilar air space\n opacities.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-03-01 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 947267, "text": " 3:39 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: line placement? ptx?\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66M s/p pancreatic debridement s/p re-wiring of left subclavian\n\n REASON FOR THIS EXAMINATION:\n line placement? ptx?\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Left subclavian line placement.\n\n Single AP view of the chest is obtained; at 15:45 hours is compared\n with the prior radiograph performed approximately seven hours previously. No\n significant adverse interval change is noted. There is a left subclavian line\n with its tip likely in the distal SVC. No convincing pneumothorax. Unchanged\n bilateral pleural effusions and patchy opacities both bases, left greater than\n right.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-03-10 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 948655, "text": " 12:51 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: interval change in pancreas? interval change in abdominal/pe\n Admitting Diagnosis: SEVERE PANCREATITIS\n Field of view: 44 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with h/o necrotizing pancreatitis s/p debridement. for\n surveillance. please evaluate with PO gastrograffin and IV contrast.\n REASON FOR THIS EXAMINATION:\n interval change in pancreas? interval change in abdominal/pelvic structures?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with history of necrotizing pancreatitis status\n post debridement.\n\n Comparison is made to prior study done on .\n\n TECHNIQUE: Axial MDCT images are obtained after administration of 130 cc of\n Optiray intravenously. Oral contrast was also used. Sagittal and coronal\n reformatted images were obtained.\n\n CT OF ABDOMEN WITH IV CONTRAST: The visualized portion of lung bases do not\n demonstrate any pulmonary nodule. There is mild pleural effusion on the right\n side. There is mild degree of atelectatic changes at the right lung base.\n\n The patient is status post cholecystectomy, gastrostomy, jejunostomy and two\n pigtail drainage catheters within the pancreatic bed. The spleen, adrenal\n glands, kidneys, loops of small and large bowel are unremarkable. Gallbladder\n contains a gallstone but there is no evidence of cholecystitis.\n\n Small pseudocyst dissects to the caudate lobe of the liver and measures 21 x\n 40 mm. The head and most of the body of pancreas do not enhance consistent\n with pancreatic necrosis. Small portion of the body and tail of the pancreas\n are enhancing appropriately. Multiple fluid collections are seen within the\n pancreatic bed. There are at least 3 areas of fluid collection within the\n anterior abdominal wall, the largest of which measures 26 x 26 mm. There is\n also a focal area of fluid collection in the retroperitoneum that measure 35 x\n 45 mm. The proximal portion of the SMV and splenic vein are severely\n attenuated by the fluid collection within the pancreatic head and neck.\n Thrombosis in this area cannot be excluded. No pseudoaneurysm is seen,\n however, this is not a CT angiogram study. No evidence of pancreatic\n hemorrhage is seen.\n\n CT OF PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, distal small bowel\n loops, urinary bladder and distal ureters, are unremarkable. Small amount of\n free fluid is extending to the pelvis through parapelvic gutters. No\n pathologic pelvic or inguinal lymph nodes are seen.\n\n BONE WINDOWS: No concerning lytic or sclerotic lesions are noted.\n\n IMPRESSION:\n (Over)\n\n 12:51 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: interval change in pancreas? interval change in abdominal/pe\n Admitting Diagnosis: SEVERE PANCREATITIS\n Field of view: 44 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Status post pancreatitis debridement with significant reduction of the\n fluid collection in the pancreatic bed. No evidence of pancreatic hemorrhage\n is seen.\n 2. Nonenhancing areas within the pancreatic head and body are consistent with\n pancreatic necrosis with no complication including gas collection.\n 3. Severe attenuation of proximal portion of a splenic vein and superior\n mesenteric vein. Thrombosis cannot be excluded in these vessels. No\n pseudoaneurysm is found although this study is not CT angiogram.\n 4. Status post cholecystostomy, jejunostomy, gastrostomy and two drainage\n tubes placement within the pancreatic bed.\n 5. Atelectasis of the right lower lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-03-08 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 948233, "text": " 9:11 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute change?\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with prolonged ICU stay. Stable R arm weakness. h/o prolonged\n sedation now off with continued sedation.\n REASON FOR THIS EXAMINATION:\n acute change?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD.\n\n INDICATION: 66-year-old male with prolonged ICU stay. Stable right arm\n weakness. History of prolonged sedation. ?Acute change.\n\n COMPARISON: and .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: No mass lesion, hydrocephalus, shift of normally midline\n structures, infarction. Ventricles and sulci are slightly prominent,\n indicative of mild atrophy. The mastoid air cells are now nearly completely\n opacified bilaterally. Osseous and soft tissue structures are otherwise\n unremarkable.\n\n IMPRESSION:\n\n 1. No brain abnormalities detected, including no sign of hemorrhage.\n\n 2. Interval development of bilateral opacification of the mastoid air cells\n may represent accumulation of fluid due to prolonged ICU stay, however,\n infectious mastoiditis must also be considered in the appropriate clinical\n setting.\n\n\n" }, { "category": "Echo", "chartdate": "2173-02-15 00:00:00.000", "description": "Report", "row_id": 67627, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension. Left ventricular function. Ekg changes\nHeight: (in) 66\nWeight (lb): 224\nBSA (m2): 2.10 m2\nBP (mm Hg): 138/58\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 14:21\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function. TDI E/e' < 8, suggesting\nnormal PCWP (<12mmHg). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\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. 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 (1+) mitral regurgitation is seen. The estimated pulmonary artery\nsystolic pressure is normal. There is no pericardial effusion.\n\nIMPRESSION: Preserved global and regional biventricular systolic function.\nMild mitral regurgitation.\n\nCLINICAL IMPLICATIONS:\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": "2173-03-21 00:00:00.000", "description": "Report", "row_id": 143422, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , ventricular ectopy absent\n\n" }, { "category": "ECG", "chartdate": "2173-03-15 00:00:00.000", "description": "Report", "row_id": 143423, "text": "Sinus rhythm and frequent ventriculiar ectopy. Compared to the previous tracing\nof T wave inversion in the anterolateral leads has diminished. The rate\nhas increased. Otherwise, no diagnostic interim change. Clinical correlation is\nsuggested.\n\n" }, { "category": "ECG", "chartdate": "2173-02-19 00:00:00.000", "description": "Report", "row_id": 143424, "text": "Sinus rhythm. T waves in leads V1-V5 suggest myocardial ischemia. Compared to\nthe previous tracing of T wave inversion is new and ventricular\npremature beat is absent.\n\n" }, { "category": "ECG", "chartdate": "2173-02-15 00:00:00.000", "description": "Report", "row_id": 143425, "text": "Sinus rhythm.\nVentricular premature complex\nDiffuse nonspecific ST-T wave abnormalities\nLow QRS voltage - clinical correlation is suggested\nSince previous tracing of , sinus rhythm and ventricular ectopy\npresent, further ST-T wave changes seen and QRS lower\n\n" }, { "category": "ECG", "chartdate": "2173-02-13 00:00:00.000", "description": "Report", "row_id": 143426, "text": "Sinus rhythm\nDiffuse nonspecific T wave changes\nSince previous tracing of , further T wave changes present\n\n" }, { "category": "Nursing/other", "chartdate": "2173-03-03 00:00:00.000", "description": "Report", "row_id": 1416412, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech as per Carevue. Lung sounds coarse suct mod th off white sput, ABGs stable; favorable=> placed on SBT. Cont PSV.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-03 00:00:00.000", "description": "Report", "row_id": 1416413, "text": "nursing progress note\n\nneuro: pt remains w/ only fentanyl for pain/sedation. increasingly wide eyed, red faced, very uncomfortable w/ turns/repositioning, fentanyl increased for comfort. resting at present. beginning to move LUE on bed, able to squeeze lightly, moving BLE on bed. nods and shakes head to ques.\n\nresp: cpap+ps tol well, remains at 7 peep, 12 ps. abg acceptable, very mild metabolic acidosis persists. sx sm amts thick white secretions prn, cough weak. ls coarse to upper fields, clearing well w/ sx. bases dimin bilat, R>L.\n\ncv: bp stable, hypertensive w/ stimulus. nsr to sinus tachy, occas pvc's noted. small doses lopressor given, tol well. hr improves transiently. extrem warm, pulses intact. anasarca persists. lytes remain elevated. hct stable. wbc minimally rising.\n\ngi: belly slightly firm/distended. bs hypoactive. tender to palpation, noted by pt grimacing w/ assessment. t tube w/ clear bilious output, g tube w/ large amt green bilious output, tf via j tube. liquid golden stools continue, mushroom catheter placed to contain. increased drainage from jps tonight, #2>#3, drainage turgid, foul odored brown fluid.\n\ngu: foley patent cloudy sedimented yellow urine, volume qs.\n\nendo: bg's continue to be elevated, sliding scale tightened last , monitor.\n\nid: afebrile overnight, wbc 15 this am. ampicillin, diflucan, levaquin dosing continue. cx pending from midline wound and jp#2.\n\nskin: midline wound opened in 2 places, area w/ brown/dry tissue to wound bed, edges red. brown/serosang drainage to old packing, wet to dry dsgs continue . all drain sites pink, sutures intact. dsd's all remain dry. back w/ generalized healing rash, groin yeast improved, less angry red.\n\nsocial: no family contact overnight.\n\na/p: slowly improving neuro exam overnight, fentanyl increased for comfort. this am 26, currently tol. spont breathing trial well. cre remains 2.2, bun rising, 64 today. u/o remains adeq. plan for ? extubation in next 24h vs. more diuresis. bp likely able to tolerate diuresis today. follow pending wound cx, tighter control of glucose levels, aggressive pulm toilet. full icu monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-03 00:00:00.000", "description": "Report", "row_id": 1416414, "text": "Respiratory Therapy\n\nPt remains orally intubated on PSV. Weaned to +5/+5, tolerating well for the past couple hours, remained on +10/+5 most of shift. Maintaining Ve ~10L/M. SpO2 mid 90s. MDIs given as ordered. ETT rotated/retaped, remains secure/patent. See resp flowsheet for specifics.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2173-03-03 00:00:00.000", "description": "Report", "row_id": 1416415, "text": "T-SICU Nsg NOte\n Pt off fentanyl most of day. Pt still appears sedated from previous meds. Pt rests with eyes open, rarely alert. Does focus on speaker briefly when spoken to. Often nods to questions, nods no when asked if in pain. Weakly follows commands - wiggles toes, can raise L knee off bed and raise L arm to chest. Cannot hold arms up on own.\n NSR to sinus tach, HR 85- 105 with frequent PVC's. BP 95-130sys by NBP. Art line able to be repositioned and flushed this am to obtain a good waveform with good agreement with NBP. This afternoon catheter kinked and no waveform nor able to draw blood from art line. ON metoprolol 2.5mg IVP q 4 hrs, HR still 85- 105.\n Pt has had 2periods of resp exercise on 5cm PSV above 5cm PEEP. Initially pt does well with Vt in 600cc's. Pt tires and Vt goes down. O2 sats 95-96% on 5cm PEEP. Lung sounds clear upper, diminished lower. Suctined for small amts of thick white to tan sputum.\n Lasix drip started this afternoon with good diuresis. Urine now light yellow and clear. CVP - today, coming down with diuresis.\n\n Tube feedings continue at 100cc/hr of Replete with fiber and 3/4 strength via J tube. Abd firmly distended, hypoactive bowel sounds. Mushroom cath draining golden liquid stool. G tube draining green bilious fluid. T- tube draining amber bile. JP's draining grey opaque fluid. Abd incision open at top and bottom with brown fibrinous material at bottom of incision and edges beefy red.\n T max 99.8 this afternoon.\n Skin looks good - scrotum and penis red and edematous, no breakdown. Back and buttocks intact, slightly red.\n Blood glucose 150 or less today with q 4 hr sliding scale insulin. No long acting insulin ordered yet.\n wife and daughters in to visit today and updated on pt's condition.\nA: Tolerating diuresis. Blood glucose levels better. Off fentanyl drip - may need boluses . Resp exercise on 5 & 5. Still seems sedated.\nP: continue plan of care. Consider clamping G tube &/or T tube so pt has bile going into intestines to aid in absorbtion. Continue diuresis as tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-10 00:00:00.000", "description": "Report", "row_id": 1416436, "text": "T-SICU nsg note\n Pt OOB to chair this am with assist of PT and OT. Pt pivoted to chair with much assist. Pt alert, smiling, following conversation, participating in care. To CT for abd CT. Had 930cc of gastrografin contrast via G-tube, had scan, then IV contrast and repeat scan. Had D5W with bicarb prior to and after CT scan and mucomist per J tube x 4. Then to IR for double lumem PICC placement via L arm.\n Pt often oriented x 3, has difficulty saying hospital name, knows ICU and hospital, month is , season winter, year . Pleasant, conversant. Talking about when he was in Marines. Often talking with vague reference, but then does respond appropriately to responses. Improved strength and movement of R arm - can lift and brielfy hold R arm. Moving all limbs purposefully and to command.\n Lungs clear to diminishesd in bases. Face tent for humidity. Strong cough prod of thick yellow to tan sputum and plugs. NEeds oral suctioning to remove sputum.\n Brisk urine output. No lasix today.\n TF off for enteral contrast. TF restarted this evening. Only has had , 100cc stool out via mushroom cath. ABd softly distended. VAC intact, cannister changed and 450cc greeen opaque drainage in initial cannister. T-tube and G- tube clamped.\n Antibiotics discontinued this evening. AFebrile.\n Skin intact.\n Blood glucose levels low with TF off, 86 to 109 today.\nA: awake, talkative, improved strength and movement. New PICC line.\nP: continue plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-10 00:00:00.000", "description": "Report", "row_id": 1416437, "text": "correction\nNew PICC line via R arm.\n , RN\n" }, { "category": "Nursing/other", "chartdate": "2173-03-11 00:00:00.000", "description": "Report", "row_id": 1416438, "text": "nursing progress note\n\nneuro: exam continues to wax and wane, at times oriented x3, able to state name of hospital, date, etc. other times only able to state year, self. confused conversation, reoriented easily, very pleasant affect, very thankful of all care.\n\nresp: humid face tent remains on for oral moisture, o2 sats wnl. abg acceptable, slight resp alkalosis noted. denies sob/distress. cough strong, clearing thick yellow secretions, freq mouth care provided. ls clear, R base remains diminished.\n\ncv: a line remains positional, waveform sharp when aligned. site draining mod amt serosang fluid. bp stable. nsr, freq pac's. lopressor dosing continued. extrem warm, pulses intact. lytes stable. PICC RAC site wnl, port patent. could d/c TLC and a line today, ?tips for culture.\n\ngi: belly soft/distended. bs present, + flatus. stools more formed/soft, less in volume. immodium held. t tube, g tube clamped. jp drains w/ brown pancreatic output. tube feeds tol well via j tube.\n\ngu: foley patent yellow, occas sedimented urine, qs. lasix d/c'd last .\n\nid: afebrile, wbc jump this am from 12 to 17. surgery team aware. all abx d/c'd last as well.\n\nendo: bg's elevated, nph and sliding scale coverage ongoing.\n\nskin: midline incision w/ VAC dsg intact, mod amts green drainage in canister. all drain sites clean, scant amts dried serous drainage. duoderm surrounding all.\n\nsocial: no family contact overnight.\n\na/p: surveillance abd CT from yesterday w/ known small fluid collections, drains in correct position. slowly improving neuro exam, R arm getting stronger. follow wbc trend, belly exam, temps. likely to continue w/ icu monitoring at this time.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-04 00:00:00.000", "description": "Report", "row_id": 1416416, "text": "nursing progress note\n\nneuro: pt increasingly uncomfortable w/ ett, given prn fentanyl for abd pain w/ turns, etc and ativan prn for comfort. following commands well, more movement from bue tonight. nods and shakes head to questions.\n\nresp: returned to cpap+ps mode after several hrs on , ps increased to 12 as per previous settings. pt w/ slowly dropping tidal volumes, becoming labored w/ breathing trial, much more comfortable w/ higher ps. ls clear, dimin to bases R>L. cough weak, sx mod amts thick white sputum prn. abg's wnl.\n\ncv: hypertensive tonight, lopressor dosing effective for rate control and ectope, little effect to bp. icu team aware, to adjust dose. extrem warm, pulses intact. anasarca persists. lasix drip continues, over 2L negative for last 24h. lytes stable. am labs pending at this time.\n\ngi: belly firm, distended. bs hypoactive. t tube slowing in drainage volume, g tube remains w/ large amts. tolerating tube feeds via j tube well. loose stools slowing, mushroom catheter remains. c diff cx sent this am. pancrease started per tube.\n\ngu: foley patent yellow sedimented urine, as above diuresed w/ lasix. cre 1.9 at midnight, bun 64.\n\nendo: bg's improved w/ tighter, more freq checked sliding scale.\n\nid: tmax 99.6 overnight, diflucan, ampicillin, levaquin dosing continues.\n\nskin: no new issues, rash to torso improving. all drain sites clean, no s/s infection. midline wound w/ serosang/brown drainage, tissue brown, no granulation thus far.\n\nsocial: daughter and pt's long time friend in to visit, all ques answered, update provided.\n\nplan: cont. slow diuresis, goal -2L today. follow any pending cx including c diff. follow lytes, cre, replete prn. as tol, prn fentanyl and ativan for comfort. full icu monitoring.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-03-04 00:00:00.000", "description": "Report", "row_id": 1416417, "text": "RESPIRATORY CARE:\n\nPt remains intubated, supported. No changes made overnight. BS's coarse, sxing thick white secretions. Administering Combivent MDI as ordered. See flowsheet for further pt data. =65 this am. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-04 00:00:00.000", "description": "Report", "row_id": 1416418, "text": "Respiratory Therapy\n\nPt remains orally intubated on PSV. On for approx three hours, tolerated well, but then started to get tired w/ RR ^30s. Currently on +10/+5 w/ Vt ~500s RR ~low to mid 20s. SpO2 90s. MDIs given as ordered. BS w/ some exp wheezes t/o; suctioned for small amounts of thick white sputum. See resp flowsheet for specifics.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2173-03-04 00:00:00.000", "description": "Report", "row_id": 1416419, "text": "T/SICU NSG NOTE\n0700>>\n\nEVENTS: PSV ongoing w/resting as needed; no plans to extubate today.\n Gentle Lasix diuresis continues; goal 2L negative\n NPH insulin dosing initiated today\n TF's advanced to goal\n Temp on rise\n\nNEURO: responds to voice with eye opening; will nod head to questions but is inconsistent; rare spontaneous movement noted of LUE; other extremities move on bed to command. RUE remains weakest(also most edematous still). +cough/gag; perrl. PRN dosing with fentanyl for pain w/effect; prn dosing with ativan for general coping issues; especially ETT.\n\nCVS- nsr/nst w/o ectopy; lopressor dosing changed to po with prn iv dosing available. BP range w/in acceptable limits; htn episodes managed with analgesia, anxiolytic,or beta-blocker.\nNew left brachial arterial line placed on nights.\n\nRESP- remains on PSV/cpap. PSV reduced to 5cm for 3 hours when pt was noted to tire(increased RR and reduced tidal volumes); psv increased to 12cm and later decreased to 10cm. ABG's wnl; RR remains in 20's with variable tidal volumes: 380's to 500's. Breath sounds remain coarse with diminished bases. Secretions are small amounts of thick white sputum. Sats >96% on 50% fio2.\n\nRENAL: lasix 2mg/hr infusion w/o change. Negative balance of ~ 1500cc so far. K+ 3.8 with 40meq repleted. Urine: yellow w/sediment.\n\nGI- tf's advanced to goal rate: tolerating. GT clamped with minimal residuals: tolerating. Abd remains softly to firmly distended woith hypoactive bowel sounds. Mushroom catheter remains in place but no significant output this shift. Prevacid rx continues.\n\nENDO- NPH dosing started @ 12 units ; no ssri coverage required this shift.\n\nID- temp max to 100.9 diflucan and ampicillin continue. Despite verbal and written reports of levoquin dosing, NO label found on medication sheets. Teams notified; dosing resumed per order for qd dosing.\n abd wound: proxiaml and distal areas remain open to fascial sutures; serous draiange and tannish wound bed w/o evidence of granulation. W>D dsg changes continue.\n***conversion of nasal swab of to MRSA: pt on contact precautions.\n\nSKIN- anasarca continues with decrease in UE edema notable by end of shift; UE's elevated on pillows. Skin is warm with intermittent moisture noted. Diffuse reddened surfaces contiune over flanks and back; skin intact in these areas. Scattered skin tear areas and blistering noted on abdominal surface related to tape and edema. Stomadehsive applied along incision edges and around drain and tube sites for protection; minimal tape use to skin surfaces. Tannish drainage noted from around JP sites; all tube and drain site are pink.\nPerineal area remains slightly reddened and edematous; myconazol cream and powder applied to sites.\nPalpable peripheral pulses. Compression boots and sc heparin rx continue; multipodus boots.\nS>S positionint q2-3 hours d/t limited ability for self repositioning.\n\n wife and daughter, visiting today. All questions answered a\n" }, { "category": "Nursing/other", "chartdate": "2173-03-08 00:00:00.000", "description": "Report", "row_id": 1416431, "text": "t-sicu nsg note\nneuro- a+ox2, follows commands, speech still somewhat garbled albeit much improved, improved strength,strong cough.\n\nresp- spo2 94-98% on rm air, rr 20's no episodes of osa noted. coughing moderate to large amounts of thick white sputum.\n\ncvs- hr 80-105 rare pvc, hr lower following metropolol. sbp 130's-150's, tm 100.2po. 20meq kcl given x1 , remains on lasix gtt.\n\ngi- tol tf @ goal, impact 3/4str via j-tube., mushroom cath in place draining golden liquid stool in lesser amounts. abd remains soft/distended.\n\ngu- foley patent for clear yellow urine, strong diuresis.\n\nskin- abd incision open in 2 areas and w/ w->d in place. wound granulating well.\n\nendo- bs req riss q4h.\n\na: stable night, slept most of the night.\n\nP: monitor vs per routine, encourage increased mobility, maintain pulm hygiene.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-03-08 00:00:00.000", "description": "Report", "row_id": 1416432, "text": "NPN 7a-7pm\n***Ros see carevue for exact data***\n\nN: Neuro exam improving. Still confused oriented x self. Garbled speech at times, head CT today per primary team. Follows commands, mae's, right upper ext mvmt improving.\n\nCV: BP stable, ABP 120-150 syst, correlating w/ NBP. Hr 80-100 SR-ST\n\nResp: LS coarse, bases diminished.enc cough and deep breath, suc for mod amts of thick yellow from back of throat. O@ 94-97% ra\n\nGI: abd softly distended. TF at goal, 3/4 strength impact. No residuals from G/J tube. Still stooling lg amts, immodium dose increased. Abd inc open with wet to dry drsg, positive granulation.\nJP still emptying mod amts of grey translucent output.\n\nGu: Lasix drip stopped, pt on lasix. Strong diuresis, goal now 500cc a day.\n\nskin: abd with DSD, and stoma adhesive for skin protectant.\n\nLytes: K repleted as needed, repeat labs sent at 16:00\n\nHem: Stable\n\nID: Afebrile. anbx cont'd.\n\nPt oob to chair for mult hours, PT worked with patient.\n\nEndo: Fixed doses and sliding scale as ordered.\n\nP: Cont to monitor neuro status, head cT results.\nmonitor pain, medicate prn. Aggressive pulm toilet.\nMonitor GI status, cont diuresis as ordered. Monitor skin integrity, enc oob. Monitor labs, lytes replete prn. monitor bld sugars and fixed doses. Provide support.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-09 00:00:00.000", "description": "Report", "row_id": 1416433, "text": "NURSING PROGRESS NOTE 7P-7A\n\nPLEASE SEE CAREVUE FOR EXACT DATA.\n\nREVIEW OF SYSTEMS:\n\nNEURO-Pt alert, dozing occasionally. Oriented to self, inconsistantly to place and time (once told he was at he was able to verbalize he was in , MA, also knows year is , unable to recall month). Right UE flaccid, noted movement once throughout shift, however does not move to command. Left UE able to lift and hold, moves bilateral LE's on bed. Pupils 3 bilaterally and brisk. Denies pain, Roxicet ordered if needed. Repeat head ct done in AM, no changes seen.\n\nCV-Pt remains in SR rate varies 70-80's, no ectopy. Arterial line with fling SBP ranges 120-160's, NIBP SBP ranges 120-140's. Lopressor 5mg IV given x1dose. Left SC TLC, left brachial arterial line. Compression boots/ SQ Heparin for prophylaxis.\n\nRESP-Pt weaned to RA, sats 95%. Lung sounds clear, slightly diminished at bases. Productive cough with yellow thick sputum. IS encouraged, 200-250 with use.\n\nGI-Abdomen soft, distended, denies tenderness to palpation. Tube feeds at goal Impact at 125cc/hr, 3/4 strength via Jtube. Minimal residuals via GTube. T-tube remains clamped. Right side abdomen has 2JP's to bulb suction with off white output. Midline abdominal incision with proximal and distal portion open with Wet to Dry dressing , changed at 2100 on . Continues with loose liquid golden stools, Imodium ATC. Mushroom cath intact. Protonix q24hours.\n\nGU-Indwelling foley catheter with clear yellow urine, no sediment seen. UOP adequate, Lasix gtt off, Continues with Lasix 20mg . Goal to keep pt -500cc/day. -1000yesterday. K and Mag repleted this am.\n\nENDO-Insulin sliding scale and fixed dose, Blood sugars 112-166. Coverage as ordered.\n\nID-Afebrile. Continues on Ampicillin and Fluconazole.\n\nSOCIAL-Pts daughter and friend in to visit last night. Questions answered and updated on plan of care.\n\nPLAN-Monitor UOP, goal -500cc/day, LAisx as ordered.\n -OOB to chair\n -Continue antibiotics, monitor WBC's (trending down)\n -Pulmonary toileting, encourage IS/Cough and deep breathing.\n -??Possible transfer to floor per HO today??, not called out\n" }, { "category": "Nursing/other", "chartdate": "2173-02-24 00:00:00.000", "description": "Report", "row_id": 1416388, "text": "nursing progress note\n\nevents: pt w/ very poor u/o, since 1800 last eve, foley replaced w/ 18F silicone catheter w/ 10cc balloon inflated. cath irrigated easily, bladder scan showing very little to no urine. very little response to fluid resuscitation noted, urine remains very sedimented, amber to brown in color, poor volume. bp and hr improve transiently w/ fluid boluses. bun/cre continue to rise. tmax last eve 101.9, tylenol given for comfort, repeat temps improved, remains low grade febrile.\n\nneuro: when febrile pt slightly confused otherwise a+ox3. able to state family members' names, etc. mae weakly, assists w/ turns. very pleasant, able to converse freely.\n\nresp: ls clear to upper fields, dimin to bases bilat R>L. tachypneic for shift, rate 30s-40s. o2 sats wnl w/ 4lnc and 40% face tent o2. denies sob/distress despite shallow, tachypneic breathing.\n\ncv: as above transiently hypotensive, tachycardic. given total 5000cc fluid, extrem warm, pulses intact weakly. occas pvc's noted w/ slower rate. mild edema to extrem.\n\ngi: belly firm, increasingly distended, icu team aware. pt c/o mild diffuse abd pain, wincing w/ palpation. declines meds for pain. tf on hold, dobhoff patent for meds. ng to w/ large amt bilious output, occas rust in color, clearing w/ irrigation. amylase 390s, tbili 4.0. several sm soft brown stools overnight.\n\ngu: as above very poor u/o, bun 40s cre 2.2 this am. u/a sent, + rbc, bacteria, yeast.\n\nendo: bg's elevated, sliding scale coverage continues, glargine held last evening d/t feedings being held.\n\nid: as above tmax 101.9, wbc wnl this am. blood and urine cx pending from . vanco trough sent last eve, 21.7, today's doses to be held. meropenum dose adjusted for renal compromise.\n\nskin: no new issues.\n\nsocial: no family contact overnight.\n\nplan: pt w/ worsening clinical picture, suspect of ?sepsis. ?repeat abd CT d/t worsening abd exam, likely will need a line to monitor labs, lactate. fluid resuscitation as tolerated, closely monitor u/o, follow pending cx's, cont aggressive pulm toileting,follow abd exam. full icu monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-24 00:00:00.000", "description": "Report", "row_id": 1416389, "text": "T/SICU Shift Report 0700-\n66 Year Old Male NKA FULL CODE Universal Precautions\n\nAdmission - Pancreatitis\nReadmission - Line Sepsis\nReadmission - Vomiting/?aspiration\n\nPMH - Hypertension/Hypercholesterolemia\n Sleep apnea\n ARF\n Prostate CA (S/P RRP)\n\nShift Events - Central Line placement\n Arterial Line placement\n Intubated\n RUQ/Renal USS\n CT Abdomen\n Sent to OR for Resection of Pancreas\n\nReview of System:\n\nResp - CMV 14x550 PEEP 5 FiO2 60%. SpO2 >98%, RR 20-30bpm. ABG pH7.43, PaCO2 36, PaO2 286, BE 0. Breath sounds clear to RUL/LUL, diminished to RLL>LLL. Small amounts of thick/white secretions on ETT suction. Easy intubation with 8.0 ETT, immediate color change of end tidal CO2, placement confirmed by CXR.\n\nCVS - Sinus tachycardia with occasional PVCs. HR 90-120bpm, SBP 65-130, MAP 40-80, CVP 8-11, Tmax 100.1. HCT 19.6% (after fluid, given 2units PRBCs), Hb 6.7, WCC 6.7, INR 1.8 (given 2units FFP). Hypotensive in the presence of agitation, not responding to fluid bolus, started on norepinephrine 0.1mcg/kg/min (Aim MAP>60). Continues on P-boots/heparin SC. Continues on Meropenum, vancomycin held due to ARF, started on fluconazole.\n\nRenal - UO 2-20ml/hr despite 9000ml fluid bolus in previous 16hours. BUN upto 45, Creatinine upto 2.5 (from 0.8), K 4.1, Mg 1.9 (repleted w/ 2g magnesium sulfate), Ionised Ca 1.05 (repleted with 2g calcium gluconate), Phos 4.8. Maintenance fluid 150ml/hr LR.\n\nNeuro - alert/oriented prior to intubation, GCS 15. Post-intubation sedated with 60mcg/kg/min Propofol, 25mcg/hr Fentanyl. GCS 8 (e2v1m5). Unable to lighten sedation due to hemodynamic instability. No complaints of pain prior to intubation, appears comfortable post-intubation.\n\nGI - NPO since due to RUQ pain. firmly distended, nontender, hypoactive bowel sounds. CT shows free fluid, necrotic pancreas. 2xSoft stool, guiac negative. 800ml bilious output from NGT to LCS. Blood glucose stable with ISS (glarine discontinued).\n\nSkin - Skin grossly intact, slight redness to sacrum.\n\nAccess - Aline/c-line patent, some bloody drainage to dressings. Cline confirmed by CXR. 2xPIV.\n\nSocial - Wife called by Dr , updated with overnights developments. Wife, and 2 daughters discussed the OR with Dr , informed that his prognosis may be very grave. Dr /team will update the family post-operatively.\n\nPLAN - Receive from OR\n Fluid management\n Potential for increased sepsis post-operatively\n Remain intubated post-operatively\n Keep family updated\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-26 00:00:00.000", "description": "Report", "row_id": 1416397, "text": "NPN 0700-1900\n Pt awake or easily arousable to voice. MAEs, R arm weaker than LUE. Nods yes and no to questions appropriately and able to communicate basic needs this way.\n\n Resp- settings changed to MMV and tolerating well. Metabolic acidosis partially compensated. Lungs clear to coarse. Scant amt ETT secretions. Adeq sats but in last few hours sats dropping to 91% with turning.\n\n CV- SR with rare to occ PVC. Maintaining MAP>60 off pressors and with fluid decreased to 80cc/h this am. KVO'd IVF @ 1730. Afebrile. Vanco held today for trough 20. Creatinine 2.6. K and Mg wnl with afternoon labs. Bladder pressure 16 x 2. BG 70-80s. No coverage required.\n Skin w/d. Oozing mod amt serous fluid from srotum. Large amt general edema. Abd incision with staples, intact, edges approximated, no drainage. Coccyx and buttocks red. Frequently repostioned. Drains intact.\n\n GI/GU- Abd distended and firm. Barely audible BS. G-tube to gravity with drainage. J-tube used for feeding, impact 1/2 strength at 10cc/h. Not to advance. JP x 2, liquid drainage. T tube with lg amt brown bile out. No stool, no flatus noted.\n\n Plan- Cont freq repositioning. When appropriate need to begin diuresis. Monitor BGs closely. Daily Vanco troughs and dose for level < 15.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-27 00:00:00.000", "description": "Report", "row_id": 1416398, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech as per Carevue. Lung sounds coarse suct mod th off white sput. MDI given as per order. ABGs resp acidosis with marginal oxygenation; returned pt to A/C. Cont mech support.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-27 00:00:00.000", "description": "Report", "row_id": 1416399, "text": "NPN, 1900-0700\nneuro: very lightly sedated on propofol and fentanyl gtts; opens eyes to voice, inconsistently follows commands. Moves all extremitites; strong cough and gag.\n\nCV: NSR, MFVEA, 80's; SBP 120's at rest , to 160's when awakened. Gross anasarca; pulses palpable throughout. Pboots, sq heparin propy.\n\nPulm: orally intubated, MMV changed to CPAP/PS early eve, then again changed to CMV in attempt to correct mixed acidosis. Presently, settings: CMV 550 x 50% x 17 x 10 w/ ABG's 7.29/37/119/-. BS diminished at bases, CTA anteriorly; scant thick white ET secretions.\nCXR done this am, film pending.\n\nGI: abd softly distended, BD distant hypoactive. No stool or flatus; G-tube draining thick light green mucous. T-tube draining dark bile; j-ps x 2 draining turbid tan fluid. TF via J-tube: 1/2 strength replete at 10cc/hr, not to be advanced.\n\nRenal: F/C urine amber, sediment, OP marginal, 30-60cc/hr. LR @ 10cc/hr. BUN/Cr 44/2.6, basically unchanged x 24 hours. Lactate .5\n\nSkin: grossly intact; remainder of macular rash healing bilateral axillae, back and coccyx.\n\nID: Tmax 100.6po; WBC 11.6, up from 10. Vanco level pending. Cont on Meropenum.\n\nEndo: RISS, no coverage required.\n\nPsychosocial: no family contact this shift.\n\nP: adequate sedation, analgesia to allow aggressive bronchial hygeine.\n? bicarb to augment renal function in setting of adequate oxygenation, persistent metabolic acidosis, ATN. support to maximize oxygentation, if able, but pt will not extubate until significant fluid diuresis. Cont trophic TF, monitor GI OPs.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-27 00:00:00.000", "description": "Report", "row_id": 1416400, "text": "Patient remains on mechanical ventilation ABG acceptable suctioned for minimal amount of secretion will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-01 00:00:00.000", "description": "Report", "row_id": 1416408, "text": "T/SICU Shift Report 0700-\n66 Year Old Male NKA FULL CODE Universal Precautions\n\nAdm - Acute Pancreatitis\nReadmission - Line Sepsis\nReadmission - Vomiting/?Aspiration\n\nPMH - Hypertension\n Prostate Ca (S/P RRP)\n\nOR - - Pancreatic resection\n\nShift Events - T Spike 103 - Pancultured\n Central line changed over a wire\n\nReview of Systems:\n\nResp - AC 17x550 PEEP 7 FiO2 50%. SpO2 >96%, RR 17-19bpm. ABG pH 7.36, PaCO2 42, PaO2 147, BE -1. Breath sounds clear to upper to upper lobes, diminished at the bases. Thick/clear/white secretions on ETT suction. Sputum culture sent.\n\nCVS - Sinus rhythm no ectopy. HR 90-115bpm, SBP 75-130, MAP 45-95, CVP 8-15, Tmax 103.0. Peripherally warm/well perfused/palpable pedal pulses. +++ piting edema to extremities. Noriepnephrine restarted at 0.05mcg/kg/min. 2xBlood cultures sent. Continues on ampicillin Q6.\n\nRenal - UO 35-80ml/hr, inbalance for today, positive 2400ml for LOS. KVO fluids. Started on furosemide, then discontinued due to the need for norepinephrine.\n\nNeuro - Intermittent lorazepam for sedation, 50mcg/hr fentanyl. GCS 11 (e4v1m6). PERRL. Obeying commands intermittently with BLE. No evidence of pain.\n\nGI - TF continue at goal rate 100ml/hr 1/2 strength impact via J-tube. G-tube to gravity (250ml bilious output this shift). T-tube to gravity (500ml bilious output this shift). soft/distended, hypoactive bowel sounds. 2xsmall BM this loose/golden stool. Blood glucose elevated, with ISS coverage.\n\nSkin - Q2-4 turns. Red rash to torso. Probable wound infection due to presence of tenting at the incision site. Fluid from JP #3 sent for culture.\n\nAccess - Aline redressed, lines changed. Cline patent.\n\nSocial - Wife/daughter into visit today.\n\nPLAN - Maintain MAP >60\n Hold furosemide infusion O/N\n Awaiting culture results\n" }, { "category": "Nursing/other", "chartdate": "2173-03-02 00:00:00.000", "description": "Report", "row_id": 1416409, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech as per Carevue. Lung sounds coarse suct sm th off white sput. MDI given as per order. ABGs stable; no changes required . Cont mech support.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-02 00:00:00.000", "description": "Report", "row_id": 1416410, "text": "t-sicu nsg note:\nneuro- opens eyes to voice, slight gross motor movement to command, strong cough, strong gag.\n\nresp- vented on a/c , rate of 17 w/ 2 spont resps, vt 500 w/ peep 7cm, spo2 97-98% on 50%fio2., abg wnl. bs cta , diminished in bases. sm amt clear thick secretions.\n\ncvs- hr 102-118st no ectopy, maps 60's-80's levo weaned to 0.03mcg/kg/min. tm 101.8po 650mg tylenol given pjt. lytes wnl, wbc increasing 16.5. see flowsheet for all details.\n\ngi- tf str impact @ 100cc/hr via j-tube, g-tube to gravity and draining mod amts of green bile. jps draining opaque greyish fluid. biliary drain w/ large amt /brown bile. abd remains very distended, +flatus, no stool.\n\ngu- foley patent for gd amts yellow urine w/ mod amt sediment. cr. 2.2\n\nskin- pink around staples, abd ddi, sm area in upper incision w/ s/s drainage. anasarca continues, antifungal applied to areas w/ rash on back side and groin.\n\nendo- bs rx w/ riss per orders\n\na: remains febrile, slow of pressor support\n\np: monitor vs per routine, maintain pulmonary hygiene, vigilent skin care, support family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-03-02 00:00:00.000", "description": "Report", "row_id": 1416411, "text": "NPN 7a-7pm\n\n****Ros : See carevue for exact data******\n\nN: Pt with increased lethargy today. ICU team aware on . Fentanyl drip for pain decreased to 25 mcg/hr for improvement of neuro exam, still providing adequate pain control. Will arouse to voice and name, no mvmt of upper ext's, pt will move lower ext to command. Pupils equal and reactive. side rails up.\n\nCV: HR 90-112, SR-ST, occas pvc. CVP 2-7. Pt off levophed since 11am, maintaining adeq MAP 64-90. Art and NBP correlating. Venodynnes on, SQ heparin, positive pulses, Pitting edema to all ext's elevated on pillows.\n\nRESP: Pt remains intubated, Currently on CPAP and PSUPP on 50%\nLast gas 7.35/37/99/21/-4. CPT. RR 16-20, O2 sats 96-99% suctioned for moderate amts of thick white secretions.Mouth care prn. LS clr to coarse, diminished at bases.\n\nGI: Abd softly distended. Positive BS, BM LG yellow/brown loose x3. Gtube to gravity draining bilious green output 300 cc this shift. Ttube to drainage emptying 300 brown outputs. Jpx2, #2 emptying minimal amts of opaque output, # 3 with same color output 120 this shift. Fluid sent for culture from drain #3. Midline abd inc oozing pus, opened by primary team to let drain. Will follow wet to dry drsg . J tube to feeding. Tolerating now 3/4 strength impact, no residuals. H2O bolus's.\n\nGU: u/o adeq 40-60 cc q hr. Yellow, some sediment noted.\n\nEndo: Bld sugars 150-200 slididng scale tightened.\n\nLytes: Wnl, no repletion needed.\n\nAccess: Left subclavian trip lumen, drsg today. Left art line intact.\n\nID: Tmax 100.5, cultures to date negative. Pt started levofloxacin today, pt continues on ampicillin and fluconazole.\n\nP: Cont to monitor neuro exam, watch for improvement in neuro status.\n Monitor for pain, medicate prn.\n Monitor hemodynamics, Maintain adeq MAP off Levophed\n Monitor resp status, cont .\n Cont TF, monitor GI status, tubes, drainage, temps, cult's.\n Monitor bld sugars, insulin per sliding scale.\n Provide emotional support to pt and family. Monitor.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-24 00:00:00.000", "description": "Report", "row_id": 1416390, "text": "Respiratory Care Note\nPt received on cool aerosol and NC as noted. ABG's mild respiratory alkalosis with poor oxygenation. Plan to take pt to OR after intubation and CT scan. Pt intubated with #8.0 ETT without incident. ETCO2 had a positive color change. Bilateral chest excursion and BS noted. Pt placed on AC as noted - follow up ABG within normal with limits with excellent oxygenation. FiO2 weaned according to ABG. Pt transported to CT Scan for abdomen without incident. Pt taken to OR at 3pm.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-25 00:00:00.000", "description": "Report", "row_id": 1416391, "text": "T/SICU Nursing Progress Note\nS:\nO: Review of systems\nNeuro: sedated with propofol and fentanyl overnight. When propofol weaned, opens eyes, moves all extremities weakly. Not lightened enough to follow command due to hemodynamic instability.\nCVS: sinus rhythm 90-105 with increasing ectopy as sedation is lightened. Levophed on to maintain map >60. Multiple fluid bolus given overnight (6000 cc in bolus) and maintenance fluid increased to 250cc/hr. CVP initially 5, now . Peripheral pulses present though hands and feets are cool to touch. On sq heparin and venodynes.\nRESP: On a/c 12 X550 60% 5 peep. Suctioned for minimal white secretions. Breath sounds decreased in lower fields. ABG shows adequate oxygenation/ventilation. >200\nRENAL: cr down to 2.3 this am. Oliguria continues with urine output 15-30cc/hr despite aggressive volume administration. Lytes repleted as per order.\nGI: Abdomen large firm, tympanic. Absent bowel sounds. Incontinent of two pasty golden stools. ng to low constant suction draining thick bilious liquid. Dobhoff feeding tube dc'd. Pt with L sided G tube, J tube to gravity with minimal drainage. R sided chole tube with blood tinged bilious drainage. Pt. also with two JP drains to bulb suction now draining pink cloudy thick fluid. Protonix ordered for prophylaxis.\nENDO:BS 115-122. On ss insulin.\nHeme: hct this am 34. INR 1.5. On sq heparin.\nID: temp to 101.1. WBC 14.2 this am. Gram stain from pancreatic fluid with gram + cocci. On fluconozole, vanco (per levels), and meropenum.\nSKIN: midline abdominal incision in place with moderate amount of staining. Pt. with resolving perianal rash.\nSOCIAL: wife, two daughters in on eves. They called twice overnight for updates.\nLINES: L radial art line and L subclavian triple lumen in place.\nA: Unfortunate man with necrotizing pancreatitis and pseudocyst formation, now postop with large volume requirement and ATN.\nP: continue volume administration as indicated by cvp/bp. Careful monitoring of renal status, acid base balance. Support family with information. Continue appropriate level of sedation until pt ready to .\n" }, { "category": "Nursing/other", "chartdate": "2173-02-25 00:00:00.000", "description": "Report", "row_id": 1416392, "text": "Respiratory care:\nPatient remains intubated and mechanically vented. checked and alarms functioning per department protocol. Fio2 weaned to 60% overnight. ABG WNL. greater then 200. Breathsounds are decreased at bases otherwise clear.\nPlan: Continue mechanical ventilation. as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-25 00:00:00.000", "description": "Report", "row_id": 1416393, "text": "T-SICU nsg note\n Pt sedated with propofol, down to 20mcg/kg/min. Fentanyl drip continues at 50mcg/hr with occ boluses when pt nods yes to question if he is in pain. WIth these drips on, pt opens eyes to voice, often nods to questions. Doesn't squeeze hands to command (pt did not do this last time he was intubated) usually wiggles toes to command. Withdraws to nailbed pressure. Spont lifts L hand to rest on chest.\n NSR to occ ST. Remains on norepi now at .15mcg/kg/min, down from this am. Maintain MAP . 65. PVC's 0-6per min. CVP 6-9, fluid bolus given and CVP up from 6 to 9.\n Suctioned only once for scant amt of thick white sputum. Lungs clear, diminished in R base. PEEP up to 8cm, remains on 60% FIO2, set for 12 breaths, pt breathing above set rate on AC, Vt 550. Pt turned side to side, brief percussion CPT on both sides. Pt appears comfortable on current settings.\n U/O 15-30/hr. Urine is yellow with sediment. BUN & Cr from this afternoon still pnd.\n NG tube clamped. Gastric tube to gravity drainage draining green bilious fluid with mucus. J tube to gravity with no output. JP drains draining pink/brown opaque fluid. T- tube draining amber bilious fluid. Abd firmly distended, but softer than pre-op. No bowel sounds heard. No nutrition today. Small amt of soft golden stool. Bladder pressures 12- 18 today. Abd incision dressed and dry.\n Hct at 1400 down to 30 from 34. No active bleeding.\n Temp up to 100.4 PO, acetaminophen PR and temp down. On Vanco - dose given at 0900 today, fluconazole, and meropenam. OR cultures still pending, gm stain with gm + cocci.\n Back and buttocks intact. Perineum rash healed. Feet and hands warm, pink with easily palpable pulses.\n Glucose levels 114- 140 today. On sliding scale regular humulin SQ.\nCortisol stim test given, results pending.\n wife and daughter in to visit today, both pleased with pt's appearance and his opening eyes to voice.\nA: improved post-op. Still with low u/o and fluid requirement - LR at 250cc/hr with boluses. On norepi drip.\nP: Informational support to family. Medicate for pain as needed. Sedate as needed to maintain pt comfort with ET tube. Frequent position changes. Monitor lytes and glucose. Fluid as ordered. Monitor bladder pressures.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-26 00:00:00.000", "description": "Report", "row_id": 1416394, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech as per Carevue. Lung sounds coarse suct sm th off white sput.ABGs respiratory acidosis; oxygenation initially marginal improved with increase PEEP. Cont mech .\n" }, { "category": "Nursing/other", "chartdate": "2173-02-26 00:00:00.000", "description": "Report", "row_id": 1416395, "text": "NPN, 1900-0700\nneuro: arouses to voice, follows commands; lightly sedated on propofl and fentanyl gtts. Pt denies pain on fentanyl 50 mcg/hr. Moves all extremities; strong cough and gag.\n\nCV: NSR, frequent MFVEA, 80's. Norepi weaned off; SBP maintained >100, MAP>65. CVP has risen from . Moderate anasarca; pulses palpable throughout. Metoprolol 2.2 mg IV held until 0600, when pressors off, HD stable.\n\nPulm: orally intubated; MCV 550 x 12 x 60% x 10PEEP; PEEP increased early eve to correct low PaO2. ABG's this am show mild metabolic acidosis, adequate oxygenation. BS CTAb, very diminished right base.\nMinimum thick white secretions.\n\nGI: abd firmly distended; hypoactive BS. NGT clamped; sumped q 4 hours for <50cc bile. G-tube to gravity draining clear mucous after initial small amount bile. J-tube draining scant bile. T-tube draining large amount dark bile. JP's both draining turbid tan/pink fluid. Midline incision dressing C/D. No stool or flatus. Bladder pressures .\n\nRenal: F/C urine amber-->yellow, sediment; OP 30-80cc/hr. No fluid boluses required this shift. BUN/Cr 44/2.7, rising. LR rate decreased from 250cc/hr to 125cc/hr.\n\nSkin: grossly intact. Residual rash right axilla. Water blisters an abd at op-sites; changes to paper tape.\n\nEndo: RISS, BG well controlled. Cosyntropin level pending.\n\nID: Tmax 99.6po; WBC down to 10. Vanco level pending 0600 draw. Cont on merepenum.\n\nPsychosocial: no family contact this shift.\n\nA: s/p open expl lap w/ drain, g, j-tube placments; resp failure r/t worsening pancreatitis.\n\nP: low dose sedation, adequate analgesia. as able. ? d/c slem sump today; ? start feeding via J-tube. Monitor renal status closely.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-26 00:00:00.000", "description": "Report", "row_id": 1416396, "text": "Resp. care note - Pt. remaines intubated and vented, weaned to MMV tol ok at this time.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-06 00:00:00.000", "description": "Report", "row_id": 1416427, "text": "NPN, 1900-0700\nneuro: arouses to verbal w/ open eyes, nods appropriately to simple ?s, follows commands inconsistently. Moves LEs on bed weakly, LUE strongly, RUE not at all. Med w/ oxycodone x 2 for c/o back pain.\n\nCV: NSR, rare VEA, AEA, 70-80's at rest. SBP 120's at rest, to 150's w/ care. CVP 10-->6 after lasix gtt . Moderate anasarca, pulses weakly palpable peripherally.\n\nPulm: orally intubated, rested on CPAP/PS x 50%: 54, SBT x 30\" w/o distress, then returned to CPAP/PS 5/5. ABG's cont w/ metabolic alkalosis, excellent oxygenation. BS CTAb after strong cough; sx for min thick yellow secretions.\n\nGI: abd softly distended, BS hypoactive throughout. Liquid gold stool via mushroom cath, 150-200cc/4 hrs. G-tube clamped, residuals checked q 4 hours, < 10cc/hr. Chole tube draining dark bile, small amounts. JPs x 2 draining turbid tan fluid. TF via J-tube, min residuals. Surgical incison w/ opened staples distal and proximal: wet-->>dry, granulating tissue clean, min serous drainage.\n\nRenal: F/C urine yellow, sediment. Lasix gtt at 2 mg/hr. Fluid goal 2L/24 hours. (2200cc @ MN). Lytes repleted aggressively.\n\nSkin: several blisters on abd intact, healing open skin tears clean, pink. Coccyx slightly red, intact.\n\nAccess: left SCL TL pink at site, no drainage. Left brachial a-line oozing sang, damped w/ position.\n\nID: Tmax 100.4po; WBC 14.2 from 12. Cont on , fluco, amp.\n\nEndo: q 12 hour NPH + q 4 hour RISS; good BG control.\n\nPsychosocial: no contact from family .\n\nP: cont , ? extubate in next 24 hours. Lasix gtt, fluid goal 2L/24 hours. Abd drains, dressings q 4-6 hours. Monitor mentation, right arm motor for cont ? deficit vs deconditioning.\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-03-06 00:00:00.000", "description": "Report", "row_id": 1416428, "text": "T/SICU Shift Report 0700-\n66 Year Old Male NKA Contact Precautions - MRSA FULL CODE\n\nAdmission - Acute Pancreatitis\nReadmission - Line sepsis\nReadmission - Vomiting/?aspiration\n\nPMH - Prostate CA (S/P RRP)\n Hypertension\n\nOR - - Resection of necrotic pancreas\n\nShift Events - Extubated 0945\n\nReview of Systems:\n\nResp - SV on 2l NC. SpO2 >96%, RR 15-25bpm. ABG on 2l pH 7.45, PaCO2 41, PaO2 105, BE 3. Breath sounds clear to upper lobes, slightly diminished at the bases. Using IS/C&DB Q2 needs encouragement. Minimal secretions, coughing and clearing well. ?Need for Bipap overnight - due to baseline use.\n\nCVS - Sinus rhythm occasional PVCs. HR 80-100bpm, SBP 95-130, MAP 60-90, CVP 5-12 (post-extubation). Peripherally warm/well perfused/palpable pedal pulses. Continues on levofloxacin/ampicillin. P-Boots/Heparin.\n\nRenal - UO 120-300ml/hr via foley. Furosemide infusion 2mg/hr. Current balance negative 1200ml (AIM negative 2000ml), LOS positive 16500ml. K 4.1 (after 60mEq KCl), Mg 1.7 (repleted with 2g MgSO4), Ca 7.6 (repleted with 2g Ca Gluconate), Creatinine down to 1.2, BUN down to 51.\n\nNeuro - Patient remains sedated/lethargic post-extubation, 1800 clonidine held. GCS 14 (e4v4m6), pupils 3mm/3mm brisk reactive, reflexes intact. No movement noted in RUE, sensation intact, MDs aware. Obeying commands intermittently depending on level of sedation. Given 2x5ml oxycodone for abdominal pain with effect.\n\nGI - TF continue at goal rate 125ml/hr 3/4 strength impact via J-tube with minimal residuals and minimal residuals via G-tube. Continues with PPI. soft/distended (equal to baseline)/positive bowel sounds. Loperamide given for high stool output. Mushroom catheter insitu with reduced output. Blood glucose stable with ISS/NPH.\n\nSkin - wound redressed, open areas granulating. Moderate serous output from around JP #3. All drains secured. Pressure areas intact, tolerating turns/mouth care.\n\nAccess - Aline dampened due to patient positioning, patient complaining of pain at the site, MD aware - will reevaluate the need for line in AM. Cline site continues to be red, CVP waveform sharp.\n\nSocial - Visited by two daughters today, satisfied with progress, will visit tomorrow.\n\nPLAN - Pulmonary hygiene\n to RA as tolerated\n Hold clonidine for excessive sedation\n ?use acetaminophen as first line analgesia\n Wet-to-dry dressing to midline incision (next due 0400)\n Ensure drains are adequately secured\n\n" }, { "category": "Nursing/other", "chartdate": "2173-03-07 00:00:00.000", "description": "Report", "row_id": 1416429, "text": "t-sicu nsg note:\nneuro- follows commands, speech less garbled, moves le's in bed, lue w/ gd strength, no spont movement of l arm however does have tone and resists and will shake hands when asked.\n\nresp- strong cough productive for thick white-yellow sputum, requires sxn from back of throat. 2lnc w/ spo2 96-98%, abg w/ mild met alkalosis.\n\ncvs- tm 100po, hr 80's-108 nsr w/ rare apc/pvc, sbp 120's-140. lasix gtt cont. electrolytes repleted.\n\ngi- lg amt golden liquid stool via mushroom cath, abd remains distended. all drains patent, tf cont @ goal of str impact @125cc/hr via jtube.\n\ngu- copious diuresis on lasix gtt, received last dose of diamox. cyu via foley.\n\nskin- decreasing anasarca, abd dsg as documented, cont to ooze mod-lg amt serous drainage from around jp sited. midline incision w/ granulation tissue.\n\nendo- bs continue to require rtc riss coverage.\n\na: stable, diuresing well.\n\np: monitor vs per routine, follow electrolytes closely. encourage mobility.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-07 00:00:00.000", "description": "Report", "row_id": 1416430, "text": "T/SICU Shift Report 0700-\n66 Year Old Male NKA FULL CODE Contact Precautions - MRSA\n\nAdmission - Acute Pancreatitis\nReadmission - Line Sepsis\nReadmission - Vomiting/?Aspiration\n\nPMH - ARF\n Hypertension\n Sleep Apnea\n Prostate Ca (S/P RRP)\n\nOR - Resection of necrotic pancreas\n\nReview of Systems:\n\nResp - SV on RA. SpO2 >93%, RR 20-30bpm. ABG pH 7.43, PaCO2 33, PaO2 82, BE 0. Breath sounds clear to upper lobes, coarse at the bases. Thick yellow/white secretions coughed to back of throat cleared with Yankeur. Q2 C&DB/IS/CPT.\n\nCVS - Sinus rhythm with occasional PVCs. HR 80-95bpm, SBP 120-160, MAP 75-105, CVP 7-9, Tmax 99.8. Lactate 1.5. Peripherally warm/well perfused/palpable pedal pulses, decreasing edema. Continues on ampicillin/levofloxacin/fluconazole. P-boots/heparin.\n\nRenal - UO 45-400ml via Foley. Negative 1950ml today (furosemide infusion decreased to 1mg/hr - Aim 2000ml Negative), positive 14000ml LOS. Weight 102.4Kg (admission 102Kg). Na upto 146, K 4.0 (Potassium decreased to ), Mg 1.8 (repleted w/ 2g MgSO4), Ionised Ca 1.14, Phos 3.3, BUN 50, Creatinine 1.2. Penis elevated to reduce edema with effect.\n\nNeuro - Lethargic. Oriented to person/place. GCS 14 (e4v4m6). Pupils 3mm/3mm brisk reactive. MAE. No complaints of pain, given acetaminophen this AM. Clonidine held to avoid sedation.\n\nGI - TF at goal impact via J-tube (minimal residuals). Minimal residuals via G-tube Q4. T-tube - 175ml bilious output this shift. Stool output down to 375ml this shift, golden/liquid stool via mushroom catheter. Blood glucose stable with ISS/NPH.\n\nSkin - OOB to Chair for two hours. Tolerating side-lying. Preassure areas intact. wound redressed 1600 (See carevue). JP output 20ml from #2, 90ml from #3.\n\nAccess - Aline/cline patent/intact.\n\nSocial - Visited by wife and daughter, both assured that patient wouldn't be transferred to the floor until it was clinically indicated and a bed was available.\n\nPLAN - ?D/C Lasix infusion in AM\n Q2 C&DB/CPT/IS\n OOB to Chair in AM\n" }, { "category": "Nursing/other", "chartdate": "2173-02-23 00:00:00.000", "description": "Report", "row_id": 1416386, "text": "nursing progress note\n\nneuro: pt remains oriented x3 although unable to state month. can state year, place, full name. mae weakly. assists w/ repositioning. slept well most of night w/ ambien dosing.\n\nresp: ls clear to upper fields, dimin to bases bilat. cough strong, clearing secretions fairly well, occas requiring subglottic sx. rr high 20s-low 30s at rest. no apneic episodes noted, bipap remains off for night. o2 sats wnl w/ 4l nc o2. tends to mouth-breathe, oral mucosa very dry, oral care provided often.\n\ncv: sinus tachy for shift, much ectope last evening. improves w/ lopressor dosing. mildly hypotensive to 90s when sleeping. extrem warm, pulses intact. k+ repleted last evening.\n\ngi: belly soft/distended. bs present. ng to , placement checked last eve, sounds very distant. tube advanced 3-4cm, clearer sound noted. brown drainage noted, large amts for shift. irrigated multiple times d/t ? coffee gr. appearance. will monitor. scant soft brown bm x2. tf titrated toward goal rate via dobhoff.\n\ngu: foley patent amber sedimented urine, qs.\n\nid: tmax 102.9 last evening, blood cx x2, urine cx obtained. temps improved w/ tylenol, afebrile rest of shift.\n\nendo: bg's elevated w/ tf titration, icu team aware.\n\nskin: no new issues.\n\nsocial: no family contact overnight.\n\nplan: monitor ng drainage, titrate tf to goal as tolerated. follow temps, pending cx. tighter glucose control needed, ? adjust insulin sliding scale.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-23 00:00:00.000", "description": "Report", "row_id": 1416387, "text": "T-SICU Nsg note\n Pt sat on edge of bed and practiced sitting balance. pt stood and pivoted to chair with max assist of 1. In chair, hypotennsive - 75-85 systolic, pt talking, oriented, c/o not feeling good. Fluid boluses of LR 500cc x 2. BP up briefly to 90-100sys after fluid. Pt also with low u/o. Foley repositioned and irrigated multiple times, but pt remains with low u/o, concentrated amber color. Easy to irrigate foley, no resistance, no clots back. Unable to obtain UA to send.\n Pt had sudden burning abd pain in R mid section. Pt reported pain as 9 on 1- 10 scale. VEry sudden onset. Pain subsided within 30 mins after tube feedings stopped and 1mg IV hydromorphone given. PT slept briefly.\n Abd more firm and continues very distended. Active bowel sounds, lots of flatus, and several small stools, soft brown. sump to low constant suction, brown to bilious output. Feeding tube flushed with sterile water when TF off. IV fluids of D5 .45 NS at 100cc.\n Pt has been oriented, conversant, listening to conversations and remembering events from distant and recent past.\n Pt in sinus rhythm, rate 80- 120, occ PVC's. BP by NBP on either arm 85 to 110 sys.\n COntinues to bring thick white sputum to back of mouth, sometimes can bring forward to be suctioned from front of mouth, at times needs subglottal suctioning to clear sputum. Face tent for humidity. NC with good O2 sats most of day.\n Meropenam started. C0ntinues on vanco. Levoflox discontinued.\nFamily in today and appropriately concerned with pt's low BP and abd pain. Dr. in and talked to pt's wife.\nA: Hypotensive, low u/o, abd pain. TF off until at least tomorrow.\nP: Monitor glucose, IV fluids as ordered/ Monitor u/o and foley postiioning. Informational support to pt and family. Hold TF for now. Continue C & DB, frequent position changes.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-09 00:00:00.000", "description": "Report", "row_id": 1416434, "text": "T-SICU nsg note\n Neuro status changing. Initially alert, Ox1, but able to converse on a topic. Lethargic at times, despite attempts to keep pt awake, pt falling asleep during PT exercises. This evening, pt talking spont but I cannot understand references - mortgage, 27, push the button. Pt very pleasant, and sometimes agrees with me if I try to relate his comments to here and now. Follows commands with feet, and occ with L arm, not with R arm. Usually nods to questions or answers verbally. No sedatives nor narcotics given.\n Afebrile. COntinues on ampicillin and fluconazole.\n Team opened abd incision today, removing all remaining staples. VAC dressing applied to 125 continuous suction. Tan fluid draining via VAC. Abd soft, active bowel sounds, liquid brown stool via mushroom catheter. T-tube clamped. G tube clamped. J tube with feedings of Replete with fiber 3/4 strength at 125cc/hr continues. Imodium increased to TID. JP's draining grey opaque fluid.\n Pt has strong spont cough, prod of tenacious yellow sputum. Pt able to get sputum up, but only to back of throat. SO pt needs oral suctioning to clear mouth. Lung sounds diminished in bases, clear at top. Resp rate 28-34. Wearing face tent with cool neb for humidity.\n Urine output brisk. No lasix so far today, and pt is negative fluid balance for this 24 hrs.\n Blood glucose levels 135- 150 today, q 4 hr sliding scale regular insulin given and NPH insulin given.\n Back and buttocks intact, peri area clean and healthy looking. Blister on abd from tape red, not open.\nA: mental status changable. Otherwise stable and progressing.\nP: re-check lytes, continue plan of care. Informational support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-10 00:00:00.000", "description": "Report", "row_id": 1416435, "text": "nursing progress note\n\nneuro: pt oriented x1 only, although able to state all family members' names, where he lives (city and state), what branch of military he used to be in. conversation disjointed most of shift. following commands well, calm. moving R arm on bed when prompted, signif weaker than left.\n\nresp: ls clear, dimin to bases bilat. o2 sats 99-100% w/ 35% face tent o2. requiring humidification d/t extrem. dry oral/nasal mucosa, having diff. clearing secretions w/out. o2 sats stable on room air. rr 20s. expectorating thick yellow secretions. cough strong.\n\ncv: a line w/ fling off and on, nibp stable. nsr, rate 70s-80s, pac's freq. lopressor po dosing cont. lytes repleted per orders. extrem warm, pulses intact. edema much improved.\n\ngi: belly soft/distended. bs present. liquid, foul golden stools persist despite immodium dosing, mushroom cath intact. str. tube feeds at goal rate.\n\ngu: fole patent clear to cloudy yellow urine, diuresed well w/ lasix qd.\n\nid: afebrile, diflucan, ampicillin dosing continued. most recent cdiff cx pending, last 3 negative.\n\nskin: midline wound w/ intact VAC dsg, sm amts brown drainage in canister. all drain sites dry, sutures intact. jp drains w/ same pancreatic output, murky brown.\n\nendo: bg's slightly elevated, nph, sliding scale dosing continued.\n\nsocial: no family contact overnight.\n\na/p: neuro exam waxing and , at best oriented x2. continues to be signif weaker to RUE. persist diarrhea ongoing despite immodium. cont aggressive pulm hygeine. send stool for o+p, surveillance abd CT today.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-01 00:00:00.000", "description": "Report", "row_id": 1416407, "text": "nursing progress note\n\nneuro: sedated w/ midaz, adjusted d/t pt's being wide eyed, uncomfortable w/ ett last eve, tol well at 4mg/h. fentanyl drip cont, pt shakes head no to ques of pain when lightened. following commands, mae weakly.\n\nresp: ac mode support, no changes made overnight. abg acceptable, partially compensated metabolic acidosis persists. occas overbreathing w/ stimulus. sx mod amts thick white secretions prn. cough weak. ls clear, dimin to bases bilat.\n\ncv: levophed remains off, maintaining map>60. fair response to last eve's lasix dose, -1300cc last 24h. nsr to sinus tachy, no ectope. given lopressor x1 this am w/ slight dip in bp, hr improved to 90s. extrem warm, pulses intact. anasarca persists. hct stable.\n\ngi: belly less distended, softer. bs present. +flatus. no bm tonight. g tube w/ sm amts green mucoid drainage, t tube w/ brown bilious output, large amts. jps both w/ murky light brown fluid more from #3. tol. slow titration of tube feeds.\n\ngu: foley patent yellow sedimented urine, volume qs. bun rising, 52 this am. cre down to 2.3. lytes slowly returning to baseline as kidney fx improves.\n\nendo: bg's stable.\n\nid: tmax 100 overnight, cont w/ ampicillin, diflucan dosing only.\n\nskin: belly w/ generalized pink hue, drain sites all pink, jps w/ copious amts serous leakage, dsds changed freq. red mottled rash returning to bilat sides of torso, ? cause. will monitor. yeast rash to groin, micatin cream as ordered.\n\nsocial: daughter called last night for update, all ques answered.\n\nplan: cont midaz, fentanyl to optimize ventilation. likely to continue gentle diuresis, cont to follow bun,cre, u/o. follow abd exam, drain output. titrate tube feeds as tolerated. meticulous skin care, full icu monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-05 00:00:00.000", "description": "Report", "row_id": 1416425, "text": "T/SICU NSG NOTE\n(Continued)\ninues to drain lite tan fluid mostly from distal opening of incision. W>D dsg continue . Wound bed noted to have tannish tissue with moist pink edges. No change in character of drainage.\n\nHEME- stable low hct; no action at this time\n\nSKIN- noticeable decrease in anasarca; warm extremites with palpable pulses. No new skin issues. sc heparin, compression boots in use; multipodus boot and gel pads under heels altenating: no pressure areas or reddness noted. Srotal edema decreased; perineal area remains generally reddened w/o breakdown- myconazole cream and powder applied per order.\n\nSOCIAL- multiple family members visiting today; many questions continue with regard to pt's overall condition and progress; family looking for indications for timing of pt improvemment and reassurances regarding his recovery. They continue to indicate frustration with the length of his hospitalization, slow progress, and ongoing fevers and rspiratory failure, and also his profound weakness and lethargy. They expres their weariness. All concerns have been discussed by multiple health team members. Dr has phoned pt's daughter, to discuss her specific questions regarding the current plan and course of care(specifically: fevers, culture status, and her request to have repeat abd CT performed at this time.\n\nASSESS- ongoing low grade temps\n lethargy unrelated to sedation\n profoud weakness and RUE immobility\n failure to \n\nPLAN: as stated throughout note.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-03-06 00:00:00.000", "description": "Report", "row_id": 1416426, "text": "Resp care\nPt did well yesterday tolerating two periods of PS reduction to 5cm. At about 2300 he was placed on PS of 10cn to rest him during sleep. BS equal with occasonal rhonchi which improves post sx. He was sxed during the shift for a sm - mod. amount of sputum. His this am was good and I will atempt a SBT from 0600 till 0630 if tolerated.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-03-04 00:00:00.000", "description": "Report", "row_id": 1416420, "text": "T/SICU NSG NOTE\n(Continued)\nnd POC upsdates discussed.\n\nASSESS: 66 yo male with necrotizing pancreatitis and drainage of pseudocyst . Hospital course complicated by SIRS and recurrent resp failure requiring reintubation x3. Currently pt is debilitated and is failure to . Low grade temp persists.\nNew MRSA conversion of surveillance nasl swab.\n\nPLAN- PSV as tolerated; assess for ability to extubat \n monitor temp, wbc; cont antibiotc coverage; reculture with spike>101.5\n cont with pain assessment/management\n cont diuresuis as tolerated; monitor BUN/creat levels.\n assess insulin rx effectiveness.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-28 00:00:00.000", "description": "Report", "row_id": 1416404, "text": "Nursing\nSee flowsheet.\n\nPt. neurologically appropriate when sedation lightened. Able to follow few simple commands very weakly. Propofol gtt d/c'd and midaz gtt initiated with good effects, improving comfort, BP, and pt. more able to \"communicate\". Fentanyl gtt increased to 75mcg with better pain control per pt.\n\nVS as documented. MAP occasionally dipping to 57-58 this a.m., increased with minimal stimulation. Levophed off all day and MAP largely at 70. SKin warm and dry, anasarcic. CVP positional, but 12+/- when appropriately positioned.\n\nPt. tolerating present settings with slightly improved ABG's drawn this afternoon.\n\nUO adequate. When BP would allow, and p.m. labs noted, 20mg IV lasix given per a.m. round discussion with some response. BUN/crt/K stable at present time - all fluid and electrolyte issues discussed at length with H.O., including unaccountable loss from wounds.\n\nAbd. soft, very taut with edema. Distant BS's noted. Pt. has had 2 BM's today. TF's advanced by 10cc/hr. All wounds as noted on flowsheet. Abd remains warm to touch and slightly pink, incision raised by approx 2 cm. Team aware. Less seepage from JP sites this afternoon. Outputs, etc. per flowsheet. BG stable.\n\nDaughters in to vistit this afternoon.\n\nPLAN:\nContinue to assess volume status, hemodynamics, follow labs closely.\nAssess readiness to from ventilator.\nOptimize comfort, safety, nutrition.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-28 00:00:00.000", "description": "Report", "row_id": 1416405, "text": "Patient remains on mechanical ventilation with a resp acidosis.OC 17 bpm a present time.Passively resting more awake now BS diminished clear on MDI with check will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-01 00:00:00.000", "description": "Report", "row_id": 1416406, "text": "Resp Care Note:\n\nPt cont intub with OETT sedated and on mech as per Carevue. Lung sounds coarse suct mod th off white sput. MDI given as per order. ABGs stable; no changes necessary . Cont mech support.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-05 00:00:00.000", "description": "Report", "row_id": 1416421, "text": "Resp. care\nBS are equal and generaly clear. His PS was increased to 12 over night as per order. It as noted that at times he would have 5 to 10sec. pauses in his resp. rate on the PS of 12. His this AM was 90\n" }, { "category": "Nursing/other", "chartdate": "2173-03-05 00:00:00.000", "description": "Report", "row_id": 1416422, "text": "ASSESSMENT AS NOTED IN CAREVUE\n\nRES: ON 5X10, LS CLEAR, DIM BASES, -95, ABG WNL, NONPROD COUGH\n\nNEURO: DOES OT MOVE R.ARM, WEAKLY MOVES BOTH LEGS, FOLLOWS SIMPLE COMMANDS, +GAG,+COUGH\n\nCV: SBP UP TO 160S-GETTIN LOPRESSOR 50 AND PRN, IN NSR/S.TACH, GENERAL EDEMA, +PULSES\n\nGI: TOL TF AT 125, UNABLE TO PULL RESIDUALS, LIQUID STOOL 500CC,\nABD FIRM DISTENDED, +HYPO BS,\n\nID: REMAINS ON AMPICILLIN, FLUC, , T 100.6\n\nSKIN: PERFUSES, ABD WOUND OOZING MOD/LARGE AMNT SEROUS, DSG WAS CHANGED TWICE\n\nGU: ON LASIX GTT 200-250/H, K WAS REPLETED TWICE, NEG 1400CC SINCE MIDNIGHT\n\nHEME: HCT DOWN 25.9 12AM, WAS REDRAWN AT 6AM.\n\nPLAN: MONITOR VS, FULL SUPORT, TRY TO PS, LYTES REPLETION\n" }, { "category": "Nursing/other", "chartdate": "2173-03-05 00:00:00.000", "description": "Report", "row_id": 1416423, "text": "Resp Care\nPt remains intubated. Current settings: CPAP 10/5 50 %. Pt was placed on CPAP 5/5 for about 3 hrs and tolerated well. MDI's given, no other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2173-03-05 00:00:00.000", "description": "Report", "row_id": 1416424, "text": "T/SICU NSG NOTE\n0700>>1900\n\nEVENTS: Diuresis continues; aldactone and diamox added to better manage electrolytes and metabolic alkalosis;additional K+ repletion.\nLasix drip continues with effect.\n\n D5W 1 Liter infusing for elevated serum sodium\n\n RUE ultrasound done to assess flaccid, edematous right arm: peripheral clot in brachial vein noted: no change in therapy made.\n\n Discusssions ongoing with family, ICU attending, surgical resident and this RN for multiple questions and concerns regarding patient's condition, progress, and plan of care.\n\nNEURO: perrl, opens eyes to voice; will inconsistently follow some commnads to move LE's; independently moves LUE against gravity; NO spontaneous movement of RUE bur withdraws to nailbed pressure.\nPRN dosinfg with oxycodone and fentanyl for pain mngmnt; clonidine therapy po started for combined hemaodyanmic and anti anxietal benefits. NO ativan provided this shift. Pt is able to repsond to questions regarding pain and breathing condition; pt nods to indicate pain status or if breathing is uncomfortable: see careview for assessment and treatment.\nPt remains lethargic with minimal spontaneous activity.\nA RUE US was done and a peripheral brachial clot was observed which does not extend centrally.\n\nCVS: NST with rare pvc noted. Lopressor dosing increased; prn dose of 5mg ivp provided x1; HR now ranging in 70-80's. BP is adeqautely controlled with lopressor and clonidine dosing.. CVP 7-8.\nIVF: 1L d5w today.\n\nRESP- discussed weaning plan this am: pt to exercise on psv/ppep @ \nas tolerated (2-3 hours) then rest and repeat as tolerated over today and tomorrow. If pt continues to indicate that he tires on minimal psv(decrease in tidal volumes and increase in RR with observable distress) than a discussion regarding tracheostomy will follow with family and might occur as soon as suunday; Dr will be ICU attending on weekend.\nPt tolerated 3 hours of without significant change in RR,tidal volumes or vital signs. He denied resp distress. Pt was rested and is now returned to for exercising interval as tolerated.\n Sat remain 98-100% on 50% fio2 and 5 peep. Breath sounds remain coarse and diminished; secretions are small amounts of thicj white sputum. Cough and gag intact and strong.\n\nRENAL- lasix at 2mg/hr continues with goal ~ 2L negative: pt on track for this. Potassium orders adjusted to repleted K+ more efectively following urine K assessment.\n\nGI- tube feeds continue at goal rate; stooling continues intermittently via mushroom catheter in mod volume: see careview I&O.\nG tube remains clamped with Q 4/hour residual checks; no residual >135cc. Prevacid continues. Abd is soft/distended with bowel sounds.\n\nENDO- NPH 12 units continues with q 6/hour ss coverage with regualr insulin; blood glucose in control.\n\nID- temp max 101.1>>100.4 without intervention. Antibiotics continue unchanged. WBC steady at 13.5 NO cultures done per ICU & surgical team assessment at this time. Abd wound cont\n" }, { "category": "Nursing/other", "chartdate": "2173-02-27 00:00:00.000", "description": "Report", "row_id": 1416401, "text": "T/SICU Shift Report 0700-\n66 Year Old Male NKA FULL CODE Universal Precautions\n\nAdmission - - Acute Pancreatitis\nReadmission - - Line Sepsis\nReadmission - - Vomiting/?Aspiration\n\nPMH - Hypertension\n ARF\n Hypercholesterolemia\n Prostate Ca (S/P RRP)\n Sleep Apnea\n\nOR - Pancreatic resection\n\nShift Events - Restarted norepinephrine\n 1 amp sodium bicarbonate\n\nReview of Systems:\n\nResp - CMV 20x550 PEEP 10 FiO2 50%/ SpO2 >95%. ABG pH 7.34, PaCO2 42, PaO2 109, BE -2. 1 amp sodium bicarb. Breath sounds clear to upper lobes, diminished at the bases. Small-moderate white/clear secretion on ETT suction Q2. Moderate oral secretions.\n\nCVS - Sinus rhythm, occasional PVCs. HR 80-90bpm, SBP 80-140, MAP 55-80, Tmax 99.2. Norepinephrine 0.05mcg/kg/min. Peripherally cool, +++ piting edema, palpable pedal pulses. Vancomycin held (level 15.7), meropenem dose decreased to . Continues on heparin/p-boots.\n\nRenal - UO >40ml/hr, currently in negative balance for 24hours. KVO fluids. Lytes stable.\n\nNeuro - Sedated w/ 40mcg/kg/min propofol, 50mcg/hr fentanyl. GCS (e3-4v1m6), pupils 3mm/3mm brisk reactive, denies pain. MAE. Answering questions when lightened from sedation. Team would like to maintain heavy sedation for ventilation.\n\nGI - TF advanced 10ml Q6, currently 30ml/hr 1/2 strength impact (goal rate 140ml). remains firm distended, bladder pressures discontinued. No BM today. Blood glucose stable, no coverage necessary.\n\nSkin - Pressure areas intact.\n\nAccess - Aline/cline patent, dressing intact, lines changed.\n\nSocial - Wife/daughters into visit, all updated with status, POC.\n\nPLAN - Maintain sedation overnight\n ?Further bicarb if acidosis returns\n ?Diuresis tomorrow\n Advance TF Q6 by 10ml\n" }, { "category": "Nursing/other", "chartdate": "2173-02-28 00:00:00.000", "description": "Report", "row_id": 1416402, "text": "Resp Care Note:\n\nPt cont intub with OETT sedated and on mech as per Carevue. Lung sounds sl coarse suct sm th off white sput. MDI given as per order. ABGs cont acidotic with good oxygenation; no changes required at this point. Cont mech support.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-28 00:00:00.000", "description": "Report", "row_id": 1416403, "text": "nursing progress note\n\nneuro: pt remains more heavily sedated w/ propofol and fentanyl. opens eyes occas to sounds in room, stimulus. following commands when lightened, mae weakly. fent. boluses given w/ turns/repositioning.\n\nresp: no changes overnight, remains on ac mode support, 50%, 600x17, 10 peep. abg's acceptable, mild metabolic acidosis persists. pco2 wnl. occas overbreathing w/ stimulus. sx sm amts thick white/clear sputum prn. cough, gag intact.\n\ncv: levophed weaned off at present, map remains >60. nsr, rare pvc's noted. extrem warm, pulses intact, anasarca persists since recent fluid resuscitation. cvp down to 9 w/ levophed off, will follow. hct stable this am. wbc remain wnl.\n\ngi: belly firm, distended, bs hypoactive. tol slow titration of tube feeds via j tube. g tube w/ sm amts bilious output, t tube w/ large amt much more concentrated bilious fluid. jps to RLQ w/ large amt serous drainage to sites, #3 w/ murky light brown output, mod amts. #2 w/ minimal serous output. no flatus, no bm.\n\ngu: foley patent yellow sedimented urine, volume qs. bun/cre very slowly improving, cre 2.4 this am. all lytes slowly improving as well.\n\nendo: bg's stable.\n\nid: tmax 100 last eve, improved w/ environmental cooling. wbc as above wnl, continues w/ meropenum, vanco, diflucan dosing.\n\nskin: belly w/ large pink surface, angry appearance in some areas near drains, incision. very warm to touch. staples intact to midline, top of incision w/ old bloody drainage, dsd changed x1. copious amts serous drainage from jp sites, dsgs changed freq. scrotal edema improved, remains reddened.\n\nsocial: wife called last evening for update, all ques answered. support provided ongoing.\n\nplan: cont to keep pt well sedated, no aggressive changes at this time, maintain as compensated an acidosis as possible. cont to support bp as needed w/ increased sedation. follow bun/cre trend, ? bicarb drip to buffer kidneys until full function returns. cont to slowly titrate tube feeds to goal rate. full icu monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-09 00:00:00.000", "description": "Report", "row_id": 1416349, "text": "resp care note\n\nPt is aware and respords appropriately to many questions.Pt was changed AC ventilation because he was often poorly synchronized with ventilator in that mode. He has been on MMV (650x12) with PSV 15/5. His ABG on this mode is normal. Pt was given combivent ~ Q 4-6 hrs. RSBI was not done this morning because pt is agitated and is having up to 15 PVC per minute.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-09 00:00:00.000", "description": "Report", "row_id": 1416350, "text": "TSICU-NPN/0700-1900\nNeuro: Pt alert and making appropriate facial expressions in regards to to questions asked and also nodding head to answer. MAE's, follows commands appropriately, PERRLA 2-3mm, brisk reaction. Pt receiving Fentanyl PRN with good pain control (per VS and grimace) and Ativan now ordered ATC and PRN for agitation. Ativan apperaing to be semi-effective for restlessness/agitation.\n\nCV: NIBP 150's sys. and HR 80's with frequent ectopy-pt continues to receive IV Lopressor Q4hrs. CVP 12. SQ Heparin/P-boots for prophlaxis. +pp, +csm.\n\nresp: Pt remains orally intubated and on MMV (PS 15, 5 PEEP) and will be possibly extubated tomorrrow pending the results of the RSBI. Pt making more attempts to independantly clear secretions, however still needed frequent oral sxn, and occasional ETT sxn (secretions still thick and whitish colored). Mouth care done per VAP protocol.\n\nGI: Abd softly distendeed, BS+, mushroom cath remains in place and continues to drain sm amts of brown liquid stool. Post Pyloric tube in place with TF running-now changed to 3/4 st and is to be incresed 10cc Q8h, to a goal of 100cc/hr,(Pt to be increased at tonight). OGT draining mod amts of green bilious fluid. Protonix ordered for prophlaxis.\n\nRenal: Diuresis continues-20mg Lasix given this am and Diomox D/C-goal is for pt's fluid status to be in the neg. Foley draining sufficient amts of clear yellow/amber colored urine.\n\nEndo: Insulin gtt continues to be titrated, pt has been at 6-7 units/hr for most of the day, BS appear to be stabilizing.\n\nSkin: Pt turned and repositioned frequently throughout day- Fungal rash still presen throughout torso and RUE, Miconozole cream applied and fan on for pt comfort. Slight breakdown (? from rash) present on R upper buttock-OTA.\n\nID: pt afeb, WBC 22, and continues on Fluconazole and Meropenem.\n\nSocial: Pt's family in for most of the day, and have all spoken with TSICU team and Dr. team regarding POC. One of pt's daughters overstepping at times regarding pt care, however was receptive to set by nurse after being spoken to (i.e visiting hrs, etc).\n\nPOC: to extubate tomorrow am\n continue to increase TF Q8 to goal of 100cc/hr-monitor abd for further distension.\n Monitor skin rash/integrity-continue miconazole cream\n update family on POC\n replete lytes PRN\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-09 00:00:00.000", "description": "Report", "row_id": 1416351, "text": "resp care - Pt remains intubated on MMV. PS was weaned from 15 to 12 with Vts from 450 to 600. Pt has periods of anxiety that increase RR and MV. Secretions are diminishing in amount and frequency of suctioning. BS are mostly clear. Some rhonchi in upper lobes clear on suctioning. Continued weaning planned.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-11 00:00:00.000", "description": "Report", "row_id": 1416357, "text": "NURSING PROGRESS NOTE:\n\nSEE CAREVUE FOR EXACT DATA\n\nNEURO-Pt. more alert throughout shift. Speech somewhat garbled, however able to state name and year. Unsure of place and month. Pleasantly confused (singing/talking to self). Continues to have difficulty tracking. Pupils 4 and briskly reactive, MAE's. Follows commands at times.\n\nCV-SR 80-90's with frequent PVC's/APC's. SBP 110-130/50-60's MAP 70's. Lopressor 10mgIV q4hours. Left SC TLC with CVP ranging . Compression boots and heparin. HCT stable at 29.1\n\nRESP-Extubated at about 1200. Humidified face tent on 50%FIO2, tolerating brief periods off O2. Deep suctioned for thick white secretions. Pt with strong productive cough. Lung sounds clear to coarse at times.\n\nGI-Post pyloric feeding tube with tube feeds at goal (100cc) Impact 3/4strength. NGT to LCWS with green bilious drainage. Abdomen soft, present bowel sounds. Muchroom cath with golden liquid stool. Protonix.\n\nGU-20mg lasix given at beginning of shift. Goal 3L negative daily, yesterday negative 2L, presently negative 600cc. Indwelling foley catheter with clear yellow urine output. AM lytes WNL. BUN rising.\n\nENDO-Continues on ISS. Insulin at 2-6units throughout shift.\n\nID-Tmax 99.6. Meropenum and Fluconazole as ordered.\n\nSKIN-Fungal rash to groin, bilateral UE's and truck clearing. Miconazole cream to rash.\n\nPLAN-Continue with pulmonary toileting, O2 as tolerated.\n -Monitor UOP, fluid status.\n -Titrate insulin gtt sliding scale.\n -Antibiotics as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-11 00:00:00.000", "description": "Report", "row_id": 1416358, "text": "nursing progress note\n\nneuro: pt oriented x2 at best, usually to person only. recognizes family members intermittently. mae well, good strength. speech slowly improving. follows commands intermittently. cough strong.\n\nresp: clearing secretions on own, cough strong. ls clear to coarse, dimin to bases. rr teens to 20s, regular. o2 sats stable on 40% humid o2.\n\ncv: bp stable w/ lopressor dosing q4h. nsr, occas. pvc's noted. extrem warm, pulses intact. lytes stable from this am.\n\ngi: belly soft/distended, minimal tenderness. loose golden stools persist, small volume. ng w/ large output, golden in color as well. appeared like tf this am, KUB verified that dobhoff remains post pyloric. bs present. reglan dosing started d/t large ng output.\n\ngu: foley patent amber occas cloudy urine, qs.\n\nendo: bg's managed w/ insulin drip ongoing, team in today. plan to start lantus dosing at night w/ sliding scale coverage for day.\n\nid: yeast rash improving to torso and groin, miconazole cream, diflucan iv continued. wbc 17 this am.\n\nsocial: daughters and wife in for visits today, updates provided.\n\na/p: slow to clear neurologically, little improvements noted throughout day. insulin drip to stop tonight, lantus dosing to start.\nfollow belly, neuro exams ongoing, possible transfer to stepdown vs floor tomorrow if continuing to improve.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-17 00:00:00.000", "description": "Report", "row_id": 1416374, "text": "NPN 0700-1900\n Neuro- was much more awake today. Orientated, weak voice, asking for family members, laughs at jokes and communicates needs. OOB to chair in am and stayed up for 4 hrs, hoyered as he has very little stregnth in legs. Physical Therapy aware of pt's improved MS and will see him in the am.\n\n Resp- On 5lnc with good sats. Lungs clear throughout. Strong productive cough. Given lasix in am with good response. However sats drifting down to low 90s in afternoon, lungs now with crackles throughout. Md made aware and another 10 mg lasix given with good response. Lung sounds clear with few crackles in RLL remaining. Sats improved and able to O2 down.\n\n CV- NSR with PVCs and PACs, less ectopy as day progressed. HTN and lopressor changed to po and lisinopril added. Aline d/c'd. TLC wnl, heplocked. KCL given with lasix dose. BG 140-150s. Afebrile. Large amt peripheral edema persists. Good CSM. Skin rashes healing well. No breakdown noted.\n\n GI/GU- Abd softly distended. Passing flatus. +BS. Denies N/V. NGT clamped at 8 am and at 1200 50cc out. Dr aware and NGT d/c'd. Pt able to swallow without difficulty and started on clears. Tolerating well. Foley patent with good UO, clear yellow, occ sediment.\n\n Wife and 2 daughters visited today. Dr spoke with . updated at bedside of pt improving condition.\n\n Plan- Cont to mobilize pt as tolerating. Insure PT visits in am.\nCont to diuresis as tolerated. Encourage C&DB, pt is very cooperative with care. Transfer to floor tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-18 00:00:00.000", "description": "Report", "row_id": 1416375, "text": "NPN, 1900-0700\nneuro: lethargic, arouses easily. Follows commands, moves all extremities weakly. No focal deficits denies pain.\n\nCV: SR, MFVEA, AEA. SBP better controlled w/ lisinopril, 120's-140's.\nPulses palpable throughout; moderate anasarca persists. Single self-limitting episode brady to 40's just before vomitting, ? vagal.\n\nPulm: BS course anteriorly, clears w/ strong cough productivve thick tan/white sputum.. Crackles bibasilar. Sats 98-100% on 4 L/NP\n\nGI: abd distended, active BS. Large softly formed stool x 2, heme neg. Vomitted large amount bile early eve, treated w/ anzimet, no further emesis during noc. TF were advanced per order to 90cc/hr. Pt vomitted again 0600, large volume, probably TF, by smell and visual. sump inserted w/ returns of TF and bile. TF held until KUB obtained to assess Dobhoff placement. BS active throughout.\n\nRenal: F/C urine clear yellow, adequate OP. Moderate response to lasix 10mg IV (~600cc). K+ repleted, other chems WNL. ~3L +/LOS\n\nSkin: no pressure areas. Minor abrasion coccyx healing w/ aloe cream. Overall torso rash healing w/ miconazole cream.\n\nID: WBC elevated to 15.2 from 10. Afebrile, no antibx.\n\nEndo: BG controlled fairly well w/ RISS, +glargine @ HS.\n\nHeme: Hct stable\n\nPsychosocial: no family contact .\n\nP: NPO until KUB obtained; sump stomach. Monitor BG carefully. Aggressive bronchial hygeine. Transfer to floor, start PT.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-20 00:00:00.000", "description": "Report", "row_id": 1416378, "text": "TSICU NPN:1900-0700\nEVENTS: Pt spiked temp of 102.3 (101,3 ax)at 0100, HO notified and urine and blood cxs were sent. Sputum cx waiting to be collected, pt had been coughing up sm amts of green tinged sputum, but was unable to expectorate into spec cup at the time.\n\nNEURO: Pt A/Ox2-3, appearing more somulant when temp spiked, but still answering questions appropriately, following commands, and MAEs. C/O pain once overnight and IV Dilaudid given with gooed effect per pt.\n\nCV: HR 80's-90's, NSR with frequent PVCs. NIBP 120's-150's sys. CVP 1-3. Venodyne boots and SQ Heparin as ordered for prophlaxis. +pp, +csm.\n\nRESP: Pt expectorating thick green colored secretions into yankeur sxn with assistance from RN. Lung sounds clear/coarse and equal with occasional insp. wheezes noted in RUL. O2 sats 95% on 5L NC.\n\nGI: Dobhoff in place with 3/4 st. Replete with fiber running at goal of 100cc/hr as of 0600. Abd softly distended,non-tender, BS+. Pt reporting mild nausea and IV Reglan given with good effect.\n\nRENAL: Foley draining adequate amts of clear yellow urine. BUN 30, Creat 0.8. At 2300 K+ was 3.5 and was repleted. Lasix continues with fair response to.\n\nID: See above event note. No ABX at this time. WBC 13.1\n\nEndo: Blood glucose controlled per RISS. Pt also receives bedtime Lantus dose.\n\nSkin: Skin intact, rash to back improving-Miconazole powder applied. Multipodus boots in place. CVL site slightly reddened and dsg intact.\n\nSocial: No calls/visits from family overnight.\n\nPt originally admitted to ICU with necrotizing pancreatitis and then sent to floor.Re-admitted to ICU with \"resp. distress\" O2 sats 94% on bipap, Pt has since recovered and now on 5LNC.\n\nPOC: F/U with cxs\n Monitor temps/labs\n replete lytes PRN\n Monitor resp status, from O2 as tolerated.\n Update family on POC\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-20 00:00:00.000", "description": "Report", "row_id": 1416379, "text": "REspiratory Care\nPT observed over night for need of BIPAP for OSA. Pt experienced and episode of tachypnea with rr increased to 36-40 At which time pt was febrile to 102.3 orally, but pt did not demonstrate increase WOB,rr remained in a regular rate and depth with no obvious apnea and oxygenation remained good. BIPAP not introduced at this time. PT RR gradually returned to with in normal range. PT has some congestion and spontaneously coughs and raises secretions but is unable to expectorate, requiring yankauer suction for assistance with clearing secretions. PT does not cough and DB on command only spontaneously.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-21 00:00:00.000", "description": "Report", "row_id": 1416382, "text": "NURSING PROGRESS NOTE 7A-7P\n\nPLEASE SEE CAREVIEW FOR EXACT DATA\n\nEVENTS: -TLC D/C'D DUE TO GRAM POSITIVE COCCI IN BLOOD, PIV X2 PLACED\n -CT SCAN FOR ABDOMEN (FEEDING TUBE COILED IN ABDOMEN, PSEUDOCYST DEVELOPING, PRESUMED PNEUMONIA ON CT SCAN)\n -LEVOQUIN STARTED FOR ?PNEUMONIA PER SURGICAL TEAM\n - ATTENDING AT BEDSIDE, LANTUS STARTED FOR TONIGHT 10U\n\nREVIEW OF SYSTEMS:\n\nNEURO-Pt awake and alert. Oriented to self, occasionally to place (knows he is in hospital, not always correct on which one) and year (confused on month). Pupils and briskly reactive, no motor deficits. Denies any pain. OOB to chair x4hours. Transfered OOB with then able to stand and pivot back to bed. PT/OT consults ordered. Mental status much improved per family.\n\nCV-NSR rate varies 70-90's, occ. PVC's noted towards end of shift. SBP 110-150/50-60 MAP's 60-80. Continues on Lopressor 10mg IV q6hours. Right SC TLC d/c'd. Cath tip sent for culture. PIVx2 #18G placed in bilateral AC's, both with blood return/patent. Compression boots and Heparin SC prophylaxis.\n\nRESP-Lung sounds clear, slightly diminished at right base. Continues on 5LNC sats 94-97%, non-productive cough. Presumed pneumonia by CT scan per surgical team. Inhalers at bedside.\n\nGI-NPO. Abdomen softly distended, no tenderness to palpation. Denies N/V. Positive bowel sounds. Feeding tube remains clamped (coiled in abdomen), NGT to LCWS with 500cc of green bilious output. TPN d/c'd continuing on IVF's until Dobhoff repositioned in IR tomorrow. Protonix q24hours.\n\nGU-Indwelling foley catheter with clear yellow urine, voiding adequate amounts throughout day, however drifting towards end of shift. Foley flushed with sterile H2O, patient re-positioned and UOP gradually increased, reported to surgical team. Per surgical resident pt has had same issue in past, multiple foley changes and UOP gradually picks up with repostioning. Continuing to monitor. Positive 1 liter since midnight, Lasix held today per ICU team (?2000dose).\n\nINTEG-Coccyx slightly errythemic, pt c/o soreness, frequently repositioned. Per family pt had same complants prior to admission. Trunk/groin/back rash resolving.\n\nENDO-BG 165-176, coverage per ISS. attending at bedside today, Lantus to be started tonight at 10U, due to tube feeds holding, She was updated on POC and plan to start TF tomorrow pending IR.\n\nID-Gram positive cocci in anaerobic bottle, ? contaminant. Vanco holding per ICU team and Levoquin started for presumed pneumonia. Pt afebrile, WBC's 8.4 this am. Other cultures pending.\n\nSOCIAL-Pt's three daughters, wife and grandson in to visit this afternoon. They all reported this is the best they have seen him since admission. He was very verbal with them and \"back to his usual self\". Daughters reported they are very pleased with the care he has received. Spoke about PT/OT, consults placed.\n\nPLAN-IR tomorrow for Dobhoff placement\n -Continue Levoquin coverage. Follow pending cultures.\n -Monitor BG,\n" }, { "category": "Nursing/other", "chartdate": "2173-02-21 00:00:00.000", "description": "Report", "row_id": 1416383, "text": "(Continued)\ncoverage per ISS, Lantus recs.\n -Encourage activity.\n -Monitor UOP, flush/reposition as needed.\n - O2 as tolerated.\n -Continue to provide pt/family with updates and POC.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-22 00:00:00.000", "description": "Report", "row_id": 1416384, "text": "NPN, 1900-0700\nneuro: AAO x 3, calm and cooperative. No focal deficits; moves all extremities weakly. Denies specific pain. Slept poorly, in short naps, despite ambien at HS.\n\nCV: NSR, ST,80's-100's at rest despite lopressor 10 mg IV q 6 hours.\nSBP 100'd-140'd. Min peripheral edema. Pboots, sq heparine prophy.\nK+ repletd.\n\nPulm: BS CTAb, diminished right base. NP 5L sats >95%. Strong cough, productive thick white sputum.\n\nGI: abd softly distended; tender to palpation over LUQ. BS active throughout; + flatus, no stool. NPO. sump draining dark green bile, ~ 800cc/12 hours. Existing Donhoff FT intact, clamped; coiled in stomach per CT.\n\nRenal: F/C urine clear amber, OP adequate. D5 1-2 NS/20mEq KCl @70cc/hr. Chem labs WNL.\n\nSkin: grossly intact; coccyx red, intact. Diffuse macular rash has mostly healed. miconazole .\n\nPsychosocial: no family contact .\n\nID: Tmax 99.6po; WBC 8. Cont on levaquin. Pending blood cxs.\n\nEndo: RISS + glargine 10 units @ HS, good BG control.\n\nP: to IR today to replace Dobhoff, post pyloric. OOB, aggressive PT, OT. Start TF after Ft placement, adjust insulin accordingly. ? increase b-blocker.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-22 00:00:00.000", "description": "Report", "row_id": 1416385, "text": "T-SICU Nsg note\n TO IR this am for feeding tube re-positioning. SUccessfully used existing tube to place post-pyloric.\n Pt slept this am, then alert for awhile this afternoon. COnversant, bright, good short term memory. Pt also sleepy and when left alone falls easily to sleep. Good strength, helping to turn himself in bed.\n NSR to Sinus tach. No enteral beta blocker ordered yet. BP by NBP 90-120 sys on either arm.\n Strong cough, prod of thick tan sputum, but pt needs help getting sputum out of back of mouth, occ pt can bring it forward to be suctioned out, but sometimes needs oral suctioning to clear. Lung sounds clear, except diminishe R lower. O2 sats 96-99% on 4 l per NC. O2 off briefly with sats in high 90's, but when asleep and flat in bed, O2 sats < 90%, so NC re-applied.\n Adequate u/o. IV remain at 70cc/hr of D5 and .45NS\n TF started this afternoon per feeding tube. Abd softly distended, pt denies pain. Had two small liquid stools today. sump to low constant suction draining bilious fluid from stomach.\n Pt now on levofloxacin and Vanco. Temp up to 101 this am, then 97.8 PO.\n SKin much improved from last week. Only slightly red around coccyx.\n wife and daughter in to visit today.\nA; mentally alert at times. TF started.\nP follow glucose levels, increase TF rate as ordered. Cough and deep breathe, reposition. Have pt participate in ADL. Informational support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-12 00:00:00.000", "description": "Report", "row_id": 1416359, "text": "NPN, 1900-0700\nneuro: awake most of the noc w/ short naps. Oriented to person only; confused garbled speach at times. Calm and cooperative, follows commands. No focal deficits.\n\nCV: NSR, variable MFVEA; rate controlled w/ continued q 4 hr metoprolol. Pulses palpable throughout; remains anasarcic, wt unchanged past 24 hours (up 5 kg from adm dry wt). CVP 1-4\n\nPulm: BS course anteriorly, clear w/ strong cough, productive creamy yellow secretions. Bases diinished w/ scattered I/E wheezes. Sats> 95% on 40% humidified face tent.\n\nGI: abd softly distended, non-tender. BS hypoactive. Liquid brown stool via mushroom cath. NGT to LCS draining ~1000c/12 hrs dark bile. TF via post pyloric Dobhoff w/ Impact 3/4 strength @ goal, 100cc/hr.\n\nRenal: F/C urine clear amber, OP>40cc/hr.\n\nSkin: diffuse macular rash over back, upper extremities, axillae beginning to fade. Perianal area excoriated, miconazole cream applied. LSC TL site pink, no drainiage.\n\nID: Tmax 100.2po; Cont on flagy.\n\nEndo: team, insulin gtt d/c'd 2100 last eve, (BG 99--no regular given), glargine 20 units given. At 0300, BG 201, so scale changed to q4 hr insulin coverage.\n\nPsychosocial: no family contact .\n\nP: monitor neuro status for cont clearing. Aggressive bronchial hygeine, humidified O2. OOB, encourage ROM, CDB. Follow BG closely, following.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-13 00:00:00.000", "description": "Report", "row_id": 1416360, "text": "RESPIRATORY CARE: PT INTUBATED FOR ACUTE RESPIRATORY\nFAILURE.VENTILATOR SETTINGS AC MODE AS PER CV. CT SCAN\nTODAY WITHOUT INCIDENT. SX FOR COPIOUS AMTS OF THICK\nYELLOW SPUTUM. FIO2 WEANED TO .50 AND VT DECREASED\nTO 600 DUE TO ABG C/W A RESPIRATORY ALKALOSIS. WILL\nC/W AC MODE AS TOLERATED.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-13 00:00:00.000", "description": "Report", "row_id": 1416361, "text": "T-SICU Nsg Admit NOte\n Pt in resp distress on 9, intubated there. New R fem introducer placed during intubation. Neo running for low BP. Pt transferred to T-SICU. Pt hypotensive during change from transport neo to T-SICU neo drip on pump. Levo drip started and quickly neo weaned off. IV fluids given rapidly with hypotension. Art line very difficult to place, multiple attempts R and L radial and L femoral. Finally art line placed in R radial artery. Propofol drip started as pt bucking , eyes bulging, propofol with good effect. Levo weaned to .35 mcg/kg/min. U/O low initially, tons of thick tan sputum and copious thick gellatinous oral secretions.\n Off propofol for about an hour, pt opened eyes a bit to family's voice. WIggled toes to command, but did not squeeze hand to command. Occ mouthed words. PERRL. Propofol drip to allow pt to tolerate ET tube.\n NSR, no ectopy. EKG done x 2. Cardiac enzymes being cyled. Levophed drip to maintain MAP > 60.\n Pt over ventilate this eveing. Vt decreased. Continues with thick tan sputum. Lung sounds coarse. Chest CT done about 1800.\nCXR confirms ET tube placement.\n U/O up now. LR at 100cc/hr. BUN & Cr bumped up today, but this afternoon values a bit better than this am.\n sump to continuous drainage, bilious output. Feeding tube clamped. Abd very distended, but soft. Mushroom cath in place, but no output.\n Hct 29 on repeat labs. Clot in BB.\n Vanco, piperacillin started. Temp up to 102 PO. BLood culture sent. L triple lumen subclavian removed and tip sent for culture.\n Insulin sliding scale written, no exogenous insulin given today.\n Rash on chest and arms brighter red this eve - possibly due to better perfusion with levo drip decresaed. Back and buttocks intact.\n Social - Family was not called by surgical team to tell them pt had been intubatd and transferred to T-SICU. Family understandably upset when they came to visit and pt had been intubated and transferred.\n\nA: Intubated, on Levo, lots of sputum. CT of head, chest, abd done this evening, results pending.\nP: Cycle cardiac enzymes/ Monitor and treat glucose levels. Levo as able. Pulmonary toilet. Culture results pending. Informational support to family.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-14 00:00:00.000", "description": "Report", "row_id": 1416362, "text": "Respiratory Care: Pt remains on current settings, rate was decreased according to abg. Still with persistant fever. done this am = 134.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-14 00:00:00.000", "description": "Report", "row_id": 1416363, "text": "T/SICU Shift Report 1900-0730\n66 Year Old Male NKA Full Code Universal Precautions\n\nAdmission - Acute Pancreatitis/sepsis\n\nReadmission - Sepsis\n\nPMH - Hypertension/Hypercholesterolemia\n ARF\n Prostate CA (S/P RRP)\n Sleep Apnea\n\nShift Events - Fluid Bolus - Anuria\n Started on Insulin Infusion\n Failed Cortisol Stim Test - Started on Hydrocortisone\n Pan Cultured\n Troponin >0.1\n\nReview of Systems:\n\nResp - AC 16x600 PEEP 5 FiO2 50%. SpO2 >98%, RR 20-25bpm. ABG pH 7.45, PaCO2 31, PaO2 136, BE 0. Breath sounds coarse to RUL/LUL/LLL, diminished to RLL. > 100. Trialed on CPAP with immediate failure (RR >40). Given increased sedation to suppress respiration and increase CO2.\n\nCVS - Sinus rhythm no ectopy. HR 75-105bpm, SBP 100-145, MAP 75-90, Tmax 102.0. HCT 30.2%, Hb 10.1, WC down to 22.8, COAGs normalising, Lactate down to 1.4, Troponin 0.14 ( pending). Norepinephrine 0.35mcg/kg/min (Aim MAP >80). Started on Hydrocortisone. Continues on pipercillin/vancomycin/fluconazole. Pancultured 0400. Prophylaxsis Heparin/P boots.\n\nRenal - UO 0-200ml/hr, positive 7500ml for previous 24hours. BUN/Creatinine decreasing, K 4.0, Mg 2.0, Ionised Ca 1.16, Phos 4.8. Maintenance fluids 100ml/hr LR.\n\nNeuro - Sedated with 60mcg/kg/min Propofol. Unable to assess orientation. GCS (e3v1m5-6). MAE. Obeying commands intermittently with BLE. Localising to noxious stimuli. Given 2mg morphine with little effect on HR/RR, therefore it can be assumed that the patient is comfortable.\n\nGI - NPO. Post-pyloric tube Clamped, used for meds. NGT to LCS with total output in 24 hours 650ml bilious output. soft distended, hypoactive bowel sounds. Mushroom catheter removed, no BM overnight. Blood glucose >200, started on insulin infusion using the Scale currently 4units/hr.\n\nSkin - Given full bed bath/hair wash/shave overnight. Red rash to trunk/BUE/groins, cleansed with soap and water, covered with miconazole cream. Pressure areas intact. Tolerating side lying/mouth care.\n\nAccess - Aline dampened, improved with back-board. Correlating with NIBP. Femoral line dressing intact, line patent. PIVs removed due to infiltration.\n\nSocial - Wife/daughters expressed concerns about not being contact with patients sudden decline in condition, ensured by this RN that they would be contact in the presence of an acute event.\n\nPLAN - Titrate Norepinephrine (MAP >80)\n Titrate Insulin (BG 80-120)\n Maintain sedation to maintain ventilation\n Awaiting Cultures\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-14 00:00:00.000", "description": "Report", "row_id": 1416364, "text": "RESPIRATORY CARE: PT W/ 7.5 ORAL ETT IN PLACE.\nREMAINS ON AC MODE AS PER CV. CHECK \nAND DO A TRIAL OF PRESSURE SUPPORT TODAY.SX\nFOR WHITE BUT LESS SPUTUM TODAY AND MORE AWAKE.\nWILL C/W VENTILATORY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-14 00:00:00.000", "description": "Report", "row_id": 1416365, "text": "T-SICU Nsg note\n With propofol off for about 1/2 hr, pt opens eyes spont, nods to questions, looks at speaker, wiggles toes to command - does not move arms to command. Does blink to command. Facial expressions changing with conversation topics, seems appropriate. Propofol weaned to 25mcg/kg/min with pt on PSV and pt seems comfortable. Hydromorphone given x 2 today, but pt nods no to pain when asked. Hydromorphone given prior to line placement and prior to foley change. Lorazepam given x 1 this eve as pt restless and nodded yes to feeling uncomfortable.\n NSR, no ectopy. Levo weaned to maintain MAP > 75. No metoprolol given as pt still on Levo drip. NBP on L arm agress well with R radial art line. Art line still dampened waveform at times, waveform becomes sharp with wrist &/or catheter reposition.\n PSV of 8cm above 5cm PEEP with good ABG. Changed to PSV this afternoon. Vt consistently 600-800cc on PSV 8cm. Much less sputum today. LUng sounds coarse throughout.\n Foley cath changed this afternoon as after irrigation no return of irrigation fluid nor urine. NEw 20 Fr Toley cath inserted, 10cc NS in balloon. No difficulty inserting new catheter. Old catheter examined after removal, no clot or obstruction at tip. New cath not draining next hr, so balloon down, catheter pulled out a bit, then small amt blood in urine and blood from meatus, then foley drained easily, balloon re-inflated with 10cc NS. U/o has been good. LR continues at 100cc/hr. Lytes good, not repleted during day shift.\n Abd softly distended. Bowel sounds present. No stool today. NG draining lots of bilious fluid, about 500cc during day. No tube feedings today.\n Temp down to 98.7 this afternoon, no acetaminophen given. Continues on vanco, Zosyn, fluconazole. CUlture results still pending.\n COntinues on insulin drip, rate down to 1unit/hr for this afternoon. Hydrocortisone given q 6 hrs as ordered.\n Perineal rash much improved. Miconazole cream applied liberally to back, chest, abd, thighs, peri-rectal, perineal area. R fem line site clean and dry, no hematoma.\n wife in to visit for several hours this am into afternoon. PT's daughters and in to visit this afternoon. nephew and wife in to visit this evening. Family's questions about care answered. T-SICU phone number given to wife, and . I encouraged family to call with any questions or to get an update.\nA: Afebrile. U/O improved. Levo weaned down. Glucose control improved with insulin drip. ON PSV. Able to propofol down. MOre appropriately interactive with family and staff today.\nP: Vanco level in am. Continue to monitor glucose levels and titrate insulin drip. Informational support to family. Help pt feel safe, lorazepam prn. Consider starting TF tomorrow.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-15 00:00:00.000", "description": "Report", "row_id": 1416366, "text": "T/SICU Shift Report 1900-0730\n66 Year Old Male NKA FULL CODE Universal Precautions\n\nAdmission - Acute Pancreatitis\nReadmission - Sepsis\n\nPMH - Hypertension/Hypercholesterolemia\n ARF\n Sleep Apnea\n Prostate Adenocarcinoma (S/P RRP)\n\nShift Events - Norepinephrine weaned to 0.025mcg/kg/min\n Insulin Infusion weaned to 1unit/hr\n 1000ml Fluid bolus for poor urine output/low CVP\n\nReview of Systems:\n\nResp - PS/CPAP PS 8 PEEP 5 FiO2 40%. SpO2 >96%, RR 10-25bpm, TV 600-800ml. ABG pH 7.39, PaCO2 43, PaO2 91, BE 0. Breath sounds clear to RUL/LUL, diminished to RLL/LLL. Minimal secretions on ETT suction.\n\nCVS - Sinus rhythm with frequent PVCs. HR 70-95bpm, MAP 65-95, Tmax 98.7. HCT down to 24.3%, Hb 8.4, WCC down to 14.7, Lactate down to 0.9. Norepinephrine 0.025mcg/kg/min (Aim MAP >60). Peripherally warm/well perfused/palpable pedal pulses. Heparin and P-boots.\n\nRenal - UO 10-140ml, positive 1500ml for previous 24hours, positive 5000ml for LOS. BUN trending downward, Creatinine now WNL, K 3.9 (repleted with 20mEq KCl), Mg 2.2, Ca 1.19, Phos 4.5. Maintenance fluid 100ml/hr LR. Given 500ml LR for poor UO, and further 500ml LR for reduced CVP. Continues to drain fresh blood from Meatus, urine clear, foley flushes easily.\n\nNeuro - Sedated with 40mcg/kg/min propofol. GCS 11 (e4v1m6). Pupils 3mm/3mm brisk reactive. MAE. Obeying commands consistently with both upper and lower extremities. Given 2mg hydromorphone with little effect prior to turning, patient denies pain.\n\nGI - Post-pyloric tube clamped. NGT to LCS (500ml bilious output overnight). soft/distended/hypoactive bowel sounds, no BM since readmission. Blood glucose 130-180 on insulin infusion, currently at 1unit/hr.\n\nSkin - Given full bed bath/hair wash/shaved overnight. miconazole cream applied to rash over trunk/arms/groins. Tolerating mouthcare.\n\nAccess - aline dampened, drawing well. CVL site bleeding, dressing intact, CVP trace sharp.\n\nSocial - Daughter updated with improvements overnight.\n\nPLAN - ?Start tube feeding\n ?Further fluid bolus/Stop norepinephrine\n - Consider SBT/extubation\n" }, { "category": "Nursing/other", "chartdate": "2173-02-15 00:00:00.000", "description": "Report", "row_id": 1416367, "text": "Respiratory Care: Pt remained on PSV of 8 P 5, all night and tolerated well. Morning abg with PO2 of 91, FiO2 decreased to 40%. Suctioned mod amt secretions. = 19.5\n" }, { "category": "Nursing/other", "chartdate": "2173-02-15 00:00:00.000", "description": "Report", "row_id": 1416368, "text": "Addendum to Shift Note\nPatient given 500ml LR fluid bolus, norepinephrine stopped 0630.\n\nPatient placed on SBT, tolerated well for 20mins, with slight increase in RR, stable O2 >99%, TV 600-700ml. Suddenly became slightly tachycardic to 100s with marked ST depression. Patient return to PS/CPAP PS 8 PEEP 5. EKG confirmed ST depression, troponin/CKs sent.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-15 00:00:00.000", "description": "Report", "row_id": 1416369, "text": "Respiratory Care: Pt to PS5, PEEP 5, Vt 500-550, RR 15-20, spO2 >93%. Pt was extubated, good cuff leak heard prior to extubation. Placed on 50% cool aerosol.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-15 00:00:00.000", "description": "Report", "row_id": 1416370, "text": "nursing progress note\n\nevents: pt extubated at 1200 w/out incident. o2 sats stable w/ humid o2 70%, managing secretions well on own.\n\nneuro: alert, oriented x3 to questions. note occas. confused conversation, easily reoriented to situation. mae, cough, gag strong.\n\nresp: as above, pt extubated at noon. ls clear to coarse to upper fields, remains dimin. to bases bilaterally. rr teens to 20s. o2 sats 97-100% 70% humid o2. clearing mod amts thick white/clear sputum.\n\ncv: levophed remains off, given fluid bolus this am d/t poor u/o. good response noted after bolus, bp stable, tolerating lopressor atc. continues w/ freq pvc's, somewhat improved w/ lopressor. rate remains 80s-90s, nsr. cardiac enzymes cycled, next due 2200. first set negative, second set pending from this aft. extrem warm, pulses intact. hct 22.9 this pm, note fluid bolus in between prior hct.\n\ngi: belly soft/distended. bs present, sm loose bm x1. mild tenderness to abdomen, diffuse in location. ng w/ large bilious output, dobhoff patent for trophic tf, slowly titrating to goal at this time.\n\ngu: poor hourly u/o noted today, catheter balloon deflated several times, allowing large volumes of output at the time. urine remains sedimented, yellow. pt occas c/o \"needing to pee\". relief noted w/ deflation of balloon. icu team aware, plan for urology consult. scant bleeding at meatus.\n\nendo: solumedrol dosing continued, insulin drip ongoing, minimal requirement today, (note tf rate and lack of tpn).\n\nid: afebrile, wbc wnl. zosyn, vanco, diflucan continue.\n\nskin: rash improved to groin, torso, upper extrem. miconazole cream continued.\n\nsocial: pt's wife and daughter in for visit today. updates provided, very pleased to see pt extubated, doing well.\n\na/p: pressors remain off, vss. uneventful extubation, mental status clearing, cough very strong, effectively clearing secretions. ongoing issues w/ urinary retention, urology consult to be obtained. minimal insulin requirements at this time, await c peptide level. plan for aggressive pulm toilet, full icu monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-02 00:00:00.000", "description": "Report", "row_id": 1416322, "text": "Respiratory Care\nPt was received from OSH intubated and on vent support, intubated with a #8.0 ETT 23 @ lip. Vent changes after arrival was from A/C to PSV w/CPAP (18/5). Pt became tired and was placed back onto A/C. PEEP and FiO2 were increased to 8PEEP and 0.50FiO2 due to sats remaining 90-92% on 0.40 and 5. Lung sounds were clear in the apical regions and very diminished in the bases. Last ABG was WNL. Care plan is to continue to wean settings as tol. Continue daily PSV as tol. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-02 00:00:00.000", "description": "Report", "row_id": 1416323, "text": "nursing admit/progress note\n\npt is a 66 yo male admitted to OSH w/ c/o diffuse abd pain. upon CT pt found to have gall stones, admitted to floor. on pt w/ increasing resp difficulty, low bp, low u/o. repeat CT revealed evolving pancreatitis w/ necrosis to pancreas head. pt admitted to ICU and placed on bipap. abg's acceptable for next couple days, although pt's wob increasing, eventually leading to intubation . abg's stable since intubation. transferred to under Dr. service for further tx.\n\nsee admission h+p for full medical hx, meds.\n\nevents for shift: pt admitted at 1100 w/ obvious wob, fighting vent. sedation and pain meds adjusted, pt much more comfortable. became hypotensive w/ poor u/o, given total 3000cc ivf w/ some effect noted to bp and u/o. cvp w/ little improvement, remaining . sedation lightened for neuro exam at 1500, pt very hypertensive, tacnypneic to 30s, asynchronous w/ vent. resedated w/ little return to prev. comfort level. returned to ac mode, o2 sats down to 91%, ls more coarse after fluid. peep and fio2 adjusted w/ some improvement. sedation increased, breathing more comfortable at present, rate remains 28-30 w/ adeq abg.\n\nneuro: off sedation pt mae, opens eyes to voice. not following commands, perrla, 2mm. pain controlled w/ fentanyl. propofol titrated for comfort.\n\nresp: as above, pt w/ o2 sats currently 93-94% w/ peep 8, fio2 50%. ls coarse to uppers, very poor air exchange to bases, R worse than L. sx scant amts clear thin sputum. abg acceptable, pao2 down to 77.\n\ncv: htn, increased pac's and one episode of self limiting svt to rate 160s w/out sedation. hr 80s-90s and regular. extrem warm, pulses intact. lytes repleted per orders. as above requiring fluid boluses d/t initial hypotension and poor u/o.\n\ngi: belly soft, very distended. bs hypoactive, most to L abd. scant amt loose brown stool. og to lws w/ large amts bilious output. dobhoff placed, awaiting kub to verify placement. tpn d/c'd on admission.\n\ngu: poor u/o on admit, foley irrigated w/ diff., old cath clogged w/ sediment upon removal. cath replaced w/ 18F silicone catheter w/ no issue. flushes easily, draining well. urine darkening, becoming icteric in color.\n\nendo: bg's elevated, slowly improving w/ tpn off. sliding scale prn.\n\nid: tmax 100 since arrival, wbc rising, now 23. meropenum dosing cont. blood, urine cx obtained.\n\nskin: rash to back, area dry, no open skin noted.\n\nsocial: pt's wife and daughter in for visit, many questions answered, spoke to Dr. and team this pm re: plan of care.\n\na/p: 66 yo male w/ pancreatitis and worsening bibasilar pleural effusions. higher peep and fio2 requirement this eve, ls more coarse. u/o and bp improved after fluid challenge. plan to monitor pulm status, adjust support as needed. follow labs, u/o, hemodynamics.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-03 00:00:00.000", "description": "Report", "row_id": 1416324, "text": "Resp Care\nPt. remains intubated overnight. PEEP increased d/t marginal oxygenation> responded well.Overbreathing set rate by 12-14bpm for avg MV 12-14lpm. Morning abgs within acceptable parameters.\nBS:dim. over RML/RLL, decent aeration over left.\nPlan:Cont. current support.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-04 00:00:00.000", "description": "Report", "row_id": 1416328, "text": "TSICU NPN 1900-0700\nREVIEW OF SYSTEMS:\n\nNEURO: Pt sedated on Ativan gtt at 3mg/hr, Fentanyl gtt at 50mcg/hr started last evening for pain with good effect. Pt occasionally opens eyes spontanously. Moves all extremities on bed. Pupils 2mm, briskly reactive.\n\nCV: SR 80-90's, no ectopy noted. SBP ranging 100-140's, increasing to 170-180's with movement/turning. P-boots intact. SC Heparin TID. HCT stable at 30.3. Right IJ TLC. Right Left radial arterial line.\n\nRESP: Orally intubated on CMV 600X16, 10 PEEP, 40% FIO2. LS coarse, diminished at bases. Suctioned for thick clear secretions. Most recent ABG: 7.42/41/92/28/1. SATS 94-98%.\n\nID: TMAX 102.3, tylenol given and fan applied. WBC down to 18.6 this am.\n\nENDO: BS covered per RISS.\n\nGI: Abd obese. Present BS. Tropic TF started last evening, infusing at 10cc/hr. TPN infusing at 42cc/hr. OGT to LWS draining bilious output.\n\nGU: Foley draining amber colored urine. Adequate UO.\n\nSKIN: Red rash to torso/back.\n\nSOCIAL: No contact from family overnight.\n\nPLAN: Wean from vent as tolerated, montior WBC, BS, pain control.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-04 00:00:00.000", "description": "Report", "row_id": 1416329, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Latest abg results determined a mild metabolic alkalemia with very good oxygenation on the current settings.\n\nNo RSBI measured due to the level of PEEP currently required.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-05 00:00:00.000", "description": "Report", "row_id": 1416335, "text": "nursing prog note\n\nneuro: pt remains sedated w/ fentanyl, midaz weaned to off only after returning pt to ac mode vent support. mae, opens eyes spont., no following of commands. cough and gag weak.\n\nresp: tolerated cpap+ps mode until 11 am, pt becoming increasingly tachypneic, hyperdynamic, appearing air hungry, \"guppy breathing\", taking very large volumes 8-900cc. returned to ac mode, w/ rate set 16, 10 peep remaining. pt much more comfortable, bp and hr improved. able to wean sedation slightly as result. ls clear, dimin to bases, improving air exchange noted. sx mod amts thick white sputum prn.\n\ncv: bp labile, dependent on stress level, directly r/t sedation. nsr, occas ectope w/ stimulus. extrem warm, pulses intact. lytes wnl. gentle diuresis started today, lasix drip titrated to goal -40cc/h (1L/d).\n\ngu: foley patent amber/icteric urine, as above diuresis cont.\n\ngi: belly soft, distended. bs+, no flatus, no bm. trophic tf via post pyloric dobhoff currently, to change to 1/2 str. and titrate to goal. ogt to lws as of this am, large amts icteric bile draining.\n\nendo: rising insulin demand for shift, drip titrated as protocol. this late pm bg's beginning to regulate, will closely monitor.\n\nskin: rash to back initially looking improved, this afternoon increasingly red, will monitor.\n\nsocial: pt's daughters and wife in to visit over day, updates provided. all ques answered.\n\na/p: 66 yo male w/ necrosing pancreatitis, today w/ rising insulin resistance. tolerated cpap+ps mode vent support all last night, tiring this mid morning, returned to ac mode. plan to increase tf toward goal, adjust tpn as ordered. ongoing management of glucose levels, maintain adeq sedation level, rest on vent overnight.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-06 00:00:00.000", "description": "Report", "row_id": 1416336, "text": "NPN, 1900-0700\nNeuro: No sedative meds required; fentanyl 50 mcg/hr w/ apparent adequate analgesia. Pt opens eyes spontaneously, moves all extremities on bed. Does not follow commands or track w/ eyes. Weal gag, strong, productive cough.\n\nCV: NSR, salvos of VEA during hyperdynamic episodes. SBP 90's-140's at rest, to 180's when agitated (during care). Pulses palpable throughout; moderate anasarca. K+ repleted aggressively R/T diuresis.\n\nPulm: orally intubated, remaining on AC 650 x 50% x 16PS x 10PEEP. ABG's reveal adequate oxygenation w/ compensated nl pH. BS course anteriorly, very diminished at bases, left fields laterally. Mod amounts thick white secretions w/ occasional thick tan sputum. Oral thrush resolving w/ nystatin.\n\nGI: abd more distended, soft; BS very hypoactive. No stool or flatus.\nOGT to LCS draining ~50cc/hr icteric bile. 1/2 strength Impact TF via post pyloric Dobhoff left nares; advanced by 10cc q 12hours, flushed w/ 50cc H2O q 4 hours.\n\nGU: F/C urine clear yellow w/ diuresis on lasix gtt titrated to overall neg balance liter/24 hours including OGT drainage.\n\nSkin: macular rash over back bright red intermittently, also spreading onto right flank and lightly on extemities. (This seemed to correlate to meropenum administration w/ rash fading ~ 1 hour after dose infused. Perineal rash worse w/ some areas of skin break; cont w/ miconazole powder. No pressure areas.\n\nID: WBC static at 15. Tmax 101.5po; tylenol given. Cont on meropenum.\n\nEndo: labile BG on insulin gtt, requiring large dose. Jooslin following.\n\nPsychosocial: no family contact this shift.\n\nA: necrotic pancreatitis w/ resultant pleural effusions, resp failure, difficult BG management, fevers.\n\nP: Pt requiring no sedation and less analgesia on AC, so vent wean should be brief periods of CPAP trial, if at all today. Cont on lasix gtt titrated to neg liter/24 hours. Insulin gtt protocol. Follow rash, ? etiology. Monito perineal rash for worsening breakdown.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-06 00:00:00.000", "description": "Report", "row_id": 1416337, "text": "Resp Care note\n\nPt is febrile > 101, This A.M. breathing looks labored on AC mode after pt had Morning care. He is having some PVC as well so RSBI was not done @ this time. Pt sx for mod amts of tk tan secretions t/o night. Pt given combivent Q 4-6 PRn. Will continue to monitor pt and modify support as needed.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-06 00:00:00.000", "description": "Report", "row_id": 1416338, "text": "Resp Care: Pt remains intubated via #8 ETT secured 23cm at lip. BS rel clear bilat w/ few scatt ra; base. Sx'd for small amts thick tan sputum. MDI's given as ordered. Attempted on PSV/CPAP today. Pt having irreg breathing pattern, with good Vt's. Periods of agitation. Sedation being optimized by nsg. Will cont to attempt CPAP trials as tol. Please see carevue for further vent inquiries.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-06 00:00:00.000", "description": "Report", "row_id": 1416339, "text": "nursing progress note\n\nneuro: beginning to follow commands this pm, wiggling toes, sticking tongue out, etc. attempts to squeeze hand, difficult d/t edema. perrla, 2mm. mae spont. mild sedation w/ fentanyl and prn midaz w/ good effect.\n\nresp: attempted cpap+ps trial this aft, tolerated only short while, breathing becoming labored, tachypneic at times, other times w/ apneic pauses lasting 5-10sec. o2 sats remained stable, very large volumes taken w/ each breath, pt obviously stressed, hyperdynamic. returned to ac mode at 1430, 50%, 650x16, 10peep. abg acceptable, compensating for metabolic alkalosis d/t diuresis for last 24h. ls clear, dimin to bases. as per icu team new R basilar opacity on cxr, sputum cx obtained. sm amts thick white secretions.\n\ncv: hyperdynamic when stressed, when comfortable nsr, occas pvc's and pac's, rate 70s-80s. bp 100-140s at rest as well. extrem warm, pulses intact. tmax 100.3 today. lytes repleted prn. lasix drip stopped this am, diamox started . na++ and cl- rising, tpn concentration adjusted.\n\ngi: belly remains soft, increasingly distended. given glycerine supp. this eve, no flatus, no bm today. bs improving, becoming more active. tf titrated slowly toward goal rate of diluted tf.\n\ngu: foley patent amber clear urine, qs.\n\nendo: glucose levels much improved today, better regulated w/ scale titration of insulin drip.\n\nskin: R flank rash persists, does not appear to correlate w/ meropenum or any other medication infusion. rash unilateral, red, raised, angry in appearance. will monitor. appears better this pm.\n\nsocial: daughters in for visit this aft, many questions answered, updates provided on care. support provided as needed.\n\na/p: brighter neuro exam today, only requiring prn midaz for turns, skin care, tx's. did not tolerate cpap+ps well, only tolerated for short while. new R basilar opacity on cxr, sputum cx pending. cont to monitor lytes, diurese w/ diamox dosing. cont tight control glucose levels. advance tf as tol, follow abd. exam. for surveillance abd CT on Monday.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-07 00:00:00.000", "description": "Report", "row_id": 1416340, "text": "NPN, 1900-0700\nNeuro: arouses to voice w/ open eyes; inconsistently follows commands. Moves all extremities purposefully. Less restless, requiring midazolam x 1 for agitaion. Fentanyl 50 mcg/hr w/o bolus dose required.\n\nCV: NSR, variable MFVEA. SBP 90's-140's. CVP 10-14. Pulses palppable throughout; moderate anasarca persists. Pboots, sq heparin prophy.\n\nPulm: orally intubated on AC 650 x 10 x 50% w/ adequate ABG's when weaned to 40%. CPAP/PS x 40% after RSBI 56, well tolerated iitially. Will monitor , pt tolerance. Sx thick white sputum in small amounts. Oral mucosa clearing from thrush. BS course anteriorly, diminished throughout posteriorly, very dim at bases.\n\nGI: abd hugely distended, soft; BS active throughout. No stool or flatus. OGT to LCS draining icteric bile. Impact 1/2 strength infusing via post pyloric Dobhoff at 50cc/hr; rate advance by 10cc q12 hours, flushed w/ H2O 50cc q4 hrs.\n\nRenal: F/C urine clear amber; OP marginal , 20-60cc/hr; poor diuresis from diamox. Lytes WNL this am.\n\nSkin: macular rash over back less angry. Red macular rash over right flank, now into right axilla w/ diffuse papular pattern. Perineaal rash very angry red, macerated w/ open skin on medial thighs. Miconazole powder and attempting to keep skin dry.\n\nID: WBC down to 14; Tmax 100.2po. Cont on meropenum. Cxs neg or pending.\n\nEndo; Cont on insulin gtt protocol. BG labile , ?R/T increasing TF, change to D5W IVF's to treat hypernatremia.\n\nPsychosocial: no family contact .\n\nA: necotizing pancreatitis w/ resultant pulmonary effusions, respiratory failure, difficult glucose/insulin control, worsening rash, etiology unknown. Slowly inproving respiratory status, tol increasing TF, no bowel function yet, WBC cont downward.\n\nP: CPAP/PS at current settings as pt tol., follow BG closely protocol, advance TF 10cc q12 hours to goal 70cc/hr. Add colace. Monitor rash, ? more aggressive rx of perineal excoriation.\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-07 00:00:00.000", "description": "Report", "row_id": 1416341, "text": "Resp Care Note\n\nPt placed on PSV 12 /+5 early a.m. after RSBI found to be in weanable range. Pt easily agitated but seems comfortable on these settings. Weaning PSV is not suggested @ this time due to multiple other medical issues. Suggest pt should remain @ 12/+5 as long as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-08 00:00:00.000", "description": "Report", "row_id": 1416344, "text": "Altered Respiratory Status\n\nPt sedated on Propofol@15mcg/kg, Fentanyl@75mcg/hr. Pt opens eyes, moves all extremities, rarely follows commands.\n\nSR with ectopy. Left radial aline dampened. Lopressor as ordered. Pt receiving Albumin-CVP 5-8. Pt has pneumoboots on and recieving Heparin SC.\n\nNo vent changes. Pt continues to have \"guppy type\" breathing on PSV. Suctioned for scant amt. clear sputum. Breath sounds clear and diminished in bases. Sats 97%. RR 20-26.\n\nAbd. soft and grossly distended. Copious amt. of brown liquid stool. Mushroom cath placed. Tolerating tube feeds at 1/2 strength, 60cc/hr. TPN continues. OGT to suction-draining bile in large amts.\n\nUrine output adequate; pt on Diamox.\n\nInsulin drip protoccol. BS around 150-contining to titrate Insulin up.\n\nTemp spike to 102.6-pt was pan cultured.\n\nGroin rash less red; back rash remains. Anasarca continues.\n\nNo contact with family overnight.\n\nPlan: Wean from vent as tolerated. Monitor Insulin requirement. Access for sepsis. Support pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-08 00:00:00.000", "description": "Report", "row_id": 1416345, "text": "TSICU-NPN/0700-1500\nNeuro: Pt off Propofol gtt since 0730 and tolerating fairly. Opening eyes spontaneously and MAEs. Pt following command to wiggle toes, but not following others, PERRLA 2-3mm, brisk. Fentanyl gtt continues at 75 mcg/hr with what appears to be good effect (per vs, and grimace)and also is receiving midazolam IV Q2-3 hrs for agitation.\n\nCV: NIBP 120's-130's systolic,arterial line d/c this am(no blood return present/no waveform) and multiple attempts made to replace, however were unsucessful. HR 80's-90's NSR with frequent ectopy, up to 13 PVCs/min. HO Frost aware and to monitor, continuing with Lopressor Q4. CVP 12-15. +pp, +csm. P-boots/SQ Heparin.\n\nResp: Pt orally intubated on CPAP+PS as charted in carevue. Weaned throughout day for ? possible extubation today. +cough (weak) and +gag reflexes. Thick clear-whitish colored secretions suctioned from ETT occasionally. Mouth care done per VAP protocol. ABG sent this am and WNL-continue ABG monitoring.\n\nGI:BS+, abd soft and becoming more distended throughout day (team aware) Glycerin supp. given with pending effect. Mushroom cath remains intact and draining scant amts of brown liquid stool. 1/2 strength Impact now at goal of 70cc/hr-dobhoff. OGT remains in place and draining bilious secretions. TPN continues and to be d/c once bag finishes.\n\nrenal: Foley draining clear yellow urine in adequate amts, 60-130cc/hr. Pt continues on Diomox . 40 meq K+ repleted this am. D5W at KVO.\n\nSkin: Rash to perinium and back continues-miconzole powder applied, and skin remains intact. Multipodus boots applied.\n\nEndo: Insulin gtt titrated up throughout day, (currently at 24 units/hr). in to follow up today.\n\nID: Meropenem and Fluconazole continue. Tmax 100.2,with fan on temp went down to 99.8.\n\nSocial: Family in to visit this afternoon and updated on POC and events overnight/throughout day.\n\nPOC: Continue to wean from vent as resp. allows\n D/C TPN once current bag finishes\n monitor temps\n assess abd/glycerin supp\n maintain skin integ\n replete lytes PRN\n" }, { "category": "Nursing/other", "chartdate": "2173-02-08 00:00:00.000", "description": "Report", "row_id": 1416346, "text": "resp care - Pt receved on PSV. PS was weaned from 14 to 12 MD . ABG showed continued metabolic alkalosis with good oxygenation. Pt developed increased WOB and VTs in the 300s in late PM and was put on full vent support. Coarse BS in upper lobes cleared with suctioning of small to moderate amounts of thick white secretions. BS in bases were diminished. Meds were given as ordered. Continued slow weaning is planned.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-08 00:00:00.000", "description": "Report", "row_id": 1416347, "text": "T/SICU Shift Report 1500-1900\nPatient appeared to be over-sedated when received by this RN, with obvious respiratory distress (gasping breaths periods of -), SpO2 94%, with additional frequent PVCs/PACs not explained by electrolytes. TV 250-350ml, with absent breath sounds at the bases. Patient placed on AC 16x650 PEEP 5 FiO2 40%.\n\nPatient's metoprolol increased to 12.5mg IV Q4, given 20mg furosemide IVP. Decreased number of PVCs, SpO2 increased to 99-100%. ABG pH 7.31, PaCO2 57, PaO2 93, BE 0. Increased breath sounds. Vent settings increased to 20x650 PEEP 5.\n\nTPN stopped, insulin infusion titrated protocol.\n\nPLAN - Recheck ABG overnight\n No Barbiturates/Reduce sedation within comfort\n Recheck lytes\n" }, { "category": "Nursing/other", "chartdate": "2173-02-09 00:00:00.000", "description": "Report", "row_id": 1416348, "text": "NPN 1900-0700\n Pt is a 66yo male transferred form OSH with necrotizing pancreatitis. Has remained sedated and intubated.\n Pt weaned from sedation. Fent gtt decrease prior to this shift and off in early am. Given IVP fent for pain and Versed 1mg x 1. He has been awake all night and restless. Subjectively pain seems well controlled. At start of shift he was not able to focus gaze or respond to voice, not FCs. In am now turning head when spoken to and briefly focuses gaze on staff. When asked questions makes facial gestures but doesn't nod or attempt to mouth words. Unable to squeeze hands to command but did repeatedly shut and open eyes to command. MAEs well.\n Pt changed from A/C to MVV when noted to again having abdominal and gasping breaths. Breathing appeared more regular with setting change and ABGs wnl. Lungs coarse, good air movement and diminished bases. Weak cough with small to mod amt thick white secretions.\n CV- SR with freq PVCs and occ PACs. BP stable. Lytes wnl. LAsix given at 2230 to maintain even fluid balance, good response. Cont on Diamox q12h. Tmax 101.8, cx pending from at 0100. Treated with tylenol and afebrile rest of shift. Diaphoretic after fever broke, skin w/d since. Yeast in groin area remains red and inflammed. No broke areas noted except small area on inner part of L buttock. over back and sides is blotchy and red. Similar appearance to common drug rx rashes.\n Endocrine- BG at 1900 treated with D50. Responded and insulin gtt restarted as BG cont to rise. BG now with good control on 6.0-7.0u/h.\n GI/GU- Abd soft but markedly distended. Hypo BS. Mushroom cath in place with small amts liquid stool. Foley patent with adeq amt urine.\n Social- No contact with family overnight.\n Plan- Treat pain with PRN fentanyl. Try to minimize sedation to improve pt MS. as tolerated. Dr to discuss increasing impact TF to stregnth with team this am.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-16 00:00:00.000", "description": "Report", "row_id": 1416371, "text": "NPN, 1900-0700\nneuro: awake, oriented to person and place, calm and cooperative. Confused upon awakening, but re-orients easily. Slept in naps only, startles awake easily.\n\nCV: NSR, ST, MFVEA/AEA, 60's-80's w/ lopressor. SBP rising at rest to 160's. Moderate anasarca; pulses palpable throughout.\n\nPulm: BS course anteriorly, clear w/ strong cough, productive of thick white secretions. FiO2 weaned to NP 5L w/ sats > 95%.\n\nGI: abd softly distended, hyperactive BS all quads. NGT draining large volumes dark bile. Post pyloric Dobhoff w/ replete 3/4 strength, advancing 10cc q 8 hrs, now at 30cc. Large soft brown, heme neg stool.\n\nRenal: F/C draining sediment laden yellow urine, 40-100cc/hr. Continual sang ooze from meatus. Irrigated x 1 w/o clots returned.\nIVF changed to D51/2 w/ 20K at 50cc/hr. K+ repleted for 2.9.\n\nSkin: diffuse red macular rash improving over torso and back, still red under axillae; groin rash much improved. Coccyx red, skin ?just beginning to abrade. Turned off of back, aloe applied.\n\nID: WBC normal; afebrile . Vanco trough drawn before 0800 dose this am. Cont on zosyn.\n\nEndo: insulin gtt cont, BG less labile.\n\nHem: serial Hcts stable at 22.\n\npsychosocial: daughter called w/ many concerns and questions; she voiced a desire by the family that the pt be seen by his own urologist, Dr. .\n\nA: necrotic pancreatitis, slowly recovering , w/ ? septic event 48 hours ago, now w/ normalizing WBC, improving resp function, clearing mental status, stablizing BG, HTN evolving, ? r/t fluid resuscitation of past 48 hours.\n\nP: cont aggressive bronchial hygeine. Allow auto diuresis, reduce IVF's, cont insulin protocol. ?OOB, PT involvement; serial hcts. Urology Consult.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-16 00:00:00.000", "description": "Report", "row_id": 1416372, "text": "nursing progress note\n\nneuro: lethargic today, easily awakened, difficult to keep alert. oriented x2 at best, able to state all family members' names, past events, recognizes family. denies pain, speech at times muddled. cough, gag intact.\n\nresp: ls congested to upper fields, clearing well w/ strong cough. diminished to bases bilat. o2 sats 94-100% 50% face tent, benefiting from humid o2, oral mucosa/airways dry. abg w/ resp alkalosis.\n\ncv: hypertensive to 180s w/ fluid shifts, nsr, 60s-80s, freq pvc's noted. k+ repleted as needed, gentle lasix diuresis started. all other lytes wnl. extrem warm, pulses intact. lopressor q4h continues, improved ectope noted w/ beta blocker.\n\ngi: belly soft/distended. bs present x4. no bm, + flatus. tf titrated toward goal rate, tol well via dobhoff. ng to , KUB this am, end of tube in duodenum, tube pulled back this am approx. 6-7cm, secured. smaller output noted for rest of shift.\n\ngu: foley patent yellow sedimented urine, qs. diuresed well w/ small dose lasix.\n\nendo: good glucose control w/ low dose insulin drip. solumedrol dosing continued.\n\nid: afebrile, wbc stable from this am. all abx d/c'd.\n\nskin: no new issues, rash to groin, torso, axilla improved.\n\nsocial: wife in for visit this aft, daughter called for update.\n\na/p: stable neuro exam, lethargic, napping freq today. oriented x2 at best. gentle diuresis tol well, htn noted w/ fluid shifts. beta blockade continues. cont aggressive pulm toilet/chest PT, slow diuresis for next 24-48h.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-17 00:00:00.000", "description": "Report", "row_id": 1416373, "text": "NPN, 1900-0700\nneuro: somewhat lethargic, arouses easily. Oriented to person and place; calm and cooperative. Moves all extremities weakly. Strong cough and gag. Slept well after ambien at HS.\n\nCV: NSR, frequent MFVEA, AEA. SBP ranging 120's at rest to 180's w/ activity; cont on metoprolol 10 mg IV q4 hr. CVP 5-8. Pulses strongly papable throughout; moderate anasarca persists. Pboots and sq heparin prophy.\n\nPulm: weaned from 50% face tent to NP 4L w/ sats >96%. BS CTAb anteriorly after cough productive thick white--yellow secretions. Bases diminished, scattered I/E wheezing. CPT q3-4 hours.\n\nGI: abd softly distended, non-tender; BS active throughout. + flatus, no stool. NGT sumping dark bile, decreased volume since NGT retracted.\nDobhoff post pyloric, infusing Replete 3/4 strength, progressing towards goal of 100cc/hr.\n\nRenal: F/C urine clearing form earlier bloody sediment to clear yellow w/ rare sludge. Brisk response (1L) to lasix 10 mg IV (BID). LOS fluid status ~5L+. D51/2 w/ 20mEq KCl @50cc/hr. K+ repleted aggressively.\nMin bloody drainage from meatus.\n\nSkin: macular rash over torso resolving; groin rash clearing w/ skin sloughing off. Pink abrasion coccyx healing.\n\nID: WBC WNL; afebrile. No antibx.\n\nEndo: , insulin gtt off @ MN after glargine 25 units sq @ 2200. Follow BG q 6 hours, RISS + scheduled glargine @ HS. BG have been <150 since gtt off. Cont on hydrocortizone, decreasing dose daily.\n\nHeme: serial hcts stable.\n\nPsychosocial: no family contact .\n\nP: cont aggressive bronchial hygeine. ?OOB, start PT, stimulate pt, encourage interaction. BG control orders. Cont gentle diuresis. Colace added.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-18 00:00:00.000", "description": "Report", "row_id": 1416376, "text": "NPN 0700-1900\n See Transfer Note for ROS.\nEvents\n Pt was very tired this am. Worked with Physical Therapy, did well sitting at side of bed. to chair.\n NGT to til 1300. D/c'd prior to going to Fluro for dobhoff repositioning as to avoid dislodging FT again if removed after FT refloated postpyloric. TF started at 30cc but pt again nauseated. Turned down to 20 and reglan given with little improvement. Later tried phenergan and when rechecked pt was asleep. No vomiting with nausea.\n Daughters in to visit and very apprehensive about pt transferring back to floor. vocalized many concerns (including concerns about amt of attention their father will need) which were conveyed to , nurse manager of 9 by resource RN. Pt will be in a room near RN station since he is unable to use calllight at this time, and voice weak.\n Pt is very pleasant and cooperative, good sense of humor and smiles often. Definetly motivated and though very deconditioned does asisst as much as physically possible.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-19 00:00:00.000", "description": "Report", "row_id": 1416377, "text": "TSICU NPN Admission 0830-1900\nPt admitted back to TSICU this am for respiratory distress. Per report from 9, pt was in respiratory distress with RR in 40's (pt was on Bipap, which he wears at home for sleep apnea), SATS >94%. Pt tranfered to TSICU for further montioring of resp status.\n\nREVIEW OF SYSTEMS:\n\nNEURO: Pt lethargic, yet arousalbe. Opens eyes to command, able to follow commands. Smiles to jokes, yet little communication on own. Pt orientated to self and place. Denies pain.\n\nCV: SR 70-90's, rare PVC's and PAC's noted. SBP ranging 110-140's. Left subclavian TLC. P-boots intact. SC Heparin.\n\nRESP: Pt weaned off non-rebreather upon arrival to TSICU. Currently on 4L NC with SATS >96%. LS: clear, diminished at bases. Initially pt with crackels (R>L), recieved AM lasix with improvement. RR 20-30's.\n\nENDO: BS covered per RISS. following pt.\n\nID: TMAX 100.4 upon arrival to TSICU, down to 97.8. No abx coverage at this time.\n\nGI: Abd soft, non-distended. TF re-started via dophoff tube - advance to goal of 100cc/hr as tolerated. No N/V. Positive BS. Pt tolerating ice chips.\n\nGU: Foley draining clear yellow urine. Adequate UO.\n\nSKIN: Red rash to backside, yet improving this evening.\n\nSOCIAL: wife and two daughters into visit throughout day, updated on pt's condition. TSICU HO also spoke with wife, answered questions.\n\nACTIVITY: OOB to chair with slideboard, tolerated well X 2 hours.\n\nPLAN: Monitor respiratory status, neuro status.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-20 00:00:00.000", "description": "Report", "row_id": 1416380, "text": "Tsicu npn\nO: ROS\n\nNeuro: Pt remains somulent and lethargic but arousable and appropriate when stimulated. Able to communicate needs but sleeping much of the time. Cooperative, able to assist w/ turning and range of motion. Denies pain/anxiety.\n\nCV: HR 100's w/ frequent pvc's despite po lopressor. Changed to iv lopressor w/ gd effect. HR 70's nsr w/ occasional pvc's and bp 110-120/70.\n\nResp: LS clear, diminished. SRR 12-24. 02sat stable 0n 5lnc. Denies SOB. Productive cough of lge amt of green sputum today.\n\nGI: TF at goal this am but pt vomited moderate amt bilious material and cont w/ episodic nausea. Residual >500cc and discarded. NGT placed w/ 1100cc initial output of bilious material and cont w/ bilious dnge.\nTPN ordered for tonight.\n\nEndo: Long acting insulin d/ced and placed on ss insulin w/ insulin in tpn. BS running abt 150's and covered w/ 4ureg insulin x2.\n\nRenal: Body balance abt 1700cc negative today d/t gastric output and d/ced tf. IVF started at 100cc/hr d/t low but adequate u/o. Lytes repleted and wnl.\n\nHeme: Stable\n\nID: Tmax 100.6. Cultures pnd.\n\nSkin: Intact.\n\nActivity: OOB - CHair x 3-4hrs and tol well. (Lifted). Able to help w/ turning w/ encouragement.\n\nSH: wife in briefly. Both daughters in and asking many appropriate questions and expressing concerns. Information provided. They will return tomorrow.\n\nA: Poor toleration of tf, ?etiology. Temp spike. Improved resp status.\nAltered mental status, somulence/lethargy.\n\nP: Cont to monitor and support systems. TPN tonight and follow Blood sugars closely. Cont pulm toilet. Monitor neuro status. Rehydrate and monitor fluid balance. Pt is ordered for abd ct w/ contrast tonight.\nContinued pt and family support.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-21 00:00:00.000", "description": "Report", "row_id": 1416381, "text": "NPN, 1900-0700\nneuro: AAO x 2, slept in long naps. No focal deficits; moves all extremities weakly, attempting to assist in turns. No pain, calm and cooperative.\n\nCV: NSR, frequent MFVEA, 70-100. MAP 70-90., CVP 4-7. Pulses palpable throughout; min anasarca persists. Pboots, sq heparin prophy.\n\nPulm: BS rhonchorous posteriorly, clear anteriorly. Sats> 95% on NP 5 L. Strong cough productive thick tan secretions; clears airway easily.\n\nGI: abd softly distended; BS+ x 4 quads. NPO. NGT, LCS, draining dark green bile, ~50cc/hr. Dobhoff clamped. TPN at 1st 24 hour dose.\nNo stool; no nausea, emesis.\n\nRenal: F/C urine clear amber, 30-60cc/hr. LR @60, TPN @41. Fluid balance -1500@ MN R/T high gastric output. K+ repleted.\n\nSkin: diffuse macular rash resolving; cocccyx abraded, red.\n\nEndo: RISS, +insulin in TPN; BG less labile, ranging 100-200.\n\nID: Tmax 99.1po; WBC 7.5. Single anaerobic BC bottle gm+ cocci, others pending. Vanco orderd, awaiting to decide on adm.\n\nPsychosocial: no contact from family this shift,\n\nP: abd CT this am after Baricat instilled (CT planned for 0830). Aggressive bronchial hygeine, OOB. ? D/C existing central access, replace w/ another central line, ?PICC. Monitor BG closely as TPN increased.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-03 00:00:00.000", "description": "Report", "row_id": 1416325, "text": "TSICU NPN 1900-0700\nREVIEW OF SYSTEMS:\n\nNEURO: Pt sedated on Propofol at 40mcg/kg/min. When lightened, pt opens eyes to voice, MAE. Pupils 2mm, briskly reactive. Fentanyl gtt infusing at 50mcg/hr for pain.\n\nCV: SR 70-90's, rare PAC's noted. SBP ranging 90-130's. CVP ranging . LR infusing at 100cc/hr. P-boots intact. SC Heparin TID. HCT stable at 31.2. Calcium and Potassium repleted.\n\nRESP: Orally intubated on CMV 500X16, 50% FIO2, increased to 10 PEEP last evening. SATS ranging 93-96% with most recent ABG: 7.40/40/95/26/0. LS coarse, diminished at bases. Suctioned for scant clear thin secretions.\n\nID: TMAX 101.8, tylenol given. Blood cultures sent at 1900. WBC elevated at 24.9. Meropenum for abx coverage.\n\nENDO: No coverage needed per RISS.\n\nGI: Abd obese, soft. NPO. Hypoactive BS. OGT to suction, draining large amts bilious output. Dophoff tube clamped, plan for IR today for placement. No stool this shift. Protonix for GI prophylaxis.\n\nGU: Foley draining clear yellow urine. Adequate UO.\n\nSKIN: Rash to backside - ? heat rash.\n\nSOCIAL: No contact from family overnight.\n\nPLAN: IR today for placement of dophoff tube, start TF once placed. Continue to monitor resp status, wean from vent as tolerated. Montior temps, WBC.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-03 00:00:00.000", "description": "Report", "row_id": 1416326, "text": "Resp Care\n\nPt remains intubated and on full vent support in the A/C mode. Pt was appearing to be air hungry; TV increased to 650 which is < 10cc/kilo. Increase eliminated apparent air hunger. MV has been being maintained in the 12-13L range; Plateau's 25-28. ABG 7.43/35/124/24; fio2 to 40%. BS genearally clear with occ rhonchi. Suctioning small amts of thick white sputum\n" }, { "category": "Nursing/other", "chartdate": "2173-02-03 00:00:00.000", "description": "Report", "row_id": 1416327, "text": "Progress Note, 0700-\nShift Events: - ABD XRAY\n - To IR for placement of dobhoff\n\nReview of Systems:\n\nRESP: A/C 600x16, FiO2 40%, Peep 10. RR 19-29, SpO2 >95%. 7.47/32/91/24/0. LS coarse bilaterally w/ dim bases. Sm to mod amts thin clear secretions sxn via ETT. Copious amts secretions noted w/ oralpharyngeal sxning.\n\nCVS: NSR- ST, w/ occasional PVCs. HR 83-102, A-line SBP 107-190, NIBP 96-150s, MAP 67-111, CVP 8-12. Tmax 101.7, fan on, tylenol PR given. + palpable pulses, skin warm & moist. Lopressor 10 mg Q6H & 10 mg Hydralazine Q6H:PRN to maintain SBP < 160. ID: Meropenem.\n\nNeuro: Ativan gtt infusing @ 3 mg/hr. Unable to fully assess neuro status sedation. Occasionally opens eyes spontaneously, localizes to pain, and MAEs. Pupils 2-3mm/2-3mm, briskly reactive. Fentanyl IVP 25-100 mcg Q2H.\n\nGI: Abd sofly distended, + BS, NPO. OGT to LCWS, draining moderate amts bilious drainage- 525 cc for shift total. Abd xray obtained for determination of dobhoff placement- to IR for accurate placement of dobhoff. Begin trophic TF this evening. TPN @ 42 cc/hr.\n\nGU: Pt auto-diuresing, u/o 60-200 cc/hr. D5 1/2 NS w/ 20 K @ 50 cc/hr.\n\nSkin: Rash to back, otherwise skin intact. RIJ CVL & L radial A-line.\n\nSocial: Family into see pt, spoke w/ Gold surgical team & updated as to POC.\n\nPlan of Care: Wean vent settings as tol\n Maintain SBP < 160\n Cont to monitor hemodynamics\n Titrate ativan gtt as appropriate\n Cont w/ pain management\n Start trophic TF via dobhoff\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-04 00:00:00.000", "description": "Report", "row_id": 1416330, "text": "resp care - Pt was received on full vent support. PSV trialed successfully in PM. PEEP and FiO2 adjusted to maximize weaning. ABG before CPAP was WNL. Post CPAP ABG is pending. BS clear. Sx small white frothy secretions. Continued weaning planned.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-04 00:00:00.000", "description": "Report", "row_id": 1416331, "text": "Progress Note, 0700-\nShift Events: - LSC CVL placed\n - CXR to confirm placement of LSC CVL\n - Placed on CPAP + PS\n\nReview of Systems:\n\nRESP: CPAP + PS, 8 peep, 15 PS, FiO2 50%, TV 450-500. RR 16-24, SpO2 >92%. 7.38/45/102/28/0. LS clear to coarse bilaterally. Sm amts thin clear secretions sxn via ETT. Moderate amts thin clear secretions sxn w/ oropharyngeal sxning. Sputum speciman to be collected.\n\nCVS: NSR to ST w/ no ectopy. HR 79-108, SBP 108-159 w/out stimulation. With stimulation/aggitation SBP increases to 160-180s. 10 mg IV Lopressor Q6H. 10 mg Hydralazine Q6H PRN to maintain SBP < 160. CVP 8-12. Tmax 101.8, pt. re-cultured. First set of blood cultures & urine speciman sent at 1600. Given 650 mg Tylenol PR. + palpable pulses, skin warm & moist. ID: Meropenem. Heparin TID & venodynes for prophylaxis.\n\nNeuro: Sedated on 1mg/hr versed w/ fentanyl gtt infusing at 50 mcg/hr. Unable to arouse pt heavy sedation. Occ opens eyes spontaneously, MAEs, localizes to pain. Pupils 2-3mm/2-3mm, briskly reactive.\n\nGI: Abd softly distended. Hypoactive BS. No BM. Dobhoff w/ TF @ 20 cc/hr. TPN @ 83 cc/hr. FS 108-205 covered w/ RISS. Protonix for prophylaxis.\n\nGU: Foley draining adequate amts urine. u/o 45-280 cc/hr. 10 mg Lasix given at 1400 w/ no effect, additional 20 mg lasix given at 1900 w/ minimal increase in u/o.\n\nAccess/Skin: LSC CVL placed-> RIJ CVL pulled, tip cultured. Transducer & tubing changed. Pt. has L radial A-line, good waveform, wnl. Rash to back, ? rxn to IV contrast from OSH; no change or improvement noted.\n\nSocial: Daughters & Wife in to see pt today. Spoke w/ Dr. & was informed as of POC. Will be back tomorrow.\n\nPlan of Care: Wean vent settings as tol\n Draw ABGs at 2100\n Sputum speciman to be collected\n Second set of blood cultures due\n Titrate versed gtt as appropriate\n Wean fentanyl gtt as tol\n Advance TFs tomorrow\n" }, { "category": "Nursing/other", "chartdate": "2173-02-05 00:00:00.000", "description": "Report", "row_id": 1416332, "text": "Respiratory Care:\nPatient required increases in the PSV and PEEP levels (PSV now 17 cm and PEEP +10 cm). Latest abg results determined a rspiratory acidemia with very good oxygenation.\n\nNo RSBI due to the level of PEEP currently require.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-05 00:00:00.000", "description": "Report", "row_id": 1416333, "text": "NPN, 1900-0700\nneuro: lightly sedated on versed .5mg; fentanyl 50 mcg w/ apparent adequate analgesia. Opens eyes to voice, does not follow commands. No focal deficits. Weak cough and gag.\n\nCV: NSR, ST to 120's, no VEA. SBP 100's-140 at rest, to 180's w/ care, responds well to fentanyl 10mcg bolus. Pulses palpable throughout; marked anasarca. CVP 7-10. Pboots, heparin SQ.\n\nPulm: orally intubated on CPAP/PS 10 x 17 x 50%. ABG's reveal acidemia w/ excellent oxygenation; sedation lightened in attempt to increase RR (repeat ABG's pending) BS course anteriorly, very diminished posteriorly, bases. Thick tan secretions. Oral mucosa w/ thick white plaque; started on nystatin S/S.\n\nGI: abd softly distended; hypoactive BS. OGT clamped, sumped q8 hours for 160-200cc bile. No stool or flatus noted. Dobhoff via left nares, post pyloric, instilling FS Impact at 20cc/hr, goal. NPO: TPN infusing @ 83cc/hr.\n\nGU: F/C urine clear icteric, 80+ cc/hr.\n\nSkin: fine macular rash over back. Raised red rash entire perineal area, yeast-like; started on miconazole powder. No pressure areas.\n\nID: WBC WNL; cont on meropenum. Tmax 101.8po; tylenol, blood cx x 1, sputum cx.\n\nEndo: rising BG since TPN rate doubled, requiring insulin gtt.\n\nPsychosocial: no call or visits from family this shift.\n\nA: respiratory failure, pain and fevers R/T necrotizing pancreatitis.\n\nP: maintain light sedation, adequate analgesia. Wean vent support as able. Sump stomach q 8 hours. Insulin gtt per CSRU protocol; increase insulin in TPN. PRN nystatin for oral yeast; miconazole to perineal yeast rash.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-05 00:00:00.000", "description": "Report", "row_id": 1416334, "text": "resp care - Pt received on PSV, and changed to AC due to increased WOB.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-07 00:00:00.000", "description": "Report", "row_id": 1416342, "text": "Resp Care: pt remains intubated/sedated with intermitt periods of agitation. BS coarse bilat. Sx'd for small to mod amts thick white/tan sputum. MDI's given as ordered. ABG reveals mild resp acidosis w/ hyperoxia. No vent changes made thus far. Transported to and from CT today w/o incident. Plan: cont vent support. Please see carevue for further vent inquiries.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-07 00:00:00.000", "description": "Report", "row_id": 1416343, "text": "nursing progress note\n\nneuro: pt remains alert, following commands inconsistently, direct gaze. mae well, good strength. pain well controlled w/ fentanyl drip. perrla, 2mm. cough and gag intact.\n\nresp: tol. cpap+ps mode vent support since this am, remains agitated when not sedated d/t ett, breathing at times erratic, occas. apneic pauses noted, although o2 sats remain stable. ls clear, dimin to bases, R>L. abg's remain w/ resp. acidosis, again likely d/t agitation level.\n\ncv: hyperdynamic w/ agitation, nsr, hr 70s-90s w/ freq. pvc's noted. beta blocked w/ lopressor q4h. extrem warm, pulses intact. low grade temps, tmax 99.8. cont to diurese w/ diamox as per primary team, given 1st of 3 doses of albumin this noon. lytes stable from this am.\n\ngi: belly remains distended, soft. bs present throughout. no flatus or bm as of yet. given gastrograffin today for abd CT, tf held for scan and restarted this pm.\n\ngu: foley patent amber sedimented urine, qs. diuresed as above w/ diamox, fair response noted to colloid and diamox combined.\n\nendo: glucose levels remain labile, team in to evaluate, no changes made to current regimen, cont to follow scale for insulin drip.\n\nskin: yeast rash to groin and R axilla, miconazole powder cont., also as per micro results, urine and sputum + for yeast. iv diflucan started today.\n\nsocial: wife and friend in this afternoon, daughters in this evening for visit. updated on reasons for CT, possible extubation today.\n\na/p: repeat abd CT w/ contrast done this pm, tf restarted, og to lws at this time. await CT read, plan for more aggressive bowel regimen tonight. follow lytes, cont colloid x24h, diamox ongoing. likely to extubate this evening if CT shows no need for surgery in coming days.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-10 00:00:00.000", "description": "Report", "row_id": 1416352, "text": "Nursing Progress Note 7P-7A\n\nPlease see CareVue for exact data.\n\nPt admitted at OSH for abdominal pain where CT showed gallstones. He was admitted to floor and later developed increased WOB, poor UOP and hypotension, transfered to ICU on BiPap. Repeat CT showing evolving necrotic pancreatits(40%), respiratory demand increased and pt was transfered to T/SICU.\n\nREVIEW OF SYSTEMS:\n\nNEURO-Pt awake and alert, agitated at times throughout shift. Spontaneously opening eyes, starting to track on occasion. Will open and close eyes and mouth to commands, however not following commands with extremities. Propofol/Fentanyl gtts stopped on to clear mental status, begin to to extubate. Pt with increased agitation despite not being fully awake, Ativan started PRN and ATC with Fentanyl PRNQ2hours for pain. Both given throughout shift with adequate response.\n\nCV-NSR rate 70's-80's with frequent PVC's. K replaced earlier in shift with 40MEQ. BP ranging systolic 90's-140's/50's-60's. Left SC TLC with CVP transduced ranging from . Lopressor IV 12.5mg q4hours, dropped BP to 80's-90's with first dose, gave 10mg with next dose. Discussed with HO and plan to discuss on . Heparin TID and compression boots for prophylaxis.\n\nRESP-Pt orally intubated on MMV all shift DP 12,TV 600,R12,P5 40%. Lung sounds slightly coarse at times to diminished at bases. Suctioned for small to moderate amount of thick white secretions. MA 68, placed on CPAP 12/P5/40% after , leave on CPAP as long as tolerated. ABG WNL. Possible extubation today per team.\n\nGI-Pedi tube post pyloric with Impact 3/4strength currently at 90cc/hr, advancing q8 hours to goal 100cc. Next due at 1200. No residuals. NGT to LCWS with green/yellow bilious drainage. Protonix q24hours.\n\nGU-Indwelling foley catheter with clear yellow urine output. Goal to keep pt 3L negative (achieved yesterday). Currently positive 200cc, HO aware, continue to monitor need for Lasix. Lytes WNL. BUN slightly increased 34 from 31, Amylase down to 85 from 128.\n\nENDO-Remains on Insulin gtt protocol BS 70's-150's.\n\nID-WBC's down to 18.3 from 22.0. Continues to recieve Meropenum and Fluconizole. Nystatin for rash. Sputum with 1+gram negative rods and yeast. Blood cultures pending. Cath tip,urine and stool negative. Tmax 99.1\n\nSKIN-Fungal rash noted to bilateral UE's, lateral trunk, groin and back. Applying Nystatin cream as ordered. Truck and extremity rash look like drug reaction, discussed with team and believe this is fungal, continuing to monitor. Slightly opened red area to left buttocks.\n\nSOCIAL-Pt has daughters in health care field, they have been involved with care. No family contact overnight. Wife is HCP.\n\nPLAN- to extubate in am pending , CPAP tolerance and mental status.\n -Monitor UOP goal to keep negative 3L, lasix as needed.\n -Monitor for pain/agitation, Ativan and Fentanyl ATC/PRN.\n -Monitor rash for progression, cream as ordered, ?drug reaction.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-02-10 00:00:00.000", "description": "Report", "row_id": 1416353, "text": "(Continued)\n -Follow up with cultures.\n -Antibiotics as ordered.\n -Replace lytes as needed.\n -Advance tube feeding as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-10 00:00:00.000", "description": "Report", "row_id": 1416354, "text": "RESPIRATORY CARE NOTE\n\nPAtient remains intubated and ventilated on MMV most of night. Switched to CPAP/PS this AM. No periods of apnea noted. completed on PS 5=68. ABG drawn shows good ventilation and oxygenation.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2173-02-10 00:00:00.000", "description": "Report", "row_id": 1416355, "text": "RESPIRATORY CARE NOTE\nAddendum: Patient agitated most of night. Attempted different modes of ventilation, but while patient awake he is very restless and agitated.\n" }, { "category": "Nursing/other", "chartdate": "2173-02-10 00:00:00.000", "description": "Report", "row_id": 1416356, "text": "nursing progress note\n\nneuro: pt alert, agitated, restless at times. moving all extrem, strong. perrla, 3-4mm bilat. following commands inconsistently, difficult to get pt to focus long enough to carry out commands. needs much redirecting. speech garbled, not conversing as of yet.\n\nresp: weaned to extubation at noon, pt tolerating well thus far. o2 sats 94% on 50% fio2, titrated to 70% w/ pao2 on abg of 73, pco2 38. current o2 sats improved, 96-100%. will monitor. ls coarse, dimin to bases. cough strong, clearing airway on own. rr teens to 20s.\n\ncv: bp stable, 140s-150s. hr nsr, freq pvc's noted. extrem warm, edema improved throughout. pulses intact. lytes stable from this am.\n\ngi: belly soft/much less distended. bs present, liquid golden stool draining from mushroom cath, mod amts. titrating tf to goal rate, tol well via dobhoff. ogt replaced w/ ngt upon extub., to lws w/ mod amts bilious output.\n\ngu: foley very positional, balloon deflated and catheter repositioned d/t poor u/o this am. large amt initially drained, patent since.\n\nendo: glucose levels improved, less labile. titrating insulin drip to scale ongoing. 3-7u/h consistently for last several hrs.\n\nskin: rash to torso improved, yeast rash to groin and axilla improved as well, miconazole cream applied as ordered.\n\nid: meropenum and diflucan dosing continued. wbc 18 this am.\n\nsocial: daughters in for visit this am and aft, many ques answered, updates provided.\n\na/p: successful extubation this noon, pt remains agitated. abg acceptable, fio2 adjusted, will follow o2 sats. cough strong. remains restless. plan for aggressive pulm hygeine, chest PT. cont to manage glucose w/ insulin drip as scale. abx tx as ordered.\n" }, { "category": "Radiology", "chartdate": "2173-02-22 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 946050, "text": " 9:51 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place tube post pyloric\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with necrotizing pancreatitis\n\n REASON FOR THIS EXAMINATION:\n please place tube post pyloric\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old male with necrotizing pancreatitis. Please place\n post-pyloric feeding tube.\n\n COMPARISON: .\n\n FLUOROSCOPY-GUIDED POST-PYLORIC FEEDING TUBE PLACEMENT: Under fluoroscopic\n guidance, a guidewire was inserted into the Dobbhoff feeding tube placed\n previously. After guidewire insertion, the feeding tube was then carefully\n advanced past the pyloric region with its tip terminating within the third\n portion of the duodenum. A small amount of Optiray contrast was then injected\n confirming appropriate position of the tube within the duodenum. The patient\n tolerated the procedure well with no immediate complications.\n\n IMPRESSION: Successful advancement of a Dobbhoff feeding tube with the tip\n positioned within the third portion of the duodenum.\n\n" }, { "category": "Radiology", "chartdate": "2173-02-13 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 944915, "text": " 5:22 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: PE\n Admitting Diagnosis: SEVERE PANCREATITIS\n Field of view: 44 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with w/necrotizing pancreatitis, gallstone / GB inflammation on\n initial CT now tachypnic, hypertensive, diaphoretic\n REASON FOR THIS EXAMINATION:\n PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CTA CHEST, ABDOMEN, AND PELVIS\n\n REASON FOR EXAM: Rule out PE and followup necrotizing pancreatitis.\n\n Comparison is made with prior study dated .\n\n PROCEDURE: Multidetector CT through the chest, abdomen, and pelvis was\n performed with and without IV contrast.\n\n CT CHEST:\n\n ET tube in adequate position. The heart, aorta, and great vessels are\n unremarkable. Moderate coronary calcifications are present in the LAD,\n circumflex, and right coronary artery. Subcentimeter lymph nodes are seen in\n the subcarinal and left hilar region. Diffuse ground-glass opacity and\n interlobar septal thickening is present in the upper lobes. Unchanged\n atelectasis in the right lower lobe and right middle lobe. There is a trace\n of right pleural effusion.\n\n ABDOMEN CT:\n\n Extensive necrosis in the head, neck, and mid body of the pancreas as well as\n peripancreatic inflammatory changes have no significant changes. The superior\n mesenteric arteries and veins are patent. The splenic vein and portal veins\n are patent as well. Aside from two tiny subcentimeter hypodense lesions in\n the dome and left lobe of the liver which are unchanged and too small to be\n characterized. The liver density is homogeneous and there is no biliary duct\n dilatation. Again is demonstrated a calcified stone within the gallbladder\n lumen. The gallbladder wall is not thick. NG tube tip is in the fourth\n portion of the duodenum. The spleen, adrenal glands, and right kidney are\n unremarkable. In the interpolar region of the left kidney, there is a\n subcentimeter cortical hypodense area, too small to be characterized. There\n is no hydronephrosis.\n\n PELVIC CT: Extensive diverticulosis is in the sigmoid colon without stranding\n of the adjacent fat. Pocket of air within the bladder lumen most likely\n related with prior instrumentation. There is no free fluid within the pelvis.\n No lymphadenopathy.\n (Over)\n\n 5:22 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: PE\n Admitting Diagnosis: SEVERE PANCREATITIS\n Field of view: 44 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOWS: There are no concerning bone lesions. Degenerative changes are\n seen throughout the thoracic and lumbar spine.\n\n Coronal and sagittal reformations were essential in the assessment of the\n pulmonary vasculature and extensive peripancreatic inflammatory changes.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n\n 2. No significant changes in the peripancreatic inflammatory changes due to\n necrotizing pancreatitis.\n\n 3. Diverticulosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 944251, "text": " 9:13 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: repeat cxr given limited prior study, Eval L effusion\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with necrotizing pancreatitis\n\n REASON FOR THIS EXAMINATION:\n repeat cxr given limited prior study, Eval L effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Necrotizing pancreatitis. Evaluate left effusion.\n\n COMPARISON: .\n\n CHEST AP: The endotracheal tube is about 5 cm above the carina. The tip of\n the NG tube is not visualized and is below the diaphragm. A left subclavian\n line is in the brachiocephalic vein. There are low lung volumes. Small left\n effusion is unchanged. No definite consolidations visualized.\n\n IMPRESSION: Stable small left effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 944914, "text": " 5:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed, infarction\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with w/necrotizing pancreatitis, gallstone / GB inflammation on\n initial CT now tachypnic, hypertensive, diaphoretic\n REASON FOR THIS EXAMINATION:\n bleed, infarction\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 66-year-old man with necrotizing pancreatitis, gallbladder\n inflammation, now hypertensive, tachypneic and diaphoretic. Question\n intracranial hemorrhage.\n\n COMPARISONS: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: The prior study is reviewed as scanned into PACS from an outside\n hospital, dated .\n\n There is no evidence of intracranial hemorrhage. There is mild atrophic\n change but no evidence of mass effect, hydrocephalus or shift of the normally\n midline structures. Small hypodense lesion near the -white matter\n junction in the left frontal lobe measures 6 mm in diameter and is unchanged.\n It may represent a prior infarct.\n\n Visualized paranasal sinuses are clear. There is fluid in the mastoid air\n cells bilaterally, which can be seen in intubation. There is also soft tissue\n density within the right sphenoid sinus.\n\n A nasogastric tube courses through the nose and the pharynx. The patient is\n intubated.\n\n IMPRESSION: Similar appearance of the brain, with no evidence of mass effect\n or intracranial hemorrhage. Small hypodensity in the left frontal lobe may\n represent prior infarction.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-16 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 945190, "text": " 8:15 AM\n PORTABLE ABDOMEN Clip # \n Reason: ngt location?\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with pancreatitis w/ NGT w/ increasing drainage\n REASON FOR THIS EXAMINATION:\n ngt location?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with pancreatitis and increasing NG tube\n drainage.\n\n COMPARISON: .\n\n SUPINE ABDOMINAL RADIOGRAPH: A nasogastric tube is seen with its tip at the\n pylorus. A feeding tube is seen with tip at the ligament of Treitz. The\n bowel gas pattern is unremarkable. There is increased opacity at the right\n lung base.\n\n IMPRESSION:\n 1. Nasogastric tube at the pylorus.\n 2. Dobbhoff tube at the ligament of Treitz.\n 3. Opacity at the right lung base which should be correlated with chest\n radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2173-02-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 944024, "text": " 6:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval RLL infiltrate\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with necrotizing pancreatitis\n REASON FOR THIS EXAMINATION:\n eval RLL infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Necrotizing pancreatitis. Evaluate right lower lobe infiltrate.\n\n FINDINGS: The endotracheal tube is 3 cm above the carina. The NG tube tip is\n in the stomach. There is some mild elevation of the right hemidiaphragm with\n some increase in right lower lobe/right middle lobe volume loss. Patchy areas\n of left lower lobe volume loss/infiltrate are also present. There is probable\n left pleural effusion.\n\n IMPRESSION: Increased volume loss on the right.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-11 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 944555, "text": " 8:52 AM\n PORTABLE ABDOMEN Clip # \n Reason: is the dobhoff post-pyloric?\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with pancreatitis, NG tube is aspirating tube feeds\n\n REASON FOR THIS EXAMINATION:\n is the dobhoff post-pyloric?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old male with pancreatitis and NG tube.\n\n PORTABLE ABDOMINAL RADIOGRAPH: Comparison is made with the prior abdominal\n radiograph dated . Again, note is made of nasogastric tube\n terminating in the right upper quadrant probably in gastric antrum. The\n Dobbhoff tube has advanced to the postpyloric position terminating in the left\n upper quadrant in the area of ligamentum Treitz. The abdomen is predominantly\n gasless with small amount of bowel gas, however, no significant dilatation or\n obstruction noted on this radiograph. Fluid-filled small bowel cannot be\n excluded. Note is made of surgical clips in the lower pelvis.\n\n IMPRESSION: Dobbhoff tube in the area of ligamentum Treitz. Predominantly\n gasless abdomen.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 945654, "text": " 7:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Acute process?\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with w/ nec pancreatitis with cough on BiPap\n\n REASON FOR THIS EXAMINATION:\n Acute process?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:36 a.m. .\n\n HISTORY: Necrotizing pancreatitis. Cough.\n\n IMPRESSION: AP chest compared to through 25:\n\n Lung volumes remain low with particular elevation of the right lung base and\n stable atelectasis in the right lower lung. Left lung clear. Heart size\n normal. Mediastinum midline. Feeding tube ends in the stomach. Right\n subclavian line tip projects over the low superior vena cava. No pneumothorax\n or appreciable pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 945476, "text": " 4:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia? interval change?\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with w/ nec pancreatitis with cough\n REASON FOR THIS EXAMINATION:\n pneumonia? interval change?\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Evaluate interval change, query pneumonia, patient with\n necrotizing pancreatitis with cough.\n\n Comparison is made with prior study dated .\n\n FINDINGS: Low lung volumes. There has been mild interval increase in size in\n the left small pleural effusion. Stable small right pleural effusion.\n Unchanged right lower lobe and right middle lobe atelectases. Mild increase\n in left lower lobe opacity due to atelectasis. Right subclavian vein catheter\n with tip in the lower SVC. NG tube tip is out of view below the diaphragm.\n\n" }, { "category": "Radiology", "chartdate": "2173-02-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 943936, "text": " 9:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with necrotizing pancreatitis s/p left subclavian line\n\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Fever.\n\n A single AP view of the chest is obtained at 0935 hours and is\n compared with the prior radiograph of .\n\n The left costophrenic angle area is excluded from the film. Tubes and lines\n appear unchanged. Cardiomediastinal silhouette is unchanged. There is some\n left lower lobe atelectasis, which is likely unchanged. There may be a left\n pleural effusion, but the costophrenic angle is excluded. In the right lower\n lung zone, there is some patchy opacity, which likely represents early\n infiltrate.\n\n IMPRESSION:\n\n Patchy airspace disease developing in the right base. Otherwise, no\n significant change since the prior examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-21 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 945914, "text": " 8:29 AM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: HIGH FEVER AND WHITE COUNT, NECROTIZING PANCREATITIS, EVALUATE, ? COLLECTIONS\n Admitting Diagnosis: SEVERE PANCREATITIS\n Field of view: 44 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with necrotizing pancreatitis, high fever and white count\n\n REASON FOR THIS EXAMINATION:\n collections? pancreatic necrosis? please use po and iv contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old man with necrotizing pancreatitis, high fever and white\n count.\n\n COMPARISON: .\n\n TECHNIQUE: Multidetector axial images of the abdomen and pelvis were obtained\n without and with IV contrast. 130 cc of Optiray. Oral contrast was also\n administered. Coronal and sagittal reformatted images were obtained.\n\n CT ABDOMEN: There continues to be consolidation at the right lung base which\n could represent atelectasis or aspiration. There is mild intrahepatic biliary\n ductal dilatation. A nonobstructing stone is identified in the gallbladder.\n The spleen, adrenal glands, and kidneys are unchanged in appearance. Again\n seen is near-complete necrosis of the pancreatic head. The body and tail of\n the pancreas is stable. The peripancreatic collections have significantly\n increased in size. There is now a more discrete rounded collection impressing\n on the inferior stomach measuring 8.3 x 6 cm. Inferior to the second and third\n portions of the duodenum are smaller rounded collections. The largest measures\n 4.9 x 4 cm. A nasogastric tube is identified within the stomach. The duodenum\n is edematous. There is an adjacent segment of proximal jejunum which also\n appears involved with inflammatory stranding. More distal bowel loops are\n within normal limits. There is no free air. Scattered prominent periportal\n lymph nodes are identified.\n\n CT PELVIS: Foley catheter and air are noted in the bladder. The patient\n appears to be status post prostatectomy. The sigmoid colon, rectum, and\n appendix are within normal limits. There is no pelvic or inguinal\n lymphadenopathy.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n\n 1. Progression of necrotizing pancreatitis with significant interval increase\n in peripancreatic fluid. 8.3 x 6 cm rounded collection impressing on the\n greater curvature of the stomach is starting to form a more discrete wall.\n Additional similar rounded collections along the duodenum.\n\n 2. Cholelithiasis without evidence of cholecystitis.\n (Over)\n\n 8:29 AM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: HIGH FEVER AND WHITE COUNT, NECROTIZING PANCREATITIS, EVALUATE, ? COLLECTIONS\n Admitting Diagnosis: SEVERE PANCREATITIS\n Field of view: 44 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Consolidation at the right base which could represent atelectasis or less\n likely aspiration. The appearance is not significantly changed from prior\n exam.\n\n 4. Sigmoid diverticulosis without evidence of diverticulitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-18 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 945498, "text": " 8:02 AM\n PORTABLE ABDOMEN Clip # \n Reason: ngt placement? dophoff location? obstruction?\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with pancreatitis w/ vomiting of tube feeds after ngt removed\n REASON FOR THIS EXAMINATION:\n ngt placement? dophoff location? obstruction?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with pancreatitis and vomiting of tube feeds.\n\n COMPARISON: .\n\n SUPINE ABDOMINAL RADIOGRAPH: Compared to the prior examination, the Dobbhoff\n tube has migrated and now lies coiled within the stomach. A nasogastric tube\n is also seen within the stomach. The proximal sideport is incompletely\n evaluated and may lie at or above the GE junction. The bowel gas pattern is\n unremarkable without evidence of obstruction. The osseous structures are\n unremarkable. Clips are seen within the lower pelvis.\n\n IMPRESSION:\n\n 1. Dobhoff tube coiled within the stomach.\n\n 2. Nasogastric tube tip lies within the stomach. The proximal sideport is\n not fully evaluated and may lie at or above the GE junction.\n\n 3. Nonobstructive bowel gas pattern.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-03-11 00:00:00.000", "description": "Report", "row_id": 1416439, "text": "T/SICU Shift Report 0700-\n66 Year Old Male NKA FULL CODE Contact Precautions\n\nAdmission - Acute Pancreastitis\nReadmission - Sepsis\nReadmission - Vomiting/?Aspiration\n\nPMH - Hypertension\n Prostate CA (S/P RRP)\n Sleep Apnea\n\nOR - - Pancreatic resection\n\nReview of Systems:\n\nResp - SV on RA. SpO2 >94%, RR 20-30BPM. Breath sounds clear to upper lobes diminished at the bases. Coughing and clearing independently. Using IS.\n\nCVS - Sinus rhythm occasional PVCs. HR 75-105bpm, SBP 100-145, MAP 65-85, Tmax 97.8. Peripherally warm/well perfused/minimal edema. No IV ABs. P-boots/heparin.\n\nRenal - UO 30-50ml/hr, positive 1200ml today.\n\nNeuro - Alert/lethargic, oriented to place/person. GCS 15 (e4v5m6). MAE. No complaints of pain.\n\nGI - TF at goal rate 3/4 impact via j-tube. G-tube/T-tube clamped. No BM today (loperamide held). soft/distended/hypoactive bowel sounds. Blood glucose stable with ISS.\n\nSkin - OOB to chair for two hours. Complaining of pain left eye, erythromycin ointment applied QID.\n\nAccess - Cline/Aline discontinued, line tips sent for culture. PICC line redressed/patent.\n\nSocial - Visited by wife/daughter.\n\nPLAN - CTA (with renal protection)\n ?transfer to floor \n Pulmonary hygiene\n\n" }, { "category": "Nursing/other", "chartdate": "2173-03-12 00:00:00.000", "description": "Report", "row_id": 1416440, "text": "nursing progress note\n\nneuro: alert, oriented x3 at best. exam waxes and wanes. moving all extrem, R arm strength improving slowly. c/o pain to R arm w/ passive motion. denies pain otherwise. conversation at times confused, often reoriented.\n\nresp: ls clear, dimin to bases, R>L. cough strong, clearing sm amts thick yellow sputum on own. freq oral care provided, mucosa intact. o2 sats stable on room air.\n\ncv: bp stable, given lopressor po dose as per orders. nsr, occas pvc's and pac's. extrem warm, pulses intact. lytes repleted per orders. am labs pending at this time.\n\ngi: belly soft/nt/distended. bs present, + flatus. large loose golden bm this am, cx obtained for o+p. midline wound w/ bilious appearing drainage, suction working although not completely. changed to wall sx this am, icu and surgery teams aware. jps w/ pancreatic output, foul odor.\n\ngu: foley patent clear yellow urine, qs.\n\nendo: bg's slightly elevated, sliding scale and nph dosing continue.\n\nid: tmax 99 overnight, wbc pending this am.\n\nskin: no new issues.\n\nsocial: daughters in to visit last evening, supportive. all questions answered, update provided.\n\na/p: for repeat abd CT w/ contrast today, renal protection ordered. continue to monitor neuro exam. follow i/o, wbc, drain outputs. transfer to floor when primary team clears, bed available.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-15 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 945054, "text": " 9:23 AM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: RESP DISTRESS, HYPOTENSION\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with resp distress hypotension\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n DUPLEX OF LOWER LIMBS\n\n INDICATION: Respiratory distress and hypertension, rule out DVT.\n\n FINDINGS: The right common femoral vein, right saphenofemoral junction, right\n superficial femoral vein, and right popliteal veins are all normal to\n compression. The left common femoral vein, left saphenofemoral junction, left\n superficial femoral vein, and left popliteal veins are all normal to\n compression. All veins are normal to augmentation. No evidence of any DVT.\n\n IMPRESSION: No evidence of DVT in either right or left lower limb.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-07 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 944070, "text": " 2:07 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: check for interval change\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with necrotizing pancreatitis\n REASON FOR THIS EXAMINATION:\n check for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old man with necrotizing pancreatitis, assess for interval\n change.\n\n COMPARISON: CT study from an outside hospital of .\n\n TECHNIQUE: Multidetector contiguous axial images of the abdomen and pelvis\n were obtained prior to and following the administration of 130 cc of\n intravenous Optiray contrast. Reformatted images in the coronal and sagittal\n planes were obtained.\n\n FINDINGS:\n There has been extensive necrosis of the pancreas in the interval between the\n two studies, predominantly of the head and mid body, with surrounding\n stranding of the mesenteric fat. Portions of the head has been replaced by\n necrotic debris of relative low attenuation (series 3, image 40). An area of\n relative low attenuation is also seen on this same image anterior to the mid\n body of the pancreas. The superior mesenteric arteries and veins are patent.\n The splenic vein, portal splenic confluence, splenic veins and portal veins\n are patent.\n\n There is no free air in the abdomen.\n\n Few images through the lung bases demonstrate bibasilar atelectasis, right\n greater than left. There are coronary artery calcifications present. There\n is a nasojejunal tube seen with its tip in the proximal jejunum. The liver is\n normal with the exception of a 3 mm focus of low attenuation in the left lobe,\n likely a small simple cyst. The spleen, adrenal glands, and kidneys are\n normal in appearance. In the interpolar region of the left kidney, there is a\n 4 to 5-mm focus of relative low attenuation that is too small to fully\n characterize. There is a calcified gallstone present. The gallbladder is\n otherwise normal in appearance.\n\n Both adrenal glands are normal in appearance. The caliber of the loops of\n small and large bowel are normal in appearance. And there is no bowel\n obstruction.\n\n\n CT PELVIS: There is a Foley catheter in the bladder. The sigmoid colon is\n not distended. There is no free fluid in the pelvis.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions are present.\n (Over)\n\n 2:07 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: check for interval change\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Reformatted images in coronal and sagittal planes confirm the above findings.\n\n IMPRESSION: Compared to the outside study of , there has been\n progression of the inflammatory changes surrounding the pancreas, consistent\n with the patient's history of necrotizing pancreatitis. There is near total\n necrosis of the pancreatic head with necrotic relative low attenuation\n material in this region. No well-defined drainable fluid collections are\n present at this time.\n\n" }, { "category": "Radiology", "chartdate": "2173-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 944386, "text": " 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with necrotizing pancreatitis, trying to wean vent\n\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Necrotizing pancreatitis. Trying to wean ventilator.\n\n COMPARISON: .\n\n CHEST AP: There is persistent opacity with air bronchograms in the right\n lower lung zone medially, which may represent atelectasis or pneumonia. Low\n lung volumes. The endotracheal tube terminates 4 cm above the carina. The\n left subclavian line terminates in the brachiocephalic vein. The NG tube is\n below the diaphragm. Small left effusion/atelectasis is unchanged.\n\n IMPRESSION: Persistent dense air bronchograms which may represent active\n infiltrate or atelectasis is unchanged and is seen better on the abdominal CT\n obtained .\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 944233, "text": " 7:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check for interval change\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with necrotizing pancreatitis\n\n REASON FOR THIS EXAMINATION:\n check for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:17 A.M. ON \n\n HISTORY: Necrotizing pancreatitis.\n\n IMPRESSION: AP chest compared to through 14:\n\n Lateral aspect of the left lower chest is excluded from the study. Other\n pleural surfaces are normal. Lung volumes remain quite low, but clear of\n focal abnormality. Cardiac silhouette is enlarged and mediastinal vascular\n engorgement suggest volume overload. Borderline interstitial edema is\n present.\n\n ET tube tip is at the thoracic inlet. A nasogastric tube, probably the\n feeding tube passes below the diaphragm out of view the other ends in the\n upper stomach. Tip of the left subclavian line projects over the left\n brachiocephalic vein. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 944872, "text": " 9:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval lung changes\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with w/ nec pancreatitis with fever to 101.8\n REASON FOR THIS EXAMINATION:\n interval lung changes\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: Pancreatitis and fever.\n\n One portable view. Comparison with . There is interval worsening of a\n right basilar infiltrate. The heart and mediastinal structures are unchanged.\n An endotracheal tube, left subclavian line, and feeding tubes remain in place.\n\n IMPRESSION: Interval worsening of right lung infiltrate.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-18 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 945535, "text": " 1:19 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: needs post-pyloric dobhoff placement\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with necrotizing pancreatitis\n\n REASON FOR THIS EXAMINATION:\n needs post-pyloric dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old male with necrotizing pancreatitis requiring post-\n pyloric feeding tube placement.\n\n Comparison is made to prior post-pyloric feeding tube placement dated , .\n\n FLUOROSCOPY-GUIDED POST-PYLORIC FEEDING TUBE PLACEMENT\n\n Under fluoroscopic guidance, a guide wire was inserted into the Dobbhoff\n feeding tube placed previously. After guide wire insertion, the feeding tube\n was then carefully advanced past the pyloric region with its tip terminating\n within the third portion of the duodenum slightly proximal to the ligament of\n Treitz. A small amount of Optiray contrast was then injected confirming\n appropriate positioning of the tube within the duodenum.\n\n IMPRESSION: Successful advancement of Dobbhoff feeding tube with tip\n positioned within the third portion of the duodenum.\n\n" }, { "category": "Radiology", "chartdate": "2173-02-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 944959, "text": " 8:29 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: new R SC line placement\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with w/ nec pancreatitis with fever to 101.8\n\n REASON FOR THIS EXAMINATION:\n new R SC line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Subclavian line placement.\n\n One view. Comparison with . The left costophrenic sulcus is not\n included. There is interval improvement in a right basilar infiltrate.\n Mediastinal structures are unchanged. A left subclavian line has been\n withdrawn. A right subclavian catheter has been inserted and terminates in\n the superior vena cava. Tubes remain in place. There is no other significant\n change.\n\n IMPRESSION: Interval improvement in right lung infiltrate. The right central\n line in place. No evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 946216, "text": " 8:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with w/ nec pancreatitis with cough on BiPap and labored\n respiration, now with fevers\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old male with necrotizing pancreatitis and cough on BiPAP.\n Increased fever. Rule out pneumonia.\n\n FINDINGS: Comparison is made to prior chest radiographs dated and\n .\n\n SINGLE PORTABLE AP CHEST RADIOGRAPH\n\n Unchanged appearance to low lung volumes with elevation of the right lung base\n and stable atelectasis within the right lower lung. When compared to\n radiograph from , there appears to be increased left-sided pleural\n effusion with similar appearance from radiograph dated . Since\n prior radiograph, there has been interval removal of right-sided central line,\n and nasogastric tube is identified in the stomach with distal tip not included\n on radiograph. No acute parenchymal consolidation is identified.\n\n IMPRESSION:\n\n 1. No acute parenchymal consolidation is identified.\n\n 2. Small left-sided pleural effusion with stable appearance to right lower\n and right middle lobe atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2173-02-03 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 943547, "text": " 3:42 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: needs post-pyloric tube placement\n Admitting Diagnosis: SEVERE PANCREATITIS\n Contrast: CONRAY Amt: 25\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with necrotizing pancreatitis\n\n REASON FOR THIS EXAMINATION:\n needs post-pyloric tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old male with necrotizing pancreatitis, requiring post-\n pyloric tube placement.\n\n POST-PYLORIC DOBBHOFF TUBE PLACEMENT\n\n Under fluoroscopic guidance, a currently inserted Dobbhoff feeding tube\n through the left nasal cavity was advanced post-pylorically with its tip\n located within the third portion of the duodenum. Small amount of contrast\n was injected through the tube confirming location within the small intestines.\n\n IMPRESSION:\n 1. Successful placement of post-pyloric feeding tube.\n\n" }, { "category": "Radiology", "chartdate": "2173-02-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 943355, "text": " 12:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval pulmonary status and location of central line.\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with necrotizing pancreatitis.\n REASON FOR THIS EXAMINATION:\n Eval pulmonary status and location of central line.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:23 P.M., \n\n HISTORY: Necrotizing pancreatitis. Evaluate line placement.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Marked elevation of the right lung base could be due to pleural effusion alone\n or pleural effusion in some combination with right middle and lower lobe\n collapse. Smaller left pleural effusion is present. Heart is grossly normal\n size, though right heart border is partially obscured. Nasogastric tube ends\n in the first portion of the duodenum. An ET tube is in standard placement and\n tip of the right jugular line is partially obscured, but appears to end over\n the mid portion of the SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-03 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 943464, "text": " 8:04 AM\n PORTABLE ABDOMEN Clip # \n Reason: dobhoff tube location\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with pancreatitis\n REASON FOR THIS EXAMINATION:\n dobhoff tube location\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old man with pancreatitis, assess for Dobbhoff tube\n location.\n\n Comparison is made to prior abdominal radiograph dated .\n\n TECHNIQUE: Portable supine abdominal radiograph.\n\n A gastric tube and Dobhoff tube are both identified with their tips within the\n stomach. There is decreased bowel gas noted when compared to prior\n examination.\n\n IMPRESSION:\n 1. Gastric and Dobbhoff tube tips still located within the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-02-02 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 943393, "text": " 3:22 PM\n PORTABLE ABDOMEN Clip # \n Reason: KUB - dobhoff tube placement - post pyloric?\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with pancreatitis s/p dobhoff tube placement.\n REASON FOR THIS EXAMINATION:\n KUB - dobhoff tube placement - post pyloric?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old male with pancreatitis status post Dobbhoff tube\n placement. Assess for position.\n\n Comparison is made to prior radiograph dated and chest\n radiograph from same day.\n\n TECHNIQUE: Single portable supine abdominal radiograph.\n\n A gastric tube and Dobbhoff tube are noted within the stomach, however,\n neither appears to have its tip within the duodenum. Remaining bowel gas\n pattern is grossly unremarkable.\n\n IMPRESSION:\n 1. Gastric and Dobbhoff tubes both with their tips within the distal stomach.\n\n Above findings discussed with the ordering physician, . on date of\n exam at approximately 4:30 p.m.\n\n" }, { "category": "Radiology", "chartdate": "2173-02-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 943634, "text": " 9:43 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement? pneumo?\n Admitting Diagnosis: SEVERE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with necrotizing pancreatitis s/p left subclavian line\n\n REASON FOR THIS EXAMINATION:\n line placement? pneumo?\n ______________________________________________________________________________\n FINAL REPORT\n\n PORTABLE SEMI-UPRIGHT RADIOGRAPH\n\n INDICATION: 66-year-old male with necrotizing pancreatitis for evaluation of\n left subclavian line placement.\n\n COMPARISON: .\n\n FINDINGS: There has been interval placement of left subclavian central venous\n catheter, with its tip located at the junction of the brachiocephalic vein and\n the superior vena cava. No pneumothorax is identified. Endotracheal tube is\n in standard position. Post-pyloric feeding tube extends into the duodenum.\n Right internal jugular central venous catheter remains partially obscured by\n overlying wires, but appears to terminate over the mid SVC. Elevation of\n right hemidiaphragm is unchanged, and could be due to pleural effusion alone\n or in combination with right middle and lower lobe collapse. Small left\n effusion is present, and left basilar atelectasis has worsened.\n\n IMPRESSION:\n\n 1. Status post placement of left subclavian central venous catheter, with the\n tip at the junction of left brachiocephalic vein and superior vena cava.\n\n 2. Unchanged appearance of elevated right hemidiaphragm, thought to be\n secondary to pleural effusion alone or in combination with right middle and\n lower lobe collapse.\n\n 3. Interval increase in left lower lobe atelectasis.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2164-04-17 00:00:00.000", "description": "CT ABD & PELVIS WITH CONTRAST", "row_id": 1232672, "text": " 8:38 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: AAA REPAIR\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Field of view: 44 Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 66M with hx AAA repair, now with GI bleedingClinical Question:\n aortoenteric fistula?\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YGd TUE 11:04 PM\n 1. 15 x 6 cm large right gluteal hematoma.\n 2. Status post L hemicolectomy and likely partial proctectomy with\n nonobstructing RLQ end colostomy. High density material in rectal pouch\n unchanged since , but new since . Unclear what this\n may represent but cannot exclude hemorrhage. Correlate with rectal exam.\n 3. Vascular grafts to celiac, SMA, and renal arteries are patent. No e/o\n aortoenteric fistula.\n 4. Known L ischial grade IV decubitus ulcer and osteomyelitis.\n 5. Stable right perihepatic fluid collection.\n 6. Large anterior abdominal defect with skin graft status post open\n thoracolumbar AAA repair, unchanged.\n 7. Subcentimeter anterior dome liver hypodensity (2, 17), too small to\n accurately characterize.\n 8. Gallbladder stone vs polyp.\n 9. Bilateral renal cysts.\n 10. PEG tube in place.\n\n Findings dw Dr. via phone at 9p on by x \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of abdominal aortic aneurysm repair, now with GI bleed.\n Evaluate for aortoenteric fistula.\n\n CT ABDOMEN AND PELVIS: MDCT imaging was performed from the lung bases to the\n pubic symphysis after the uneventful intravenous administration of contrast.\n Sagittal and coronal reformats and multiplanar reformats were performed.\n\n COMPARISON: CT abdomen and pelvis, .\n\n Total DLP: 774.56 mGy-cm.\n\n CTA: The patient is status post abdominal aortic aneurysm repair. The\n appearance of the aneurysm repair is unchanged since prior examinations. The\n abdominal aorta is rotated with the celiac artery (2:18) arising laterally off\n the aorta, the superior mesenteric artery also arising laterally (2:25) and\n the right and left renal arteries arising superiorly and inferiorly off the\n abdominal aorta, respectively. However, no flow-limiting stenosis is present\n and these vessels opacify normally. The left renal artery does make a slight\n hairpin bend prior to entering into the renal hilum (2:49) and there is slight\n (Over)\n\n 8:38 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: AAA REPAIR\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Field of view: 44 Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n narrowing of the right renal artery as it courses below the left renal vein\n (2:49). However, this appearance is unchanged from the prior study. No\n evidence for aortoenteric fistula is present. Minimal ectasia is present at\n the level of the common iliac artery anastomosis, stable. There is extensive\n atherosclerotic plaque along the course of the internal and external iliac\n arteries, but these vessels remain patent.\n\n ABDOMEN: A small right pleural effusion is present with adjacent compressive\n atelectasis. Left basilar atelectasis is present. Pacer wires are present in\n the right ventricle and right atrium. Minimal atherosclerotic calcification\n is present in the partially visualized heart. The spleen, adrenals, and\n pancreas appear normal. Bilateral renal cysts are present, the largest on the\n left measures 2.9 cm and the largest on the right measures 4.0 cm. No\n hydronephrosis is present. The liver parenchyma appears normal. There is a\n stable 4.2 x 1.5 cm perihepatic fluid collection (2:28). There are stones in\n the dependent portion of the gallbladder, but the gallbladder otherwise\n appears normal. No pathologically enlarged lymph nodes are present. There is\n no free fluid in the abdomen. There is PEG tube in the stomach. The small\n bowel loops are normal in caliber.\n\n PELVIS: There is a Foley within the bladder. There is slight high-density\n material which could be due to rectal bleeding; however, there is no evidence\n for an arterial fistula to the rectum to explain as high-density material\n which was not present on the prior study from . No free air or\n free fluid is present in the pelvis. There are no pathologically enlarged\n lymph nodes.\n\n BONE AND SOFT TISSUE WINDOWS: In the left gluteal region is a sebaceous cyst\n measuring 2.5 cm. There is little changed appearance to a stage IV left\n ischial tuberosity ulcer (2:178). In the right gluteal musculature is a 9.3\n (AP) x 15.0 (CC) x 6.0 (TRV) hematoma, but no evidence for active arterial\n extravasation is present within this hematoma. In the right proximal femoral\n shaft is a partially imaged soft tissue mass that occupies the marrow cavity\n (2:185). There may be slight cortical irregularity along the posterior margin\n of the femur, but no fracture is present (300b:25). Severe multilevel\n degenerative changes are present in the lumbar spine, unchanged. There is\n stable ventral wall soft tissue defect.\n\n IMPRESSION:\n\n 1. No evidence for aortoenteric fistula. High-density material in the rectum\n may be due to bleeding, correlate with rectal examination.\n\n 2. Stable appearance to abdominal aortic repair. Stable appearance to\n mesenteric vessels, and renal arteries, which remain patent.\n (Over)\n\n 8:38 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: AAA REPAIR\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Field of view: 44 Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Right gluteal hematoma without evidence for active arterial extravasation\n into the hematoma.\n\n 4. Soft tissue mass in the proximal right femur, incompletely evaluated.\n Dedicated musculoskeletal imaging is recommended.\n\n 5. Stable ventral wall defect.\n\n" }, { "category": "Radiology", "chartdate": "2164-04-18 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1232710, "text": " 8:09 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: please evaluate for bilateral DVT's\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with large gluteal hematoma\n REASON FOR THIS EXAMINATION:\n please evaluate for bilateral DVT's\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Large gluteal hematoma and question of bilateral deep venous\n thrombosis.\n\n COMPARISON: None available.\n\n FINDINGS: Waveforms in the common femoral veins are symmetric bilaterally\n with appropriate response to Valsalva maneuvers. In both lower extremities,\n the common femoral, proximal greater saphenous, superficial femoral and\n popliteal veins are normal with appropriate compressibility, wall-to-wall flow\n on color Doppler analysis and response to waveform augmentation. Wall-to-wall\n flow and compressibility are also present in the posterior tibial and peroneal\n veins bilaterally.\n\n IMPRESSION: No deep venous thrombosis in either lower extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-04-22 00:00:00.000", "description": "R CT LOW EXT W&W/O C RIGHT", "row_id": 1233345, "text": " 4:02 PM\n CT LOW EXT W&W/O C RIGHT Clip # \n Reason: evaluate soft tissue mass in proximal right femur. patient w\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with soft tissue mass in the proximal right femur, incompletely\n evaluated. Dedicated musculoskeletal imaging is recommended.\n REASON FOR THIS EXAMINATION:\n evaluate soft tissue mass in proximal right femur. patient w/ pacemaker, cannot\n get MRI\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE RIGHT FEMUR.\n\n CLINICAL HISTORY: Incidental soft tissue mass noted in the proximal right\n femur on a recent CT of the abdomen and pelvis.\n\n COMPARISON: CT on .\n\n TECHNIQUE: Axial CT images were acquired through the entire right femur in\n soft tissue and bone algorithms before and after IV contrast administration.\n Coronal and sagittal reformats were provided.\n\n FINDINGS: The right gluteal hematoma is unchanged in size and incompletely\n evaluated on this examination.\n\n In the subtrochanteric femur, there is a 1.6 x 1.8 x 4.2 cm enhancing oval\n lesion within the medullary canal. The adjacent posterior cortex of the\n posterior femur has a permeative appearance over a length of 10 cm. No other\n worrisome focal osseous lesions.\n\n There is a sclerotic eccentric lobulated ossified lesion in the distal medial\n femur in keeping with a healed non-ossified fibroma. There is rarefaction of\n the trabeculae in the superior acetabulum, likey related to osteopenia.\n\n There are mild vascular calcifications throughout the thigh. There is marked\n enthesopathy at the greater trochanter and periarticular calcifications at the\n medial aspect of the femoroacetabular joint near the femoral head-neck\n junction. There is enthesopathy at the origins of the right hamstring\n tendons. There are mild degenerative changes at the pubic symphysis and\n mild-to-moderate degenerative changes at the hip.\n\n A Foley catheter is in place. There are calcifications within the prostate.\n\n IMPRESSION: Intramedullary enhancing proximal femoral lesion with associated\n permeative destruction of the posterior femoral cortex is concerning for a\n neoplastic process. Metastatic disease, plasmacytoma, or lymphoma would be\n most likely in this age group.\n\n The findings were discussed with Dr. at 3:30 pm on by\n phone.\n (Over)\n\n 4:02 PM\n CT LOW EXT W&W/O C RIGHT Clip # \n Reason: evaluate soft tissue mass in proximal right femur. patient w\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2164-04-17 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 1232675, "text": " 8:51 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 66M with ? GI bleedClinical Question: PNA, other acute?\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n HISTORY: Question gastrointestinal bleeding.\n\n COMPARISONS: and 25, .\n\n TECHNIQUE: Chest, semi-upright AP views.\n\n FINDINGS: A tracheostomy tube is in place. There is a new left-sided PICC\n line terminating in the lower superior vena cava. A pacemaker device with a\n single lead terminates in the right atrium, as before. There is a coalescing\n opacity in the left lower lung, which suggests evolving atelectasis, based on\n the recent prior two studies, the former of which did not show the opacity.\n Aeration is overall better in the left lower lung, however. There is also a\n degree of right lower lobe atelectasis, which is again incomplete with\n somewhat improved aeration. There is no evidence for free air.\n\n IMPRESSION: Evolving left basilar opacity, probably coalescing atelectasis;\n infection is felt unlikely. No evidence for free air.\n\n" }, { "category": "Radiology", "chartdate": "2164-04-24 00:00:00.000", "description": "CT BONE DEEP BX", "row_id": 1233587, "text": " 8:54 AM\n CT BONE DEEP BX; CT GUIDED NEEDLE PLACTMENT Clip # \n Reason: Please biopsy R proximal femur mass\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ********************************* CPT Codes ********************************\n * CT BONE DEEP BX CT GUIDED NEEDLE PLACTMENT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with R femur mass concerning for metastatic process\n REASON FOR THIS EXAMINATION:\n Please biopsy R proximal femur mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT GUIDED RIGHT PROXIMAL FEMUR BONE LESION BIOPSY\n\n Indication: Diagnosis of right proximal femur bone lesion.\n\n Procedure: CT-guided right femoral bone lesion biopsy.\n\n Technique: The patient was informed of possible benefits, risks and\n alternatives. Written consent was obtained. A pre-procedural timeout was\n performed using at least 3 patient identifiers including name, birthday, and\n medical record number. Site and side of the procedure, as well as procedure\n to be performed were confirmed by the patient.\n\n A localizing CT scan was performed. An appropriate skin entry site was\n selected and the area prepped and draped in the usual sterile fashion. Local\n anesthesia in the form of 1% lidocaine was injected into the skin and\n subcutaneous soft tissues. A skin with 11G blade was made. A 16 gauge\n Bonopty device was advanced into the bone lesion and 3 bone cores were\n obtained with the Bonopty device. Then a spring-loaded biopsy device was\n advanced through the same coaxial sheath into the bone lesion. Needle position\n was confirmed by CT. Three soft tissue core specimens were obtained and were\n also submitted for pathology; the specimens were hand-delivered to the lab.\n\n The needle was removed, the skin entry site cleaned and a sterile bandage\n applied. The patient tolerated the procedure well and was transferred to the\n recovery area in satisfactory condition.\n\n No IV sedation was administered as the patient is paraplegic and has no\n sensation below the waist.\n\n FINDINGS:\n 1. Right femoral bone lesion.\n 2. CT images confirm biopsy needle within the lesion.\n\n IMPRESSION: Successful CT-guided biopsy of right femoral lesion.\n\n Dr. was present and provided direct supervision during the procedure.\n\n (Over)\n\n 8:54 AM\n CT BONE DEEP BX; CT GUIDED NEEDLE PLACTMENT Clip # \n Reason: Please biopsy R proximal femur mass\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "ECG", "chartdate": "2164-04-17 00:00:00.000", "description": "Report", "row_id": 256933, "text": "Sinus rhythm. No significant change compared to previous tracings, except for\nlack of baseline artifact.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2118-08-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682837, "text": "Ms. is a 64yo woman with h/o breast cancer in remission s/p\n chemotherapy and XRT, DM, and obesity who presents after her cat bit\n her.\n Three days prior to admission, the patient was bitten on her left leg\n by a cat at her work. Since she has been bitten by this cat before,\n she did not make much of it. The next day, her left leg began to\n become red and swollen. The redness was not resolving, and she\n developed a fever to 100 at home, so she came into the ED for care. As\n far as she knows, the cat is up to date on immunizations.\n In the ED, VS were: Tm 100.0 155/79 119 19 98%. She was noted\n to have full ROM at her ankle, so the team was not concerned about\n septic arthritis. A plain film of her leg showed no evidence of\n retained cat tooth. She was given a tetanus shot and treated with\n clindamycin and vancomycin given her penicillin allergy. She also\n received 3L of NS for her sinus tachycardia without change in her heart\n rate.\n Upon arrival to the ICU, she was comfortable without complaints.\n Cellulitis\n Assessment:\n Patient had some evidence of systemic infection given lactic acidosis\n and tachycardia in the ED. pt has red warm area of bite, no c/o of\n pain, temp 100.3, remains Tachy low 100\ns( pt\ns baseline)\n Action:\n Start ceftriaxone, cont Vanco.lactate sent , start NS 200cc/hr for 1L\n d/t elevated lactate\n Response:\n Lactate down to 2.8 from 4.1 in ED, HR 101-104 ST, vital signs stable\n Plan:\n Cont ABx, cont follow lactate, temp, cellulites.,Tylenol PRn for pain,\n to send u/a and lactate\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Upon arrival to unit BS 247. Pt had meal.\n Action:\n Given insulin per SS, hold on fixed dose of insulin 70/30. hold on\n glyburide for now\n Response:\n BS will check in the morning\n Plan:\n Cont follow BS, given home dose insulin.\n" }, { "category": "Nursing", "chartdate": "2118-08-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682820, "text": "Ms. is a 64yo woman with h/o breast cancer in remission s/p\n chemotherapy and XRT, DM, and obesity who presents after her cat bit\n her.\n Three days prior to admission, the patient was bitten on her left leg\n by a cat at her work. Since she has been bitten by this cat before,\n she did not make much of it. The next day, her left leg began to\n become red and swollen. The redness was not resolving, and she\n developed a fever to 100 at home, so she came into the ED for care. As\n far as she knows, the cat is up to date on immunizations.\n In the ED, VS were: Tm 100.0 155/79 119 19 98%. She was noted\n to have full ROM at her ankle, so the team was not concerned about\n septic arthritis. A plain film of her leg showed no evidence of\n retained cat tooth. She was given a tetanus shot and treated with\n clindamycin and vancomycin given her penicillin allergy. She also\n received 3L of NS for her sinus tachycardia without change in her heart\n rate.\n Upon arrival to the ICU, she was comfortable without complaints.\n Cellulitis\n Assessment:\n Patient had some evidence of systemic infection given lactic acidosis\n and tachycardia in the ED. pt has red warm area of bite, no c/o of\n pain, temp 100.3, remains Tachy low 100\ns( pt\ns baseline)\n Action:\n Start ceftriaxone, cont Vanco.lactate sent , start NS 200cc/hr for 1L\n d/t elevated lactate\n Response:\n Lactate down to 2.8 from 4.1 in ED\n Plan:\n Cont ABx, cont follow lactate, temp, cellulites.,Tylenol PRn for pain,\n to send u/a\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Upon arrival to unit BS 247. pt had meal.\n Action:\n Given insulin per SS, hold on fixed dose of insulin 70/30.\n Response:\n Plan:\n Cont follow BS, given home dose insulin.\n" }, { "category": "Physician ", "chartdate": "2118-08-07 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 682812, "text": "TITLE:\n Chief Complaint: cat bite\n HPI:\n Ms. is a 64yo woman with h/o breast cancer in remission s/p\n chemotherapy and XRT, DM, and obesity who presents after her cat bit\n her.\n Three days prior to admission, the patient was bitten on her left leg\n by a cat at her work. Since she has been bitten by this cat before,\n she did not make much of it. The next day, her left leg began to\n become red and swollen. The redness was not resolving, and she\n developed a fever to 100 at home, so she came into the ED for care. As\n far as she knows, the cat is up to date on immunizations.\n In the ED, VS were: Tm 100.0 155/79 119 19 98%. She was noted\n to have full ROM at her ankle, so the team was not concerned about\n septic arthritis. A plain film of her leg showed no evidence of\n retained cat tooth. She was given a tetanus shot and treated with\n clindamycin and vancomycin given her penicillin allergy. She also\n received 3L of NS for her sinus tachycardia without change in her heart\n rate.\n Upon arrival to the ICU, she was comfortable without complaints.\n Allergies:\n \n Pt states she has tolerated cephalosporins in the past.\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Medications (confirmed with pt):\n Arimidex 1mg daily\n Valsartan 160mg daily\n ASA 81mg daily\n Glyburide--unsure dose\n Insulin 70/30 70 units \n Calcium/Vitamin D/Vitamin K 500mg / 200 IU / 40mcg --not taking\n Vitamin D2 1000 unit daily--not taking\n Zoloft--recently given Rx but has not started\n Past medical history:\n Family history:\n Social History:\n * Breast Cancer--Diagnosed in with Stage IIB, ER positive,\n HER-2/neu negative cancer. Underwent lumpectomy followed by cytoxan\n and adriamycin x 4 cycles, then XRT. Started tamoxifen ; switched\n to Arimidex .\n * DM\n * HTN\n * Anxiety\n * Obesity\n * s/p TAH for fibriods in \n * s/p tonsillectomy\n PCP: \n Oncologist: \n +DM in both parents; No other family members with breast cancer.\n Works at an insurance company. Currently living with a roommate. Quit\n smoking around the age of 40. Does not drink at all. Has no pets in\n the home.\n Review of systems:\n Flowsheet Data as of 08:27 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 113 (113 - 113) bpm\n BP: 145/55(76) {145/55(76) - 145/55(76)} mmHg\n RR: 25 (25 - 25) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 108.7 kg (admission): 108.7 kg\n Height: 64 Inch\n Total In:\n 3,013 mL\n PO:\n TF:\n IVF:\n 13 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 3,013 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n 100.3 113 145/55 25 96% 2L\n Very pleasant, overweight woman in no distress.\n PERRL, EOMI, no scleral icterus.\n Mucous membranes moist, OP clear.\n Neck supple, no thyroid enlargement, no adenopathy.\n S1, S2, regular tachycardia, no murmurs or rub.\n Mild tachypnea with talking but able to speak in full sentences and not\n using accessory muscles. Lungs clear to auscultation b/l without\n wheeze or crackle.\n Abd: +BS, soft, NT, ND\n Neuro: A&O, speech intact. Strength 5/5 in UE and LE b/l.\n Left LE with erythema and warmth from below knee to above ankle, border\n marked in ED. Able to move freely at knee and ankle without pain. No\n evidence of abscess.\n No LE edema. DP +2 b/l.\n Labs / Radiology\n [image002.jpg]\n Tib/Fib film : read pending; per ED, no evidence of foreign body\n Assessment and Plan\n 64yo woman with h/o breast cancer in remission and DM presenting with\n cellulitis following a cat bite.\n # Cat bite/cellulitis:\n Patient had some evidence of systemic infection given lactic acidosis\n and tachycardia in the ED. Although she received clindamycin and\n vancomycin in the ED, she did not receive coverage for Pasteurella\n multocida. There is no evidence of septic arthritis, tenosynovitis, or\n osteomyelitis on imaging or exam.\n - will continue parenteral antibiotics given evidence of systemic\n infection\n - will broaden to ceftriaxone to cover P. multocida and vancomycin to\n cover community MRSA (day 1 = )\n - check lactate upon arrival to ICU\n - monitor exam (border marked in ED)\n - f/u final plain films to be sure no cat tooth left in wound\n - pt received Td in ED\n - tylenol PRN pain\n # Sinus tachycardia:\n Upon review of prior OMR notes, it appears she has a long history of\n sinus tachycardia at baseline (100-109). Her heart rate was somewhat\n above baseline on presentation, which may be a sign of illness from her\n cellulitis, pain, dehydration, or anxiety.\n - check TSH (last checked )\n - hold off on further IV fluids given no significant change in HR\n despite 3L of fluids\n # DM:\n - continue home insulin with a humalog sliding scale\n - hold on glyburide for now\n - continue ASA\n # Breast cancer, in remission:\n - continue arimidex (roommate will bring in her home meds)\n # Anemia: baseline Hct 32-38, current hct 34.6\n Microcytic anemia.\n - will check iron studies\n # HTN:\n - continue valsartan and ASA\n # Obesity: Pt is considering gastric bypass.\n # Anxiety: lorazepam PRN\n # FEN: diabetic, heart healthy diet\n # PPx: subQ heparin; no indication for GI PPx\n # Access: 18g PIV\n # Code: confirmed FULL\n # Comm: with friend \n # Dispo: likely to floor in AM\n" }, { "category": "Physician ", "chartdate": "2118-08-07 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 682814, "text": "Chief Complaint: Cat bite\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 64 yr old hx of breast ca in remission, DM, obesity\n Cat bit her while at work Thursday, last night had fever 100\n In ED, tachy 119, rest of vitals stable. Tetanus shot given. For pcn\n allergy, started on Vanc/Clinda\n Lactate 4.0. Also got 3 L IVF\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Penicillins\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n asa, valsartan, arimidex, insulin, glyburide\n Past medical history:\n Family history:\n Social History:\n Breast ca in remission\n DM\n Obesity\n HTN\n Anxiety\n s/p TAH for fibroids\n s/p tonsillectomy\n DM, no hx of breast ca\n Occupation: insurance company\n Drugs:\n Tobacco: ex-smoker, quit age ~40\n Alcohol: none\n Other: no pets at home, cat at work only\n Review of systems:\n Constitutional: Fever, No(t) Weight loss, not thirsty\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea\n No urinary, GI, MSK sx. All other systems negative.\n Flowsheet Data as of 09:07 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 111 (111 - 113) bpm\n BP: 132/53(72) {132/53(72) - 145/55(76)} mmHg\n RR: 19 (19 - 25) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 108.7 kg (admission): 108.7 kg\n Height: 64 Inch\n Total In:\n 3,016 mL\n PO:\n TF:\n IVF:\n 16 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 3,016 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: Tachycardic\n Peripheral Vascular: PPP\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Warm, Cellulitis left leg from ankle to knee, demarcated, non\n tender\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 120\n 34.6\n 247\n 0.7\n 12\n 25\n 96\n 3.8\n 135\n 13\n [image002.jpg]\n Other labs: Lactic Acid:4.0 --> 3.1\n Fluid analysis / Other labs: MCV 75\n Assessment and Plan\n 64 yr old with cat bite 2 days prior, presenting with left leg\n cellulitis, tachycardia.\n 1. Cat bite/cellulitis - agree with vanco/ceftriaxone, got tetanus,\n follow up on blood cultures. For Fever/lactic acidosis - repeat lactate\n pending, watch for signs of systemic infection, there have been no\n signs of hypotension, would c/w gentle hydration. Check u/a\n 2. Tachycardia - seems to be related to underlying infection but agree\n with r/o hyperthyroidism given this has been baseline HR\n 3. Thrombocytopenia - stable since \n 4. Anemia - mcv 75, check iron studies\n 5. DM - on insulin and ISS\n Rest of plan per Dr. note.\n ICU Care\n Nutrition: diabetic\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 07:14 PM\n Comments:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2118-08-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682815, "text": "Cellulitis\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2118-08-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682816, "text": "Ms. is a 64yo woman with h/o breast cancer in remission s/p\n chemotherapy and XRT, DM, and obesity who presents after her cat bit\n her.\n Three days prior to admission, the patient was bitten on her left leg\n by a cat at her work. Since she has been bitten by this cat before,\n she did not make much of it. The next day, her left leg began to\n become red and swollen. The redness was not resolving, and she\n developed a fever to 100 at home, so she came into the ED for care. As\n far as she knows, the cat is up to date on immunizations.\n In the ED, VS were: Tm 100.0 155/79 119 19 98%. She was noted\n to have full ROM at her ankle, so the team was not concerned about\n septic arthritis. A plain film of her leg showed no evidence of\n retained cat tooth. She was given a tetanus shot and treated with\n clindamycin and vancomycin given her penicillin allergy. She also\n received 3L of NS for her sinus tachycardia without change in her heart\n rate.\n Upon arrival to the ICU, she was comfortable without complaints.\n Cellulitis\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2118-08-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682817, "text": "Ms. is a 64yo woman with h/o breast cancer in remission s/p\n chemotherapy and XRT, DM, and obesity who presents after her cat bit\n her.\n Three days prior to admission, the patient was bitten on her left leg\n by a cat at her work. Since she has been bitten by this cat before,\n she did not make much of it. The next day, her left leg began to\n become red and swollen. The redness was not resolving, and she\n developed a fever to 100 at home, so she came into the ED for care. As\n far as she knows, the cat is up to date on immunizations.\n In the ED, VS were: Tm 100.0 155/79 119 19 98%. She was noted\n to have full ROM at her ankle, so the team was not concerned about\n septic arthritis. A plain film of her leg showed no evidence of\n retained cat tooth. She was given a tetanus shot and treated with\n clindamycin and vancomycin given her penicillin allergy. She also\n received 3L of NS for her sinus tachycardia without change in her heart\n rate.\n Upon arrival to the ICU, she was comfortable without complaints.\n Cellulitis\n Assessment:\n Patient had some evidence of systemic infection given lactic acidosis\n and tachycardia in the ED. pt has red warm area of bite, no c/o of\n pain, temp 100.3, remains Tachy low 100\ns( pt\ns baseline)\n Action:\n Start ceftriaxone, cont Vanco.lactate\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2118-08-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682818, "text": "Ms. is a 64yo woman with h/o breast cancer in remission s/p\n chemotherapy and XRT, DM, and obesity who presents after her cat bit\n her.\n Three days prior to admission, the patient was bitten on her left leg\n by a cat at her work. Since she has been bitten by this cat before,\n she did not make much of it. The next day, her left leg began to\n become red and swollen. The redness was not resolving, and she\n developed a fever to 100 at home, so she came into the ED for care. As\n far as she knows, the cat is up to date on immunizations.\n In the ED, VS were: Tm 100.0 155/79 119 19 98%. She was noted\n to have full ROM at her ankle, so the team was not concerned about\n septic arthritis. A plain film of her leg showed no evidence of\n retained cat tooth. She was given a tetanus shot and treated with\n clindamycin and vancomycin given her penicillin allergy. She also\n received 3L of NS for her sinus tachycardia without change in her heart\n rate.\n Upon arrival to the ICU, she was comfortable without complaints.\n Cellulitis\n Assessment:\n Patient had some evidence of systemic infection given lactic acidosis\n and tachycardia in the ED. pt has red warm area of bite, no c/o of\n pain, temp 100.3, remains Tachy low 100\ns( pt\ns baseline)\n Action:\n Start ceftriaxone, cont Vanco.lactate sent\n Response:\n Lactate down to 2.8 from 4.1 in ED\n Plan:\n Cont ABx, cont follow lactate, temp, cellulites.,Tylenol PRn for pain\n" }, { "category": "Nursing", "chartdate": "2118-08-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682893, "text": "Ms. is a 64yo woman with h/o breast cancer in remission s/p\n chemotherapy and XRT, DM, and obesity who presents after her cat bit\n her.\n Three days prior to admission, the patient was bitten on her left leg\n by a cat at her work. Since she has been bitten by this cat before,\n she did not make much of it. The next day, her left leg began to\n become red and swollen. The redness was not resolving, and she\n developed a fever to 100 at home, so she came into the ED for care. As\n far as she knows, the cat is up to date on immunizations.\n In the ED, VS were: Tm 100.0 155/79 119 19 98%. She was noted\n to have full ROM at her ankle, so the team was not concerned about\n septic arthritis. A plain film of her leg showed no evidence of\n retained cat tooth. She was given a tetanus shot and treated with\n clindamycin and vancomycin given her penicillin allergy. She also\n received 3L of NS for her sinus tachycardia without change in her heart\n rate. I took off her nasal canula this AM and her O2 sat is 95%. She\n denies complaints of SOB.\n Upon arrival to the ICU, she was comfortable without complaints.\n Initial lactate was high at 4.1 and HR elevated to 120\ns sinus tach.\n Overnight pt given one more liter IVF. HR improved. Pt afebrile.\n Lactate down to normal at 1.6. Pt continues on Vanco and clinda IV.\n She is alert and oriented with a complaint of headache. Given Tylenol.\n Transfer to commode for voiding with minimal assist.\n Blood glucose elevated to 317 this AM because we held her HS dose of\n insulin. Pt given her morning insulin plus coverage this AM and will\n eat normally as she is feeling well.\n Cellulitc left lower extremity looking less swollen and less red. Area\n is marked and not getting bigger, in fact it is less red.\n Cellulitis\n Assessment:\n Admitted with swollen, red cellulitis of left lower extremity. Her\n lactate was 4.1 and HR 120\n Action:\n Started on antibiotics and fluids.\n Response:\n Improved lactate and HR today.\n Plan:\n Continue with IV antibiotics, transfer to floor when stable.\n Hypertension, benign\n Assessment:\n Pt\ns BP 107/60 today.\n Action:\n I held her antihypertensive med this AM and will reassess as the day\n continues.\n Response:\n Plan:\n Follow vital signs closely.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Blood glucose elvated this AM due to holding PM dose last evening. She\n did get sliding scale coverage at that time.\n Action:\n Pt given her full AM dose of humolog 70/30 this AM (70 units) and feels\n well to eat a full breakfast.\n Response:\n Plan:\n Continue to follow fingerstick glucose QID and cover with sliding scale\n humolog as ordered.\n" }, { "category": "Physician ", "chartdate": "2118-08-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682902, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - admitted yesterday\n - well this AM\n Allergies:\n Penicillins\n Hives;\n Last dose of Antibiotics:\n Ceftriaxone - 09:15 PM\n Vancomycin - 05:16 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:15 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: 37.9\nC (100.3\n Tcurrent: 37\nC (98.6\n HR: 98 (98 - 113) bpm\n BP: 123/54(69) {115/43(61) - 145/65(81)} mmHg\n RR: 28 (19 - 29) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 108.7 kg (admission): 108.7 kg\n Height: 64 Inch\n Total In:\n 3,373 mL\n 933 mL\n PO:\n TF:\n IVF:\n 373 mL\n 933 mL\n Blood products:\n Total out:\n 550 mL\n 530 mL\n Urine:\n 550 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,823 mL\n 403 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n Very pleasant, overweight woman in no distress.\n PERRL, EOMI, no scleral icterus.\n Mucous membranes moist, OP clear.\n Neck supple, no thyroid enlargement, no adenopathy.\n S1, S2, regular tachycardia, no murmurs or rub.\n Mild tachypnea with talking but able to speak in full sentences and not\n using accessory muscles. Lungs clear to auscultation b/l without\n wheeze or crackle.\n Abd: +BS, soft, NT, ND\n Neuro: A&O, speech intact. Strength 5/5 in UE and LE b/l.\n Left LE with erythema and warmth from below knee to above ankle, border\n marked in ED. Able to move freely at knee and ankle without pain. No\n evidence of abscess.\n No LE edema. DP +2 b/l.\n Labs / Radiology\n 89 K/uL\n 10.2 g/dL\n 292 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 104 mEq/L\n 138 mEq/L\n 30.8 %\n 7.8 K/uL\n [image002.jpg]\n 04:23 AM\n WBC\n 7.8\n Hct\n 30.8\n Plt\n 89\n Cr\n 0.6\n Glucose\n 292\n Other labs: Lactic Acid:1.6 mmol/L\n Assessment and Plan\n CELLULITIS\n TACHYCARDIA, OTHER\n .H/O DIABETES MELLITUS (DM), TYPE II\n .H/O CANCER (MALIGNANT NEOPLASM), BREAST\n HYPERTENSION, BENIGN\n 64yo woman with h/o breast cancer in remission and DM presenting with\n cellulitis following a cat bite.\n # Cat bite/cellulitis:\n Patient had some evidence of systemic infection given lactic acidosis\n and tachycardia in the ED. Although she received clindamycin and\n vancomycin in the ED, she did not receive coverage for Pasteurella\n multocida. There is no evidence of septic arthritis, tenosynovitis, or\n osteomyelitis on imaging or exam. Lactate now normal at 1.6 and WBC\n improved. Xray without osteo\n - will continue ceftriaxone to cover P. multocida and vancomycin to\n cover community MRSA (day 1 = )\n - monitor exam\n - pt received Td in ED\n - tylenol PRN pain\n # Sinus tachycardia:\n Upon review of prior OMR notes, it appears she has a long history of\n sinus tachycardia at baseline (100-109). Her heart rate was somewhat\n above baseline on presentation, which may be a sign of illness from her\n cellulitis, pain, dehydration, or anxiety.\n - TSH normal\n - hold off on further IV fluids given no significant change in HR\n despite 3L of fluids\n - monitor of sx\n # DM:\n - continue home insulin with a humalog sliding scale\n - hold on glyburide for now\n - continue ASA\n # Breast cancer, in remission:\n - continue arimidex (roommate will bring in her home meds)\n # Anemia: baseline Hct 32-38, current hct 34.6\n Microcytic anemia.\n - monitor CBC\n # HTN:\n - continue valsartan and ASA\n # Obesity: Pt is considering gastric bypass.\n # Anxiety: lorazepam PRN\n # FEN: diabetic, heart healthy diet\n # PPx: subQ heparin; no indication for GI PPx\n # Access: 18g PIV\n # Code: confirmed FULL\n # Comm: with friend \n # Dispo: Transfer to floor today\n ICU Care\n Nutrition:\n Diabetic diet\n Glycemic Control: 70/30 and SSI\n Lines:\n 18 Gauge - 07:14 PM\n Prophylaxis:\n DVT: hep SC\n Stress ulcer: none needed\n VAP: none needed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: transfer to floor this AM\n" }, { "category": "Physician ", "chartdate": "2118-08-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 682903, "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 Overall, improved overnight.\n Maintained sinus tachycardia (baseline tachycardia)\n Tolerated 3 L NS iv fluids.\n Less tenderness of left leg.\n Offers no new complaints.\n History obtained from Medical records\n Allergies:\n Penicillins\n Hives;\n Last dose of Antibiotics:\n Ceftriaxone - 09:15 PM\n Vancomycin - 05:16 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:15 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 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 09:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37\nC (98.6\n HR: 99 (98 - 113) bpm\n BP: 123/56(72) {112/43(61) - 145/65(81)} mmHg\n RR: 19 (12 - 29) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 108.7 kg (admission): 108.7 kg\n Height: 64 Inch\n Total In:\n 3,373 mL\n 953 mL\n PO:\n TF:\n IVF:\n 373 mL\n 953 mL\n Blood products:\n Total out:\n 550 mL\n 530 mL\n Urine:\n 550 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,823 mL\n 423 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\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: 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: 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, Erythema left lower leg,\n blanching, non-tender.\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): 0x3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 10.2 g/dL\n 89 K/uL\n 292 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 104 mEq/L\n 138 mEq/L\n 30.8 %\n 7.8 K/uL\n [image002.jpg]\n 04:23 AM\n WBC\n 7.8\n Hct\n 30.8\n Plt\n 89\n Cr\n 0.6\n Glucose\n 292\n Other labs: Lactic Acid:1.6 mmol/L\n Assessment and Plan\n 64 yr old with cat bite 2 days prior, presenting with left leg\n cellulitis, tachycardia.\n Cat bite/cellulitis - agree with vanco/ceftriaxone, got tetanus, follow\n up on blood cultures. For Fever/lactic acidosis - repeat lactate\n pending, watch for signs of systemic infection, there have been no\n signs of hypotension, would c/w gentle hydration. Check u/a\n Vanco, cerftriaxone\n 2. Tachycardia - seems to be related to underlying infection but agree\n with r/o hyperthyroidism given this has been baseline HR\n 3. Thrombocytopenia - stable since \n 4. Anemia - mcv 75, check iron studies\n 5. DM - on insulin and ISS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:14 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 floor\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2118-08-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682904, "text": "Ms. is a 64yo woman with h/o breast cancer in remission s/p\n chemotherapy and XRT, DM, and obesity who presents after her cat bit\n her.\n Three days prior to admission, the patient was bitten on her left leg\n by a cat at her work. Since she has been bitten by this cat before,\n she did not make much of it. The next day, her left leg began to\n become red and swollen. The redness was not resolving, and she\n developed a fever to 100 at home, so she came into the ED for care. As\n far as she knows, the cat is up to date on immunizations.\n In the ED, VS were: Tm 100.0 155/79 119 19 98%. She was noted\n to have full ROM at her ankle, so the team was not concerned about\n septic arthritis. A plain film of her leg showed no evidence of\n retained cat tooth. She was given a tetanus shot and treated with\n clindamycin and vancomycin given her penicillin allergy. She also\n received 3L of NS for her sinus tachycardia without change in her heart\n rate. I took off her nasal canula this AM and her O2 sat is 95%. She\n denies complaints of SOB.\n Upon arrival to the ICU, she was comfortable without complaints.\n Initial lactate was high at 4.1 and HR elevated to 120\ns sinus tach.\n Overnight pt given one more liter IVF. HR improved. Pt afebrile.\n Lactate down to normal at 1.6. Pt continues on Vanco and clinda IV.\n She is alert and oriented with a complaint of headache. Given Tylenol.\n Transfer to commode for voiding with minimal assist.\n Blood glucose elevated to 317 this AM because we held her HS dose of\n insulin. Pt given her morning insulin plus coverage this AM and will\n eat normally as she is feeling well.\n Cellulitc left lower extremity looking less swollen and less red. Area\n is marked and not getting bigger, in fact it is less red.\n Cellulitis\n Assessment:\n Admitted with swollen, red cellulitis of left lower extremity. Her\n lactate was 4.1 and HR 120\n Action:\n Started on antibiotics and fluids.\n Response:\n Improved lactate and HR today.\n Plan:\n Continue with IV antibiotics, transfer to floor when stable.\n Hypertension, benign\n Assessment:\n Pt\ns BP 107/60 today at 0800. Onca awake pt\ns BP 140\n Action:\n I held her antihypertensive med at 0800 but did give it to her at 1000.\n Response:\n Vitial signs are stable.\n Plan:\n Follow vital signs closely.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Blood glucose elvated this AM due to holding PM dose last evening. She\n did get sliding scale coverage at .\n Action:\n Pt given her full AM dose of humolog 70/30 this AM (70 units) and feels\n well to eat a full breakfast. She also got 6Units humolog at 0800 for\n glucose 317\n Response:\n Pt eating well without complaints. Next fingerstick due at noon.\n Plan:\n Continue to follow fingerstick glucose QID and cover with sliding scale\n humolog as ordered. Continue sliding scale coverage.\n" }, { "category": "Nursing", "chartdate": "2118-08-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682908, "text": "Ms. is a 64yo woman with h/o breast cancer in remission s/p\n chemotherapy and XRT, DM, and obesity who presents after her cat bit\n her.\n Three days prior to admission, the patient was bitten on her left leg\n by a cat at her work. Since she has been bitten by this cat before,\n she did not make much of it. The next day, her left leg began to\n become red and swollen. The redness was not resolving, and she\n developed a fever to 100 at home, so she came into the ED for care. As\n far as she knows, the cat is up to date on immunizations.\n In the ED, VS were: Tm 100.0 155/79 119 19 98%. She was noted\n to have full ROM at her ankle, so the team was not concerned about\n septic arthritis. A plain film of her leg showed no evidence of\n retained cat tooth. She was given a tetanus shot and treated with\n clindamycin and vancomycin given her penicillin allergy. She also\n received 3L of NS for her sinus tachycardia without change in her heart\n rate. I took off her nasal canula this AM and her O2 sat is 95%. She\n denies complaints of SOB.\n Upon arrival to the ICU, she was comfortable without complaints.\n Initial lactate was high at 4.1 and HR elevated to 120\ns sinus tach.\n Overnight pt given one more liter IVF. HR improved. Pt afebrile.\n Lactate down to normal at 1.6. Pt continues on Vanco and clinda IV.\n She is alert and oriented with a complaint of headache. Given Tylenol.\n Transfer to commode for voiding with minimal assist.\n Blood glucose elevated to 317 this AM because we held her HS dose of\n insulin. Pt given her morning insulin plus coverage this AM and will\n eat normally as she is feeling well.\n Cellulitc left lower extremity looking less swollen and less red. Area\n is marked and not getting bigger, in fact it is less red.\n Cellulitis\n Assessment:\n Admitted with swollen, red cellulitis of left lower extremity. Her\n lactate was 4.1 and HR 120\n Action:\n Started on antibiotics and fluids.\n Response:\n Improved lactate and HR today. WBC also improved.\n Plan:\n Continue with IV antibiotics, transfer to floor when stable.\n Hypertension, benign\n Assessment:\n Pt\ns BP 107/60 today at 0800. Onca awake pt\ns BP 140\n Action:\n I held her antihypertensive med at 0800 but did give it to her at 1000.\n Response:\n Vitial signs are stable.\n Plan:\n Follow vital signs closely.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Blood glucose elvated this AM due to holding PM dose last evening. She\n did get sliding scale coverage at .\n Action:\n Pt given her full AM dose of humolog 70/30 this AM (70 units) and feels\n well to eat a full breakfast. She also got 6Units humolog at 0800 for\n glucose 317\n Response:\n Pt eating well without complaints. Next fingerstick due at noon.\n Plan:\n Continue to follow fingerstick glucose QID and cover with sliding scale\n humolog as ordered. Continue sliding scale coverage.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n CELLULITIS\n Code status:\n Full code\n Height:\n 64 Inch\n Admission weight:\n 108.7 kg\n Daily weight:\n 108.7 kg\n Allergies/Reactions:\n Penicillins\n Hives;\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: Breast Cancer--Diagnosed in with Stage IIB, ER\n positive, HER-2/neu negative cancer. Underwent lumpectomy followed by\n cytoxan and adriamycin x 4 cycles, then XRT. Started tamoxifen ;\n switched to Arimidex , thrombocytopenia, anemia.\n * Anxiety\n * Obesity\n * s/p TAH for fibriods in \n * s/p tonsillectomy\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:127\n D:64\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 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 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 959 mL\n 24h total out:\n 1,130 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 04:23 AM\n Potassium:\n 3.8 mEq/L\n 04:23 AM\n Chloride:\n 104 mEq/L\n 04:23 AM\n CO2:\n 26 mEq/L\n 04:23 AM\n BUN:\n 9 mg/dL\n 04:23 AM\n Creatinine:\n 0.6 mg/dL\n 04:23 AM\n Glucose:\n 292 mg/dL\n 04:23 AM\n Hematocrit:\n 30.8 %\n 04:23 AM\n Finger Stick Glucose:\n 317\n 08:00 AM\n Valuables / Signature\n Patient valuables: Pt has her black purse which I will transfer with\n her.\n Other valuables:\n Clothes: Pt has a bag of clothes sent to floor with her.\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: \n Transferred to: 11 \n Date & time of Transfer: \n" }, { "category": "Physician ", "chartdate": "2118-08-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682875, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Allergies:\n Penicillins\n Hives;\n Last dose of Antibiotics:\n Ceftriaxone - 09:15 PM\n Vancomycin - 05:16 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:15 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: 37.9\nC (100.3\n Tcurrent: 37\nC (98.6\n HR: 98 (98 - 113) bpm\n BP: 123/54(69) {115/43(61) - 145/65(81)} mmHg\n RR: 28 (19 - 29) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 108.7 kg (admission): 108.7 kg\n Height: 64 Inch\n Total In:\n 3,373 mL\n 933 mL\n PO:\n TF:\n IVF:\n 373 mL\n 933 mL\n Blood products:\n Total out:\n 550 mL\n 530 mL\n Urine:\n 550 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,823 mL\n 403 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n Very pleasant, overweight woman in no distress.\n PERRL, EOMI, no scleral icterus.\n Mucous membranes moist, OP clear.\n Neck supple, no thyroid enlargement, no adenopathy.\n S1, S2, regular tachycardia, no murmurs or rub.\n Mild tachypnea with talking but able to speak in full sentences and not\n using accessory muscles. Lungs clear to auscultation b/l without\n wheeze or crackle.\n Abd: +BS, soft, NT, ND\n Neuro: A&O, speech intact. Strength 5/5 in UE and LE b/l.\n Left LE with erythema and warmth from below knee to above ankle, border\n marked in ED. Able to move freely at knee and ankle without pain. No\n evidence of abscess.\n No LE edema. DP +2 b/l.\n Labs / Radiology\n 89 K/uL\n 10.2 g/dL\n 292 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 104 mEq/L\n 138 mEq/L\n 30.8 %\n 7.8 K/uL\n [image002.jpg]\n 04:23 AM\n WBC\n 7.8\n Hct\n 30.8\n Plt\n 89\n Cr\n 0.6\n Glucose\n 292\n Other labs: Lactic Acid:1.6 mmol/L\n Assessment and Plan\n CELLULITIS\n TACHYCARDIA, OTHER\n .H/O DIABETES MELLITUS (DM), TYPE II\n .H/O CANCER (MALIGNANT NEOPLASM), BREAST\n HYPERTENSION, BENIGN\n 64yo woman with h/o breast cancer in remission and DM presenting with\n cellulitis following a cat bite.\n # Cat bite/cellulitis:\n Patient had some evidence of systemic infection given lactic acidosis\n and tachycardia in the ED. Although she received clindamycin and\n vancomycin in the ED, she did not receive coverage for Pasteurella\n multocida. There is no evidence of septic arthritis, tenosynovitis, or\n osteomyelitis on imaging or exam.\n - will continue parenteral antibiotics given evidence of systemic\n infection\n - will broaden to ceftriaxone to cover P. multocida and vancomycin to\n cover community MRSA (day 1 = )\n - check lactate upon arrival to ICU\n - monitor exam (border marked in ED)\n - f/u final plain films to be sure no cat tooth left in wound\n - pt received Td in ED\n - tylenol PRN pain\n # Sinus tachycardia:\n Upon review of prior OMR notes, it appears she has a long history of\n sinus tachycardia at baseline (100-109). Her heart rate was somewhat\n above baseline on presentation, which may be a sign of illness from her\n cellulitis, pain, dehydration, or anxiety.\n - check TSH (last checked )\n - hold off on further IV fluids given no significant change in HR\n despite 3L of fluids\n # DM:\n - continue home insulin with a humalog sliding scale\n - hold on glyburide for now\n - continue ASA\n # Breast cancer, in remission:\n - continue arimidex (roommate will bring in her home meds)\n # Anemia: baseline Hct 32-38, current hct 34.6\n Microcytic anemia.\n - will check iron studies\n # HTN:\n - continue valsartan and ASA\n # Obesity: Pt is considering gastric bypass.\n # Anxiety: lorazepam PRN\n # FEN: diabetic, heart healthy diet\n # PPx: subQ heparin; no indication for GI PPx\n # Access: 18g PIV\n # Code: confirmed FULL\n # Comm: with friend \n # Dispo: likely to floor in AM\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:14 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": "2118-08-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 682982, "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 Overall, improved overnight.\n Maintained sinus tachycardia (baseline tachycardia)\n Tolerated 3 L NS iv fluids.\n Less tenderness of left leg.\n Offers no new complaints.\n History obtained from Medical records\n Allergies:\n Penicillins\n Hives;\n Last dose of Antibiotics:\n Ceftriaxone - 09:15 PM\n Vancomycin - 05:16 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:15 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 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 09:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37\nC (98.6\n HR: 99 (98 - 113) bpm\n BP: 123/56(72) {112/43(61) - 145/65(81)} mmHg\n RR: 19 (12 - 29) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 108.7 kg (admission): 108.7 kg\n Height: 64 Inch\n Total In:\n 3,373 mL\n 953 mL\n PO:\n TF:\n IVF:\n 373 mL\n 953 mL\n Blood products:\n Total out:\n 550 mL\n 530 mL\n Urine:\n 550 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,823 mL\n 423 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\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: 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: 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, Erythema left lower leg,\n blanching, non-tender.\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): 0x3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 10.2 g/dL\n 89 K/uL\n 292 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 104 mEq/L\n 138 mEq/L\n 30.8 %\n 7.8 K/uL\n [image002.jpg]\n 04:23 AM\n WBC\n 7.8\n Hct\n 30.8\n Plt\n 89\n Cr\n 0.6\n Glucose\n 292\n Other labs: Lactic Acid:1.6 mmol/L\n Assessment and Plan\n 64 yr old with cat bite 2 days prior, presenting with left leg\n cellulitis, tachycardia.\n CELLULITIS, LEFT LEG\n Attributable to cat bite\n cellulitis. Await\n culture results. Lactic acid normalized. Continue vanco and\n ceftriaxone.\n TACHYCARDIA\n appears at baseline. Stable. Monitor.\n THROMBOCYTOPENIA -- stable since \n ANEMIA\n await iron studies.\n NIDDM -- on insulin and ISS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:14 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 floor\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2118-08-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682827, "text": "Ms. is a 64yo woman with h/o breast cancer in remission s/p\n chemotherapy and XRT, DM, and obesity who presents after her cat bit\n her.\n Three days prior to admission, the patient was bitten on her left leg\n by a cat at her work. Since she has been bitten by this cat before,\n she did not make much of it. The next day, her left leg began to\n become red and swollen. The redness was not resolving, and she\n developed a fever to 100 at home, so she came into the ED for care. As\n far as she knows, the cat is up to date on immunizations.\n In the ED, VS were: Tm 100.0 155/79 119 19 98%. She was noted\n to have full ROM at her ankle, so the team was not concerned about\n septic arthritis. A plain film of her leg showed no evidence of\n retained cat tooth. She was given a tetanus shot and treated with\n clindamycin and vancomycin given her penicillin allergy. She also\n received 3L of NS for her sinus tachycardia without change in her heart\n rate.\n Upon arrival to the ICU, she was comfortable without complaints.\n Cellulitis\n Assessment:\n Patient had some evidence of systemic infection given lactic acidosis\n and tachycardia in the ED. pt has red warm area of bite, no c/o of\n pain, temp 100.3, remains Tachy low 100\ns( pt\ns baseline)\n Action:\n Start ceftriaxone, cont Vanco.lactate sent , start NS 200cc/hr for 1L\n d/t elevated lactate\n Response:\n Lactate down to 2.8 from 4.1 in ED\n Plan:\n Cont ABx, cont follow lactate, temp, cellulites.,Tylenol PRn for pain,\n to send u/a and lactate\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Upon arrival to unit BS 247. pt had meal.\n Action:\n Given insulin per SS, hold on fixed dose of insulin 70/30. hold on\n glyburide for now\n Response:\n Plan:\n Cont follow BS, given home dose insulin.\n" }, { "category": "Nursing", "chartdate": "2118-08-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682821, "text": "Ms. is a 64yo woman with h/o breast cancer in remission s/p\n chemotherapy and XRT, DM, and obesity who presents after her cat bit\n her.\n Three days prior to admission, the patient was bitten on her left leg\n by a cat at her work. Since she has been bitten by this cat before,\n she did not make much of it. The next day, her left leg began to\n become red and swollen. The redness was not resolving, and she\n developed a fever to 100 at home, so she came into the ED for care. As\n far as she knows, the cat is up to date on immunizations.\n In the ED, VS were: Tm 100.0 155/79 119 19 98%. She was noted\n to have full ROM at her ankle, so the team was not concerned about\n septic arthritis. A plain film of her leg showed no evidence of\n retained cat tooth. She was given a tetanus shot and treated with\n clindamycin and vancomycin given her penicillin allergy. She also\n received 3L of NS for her sinus tachycardia without change in her heart\n rate.\n Upon arrival to the ICU, she was comfortable without complaints.\n Cellulitis\n Assessment:\n Patient had some evidence of systemic infection given lactic acidosis\n and tachycardia in the ED. pt has red warm area of bite, no c/o of\n pain, temp 100.3, remains Tachy low 100\ns( pt\ns baseline)\n Action:\n Start ceftriaxone, cont Vanco.lactate sent , start NS 200cc/hr for 1L\n d/t elevated lactate\n Response:\n Lactate down to 2.8 from 4.1 in ED\n Plan:\n Cont ABx, cont follow lactate, temp, cellulites.,Tylenol PRn for pain,\n to send u/a\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Upon arrival to unit BS 247. pt had meal.\n Action:\n Given insulin per SS, hold on fixed dose of insulin 70/30. hold on\n glyburide for now\n Response:\n Plan:\n Cont follow BS, given home dose insulin.\n" }, { "category": "Radiology", "chartdate": "2118-08-07 00:00:00.000", "description": "L TIB/FIB (AP & LAT) LEFT", "row_id": 1084939, "text": " 3:07 PM\n TIB/FIB (AP & LAT) LEFT Clip # \n Reason: eval for retained cat teeth\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with leg swelling s/p cat bite\n REASON FOR THIS EXAMINATION:\n eval for retained cat teeth\n ______________________________________________________________________________\n FINAL REPORT\n LEFT TIBIA AND FIBULA RADIOGRAPH PERFORMED ON .\n\n COMPARISON: None.\n\n CLINICAL HISTORY: 64-year-old woman with leg swelling status post cat bite on\n Thursday. Evaluate for retained cat teeth.\n\n FINDINGS: AP and lateral views of the left lower leg are obtained. An arrow\n is seen along the lateral aspect of the proximal lower leg and the lateral\n aspect of the distal lower leg at the level of the ankle, indicating the site\n of trauma. Also, there are two BBs along the skin in the superior aspect of\n the left lower leg also indicating site of penetration. There is no acute\n fracture or dislocation. No definite foreign bodies are identified. Joints\n appear well aligned. Calcaneal spurs are incidentally noted. Soft tissue\n edema is noted along the left lower leg.\n\n IMPRESSION: Soft tissue swelling without evidence of retained foreign body. If\n there is strong clinical concern, ultrasound can be performed at the level of\n bite to evaluate for radiolucent foreign bodies.\n SESHa\n\n" } ]

[ { "category": "Radiology", "chartdate": "2152-12-26 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1215781, "text": " 8:02 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: LT MCA STROKE, PLEASE EVAL VASCULAR PATENCY\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with Left MCA stroke\n REASON FOR THIS EXAMINATION:\n please evaluate vascular patency\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GJq TUE 8:53 AM\n PFI:\n 1. Multiple focal acute infarcts in left MCA territory.\n\n 2. 6 mm sized multilobulated aneurysm at right MCA bifurcation.\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID DOPPLER ULTRASOUND\n\n INDICATION: A 64-year-old woman with left MCA stroke. Rule out carotid\n artery stenosis.\n\n TECHNIQUE: Grayscale and Doppler ultrasound images of bilateral carotid\n arteries were obtained.\n\n FINDINGS: Minimal homogeneous plaque is seen at the proximal left internal\n carotid artery. The peak systolic velocity in the right internal carotid\n artery ranges from 68 to 100 cm/sec and in the left internal carotid artery\n from 46 to 86 cm/sec. The peak systolic velocity in the right common carotid\n artery is 61 cm/sec and the left common carotid artery is 79 cm/sec.\n Bilateral external carotid arteries are patent. There is antegrade flow in\n the bilateral vertebral arteries. The ICA/CCA ratio on the right is 1.63 and\n on the left is 1.08.\n\n IMPRESSION: No evidence of significant carotid artery stenosis bilaterally.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-12-26 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1215782, "text": ", H. NMED SICU-A 8:02 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: LT MCA STROKE, PLEASE EVAL VASCULAR PATENCY\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with Left MCA stroke\n REASON FOR THIS EXAMINATION:\n please evaluate vascular patency\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. Multiple focal acute infarcts in left MCA territory.\n\n 2. 6 mm sized multilobulated aneurysm at right MCA bifurcation.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-12-25 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1215723, "text": " 5:03 PM\n MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST\n Reason: ise there a larghe stroke; eval for intervention\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with left mca symptoms. NO CONTARST TO BE GIVEN\n REASON FOR THIS EXAMINATION:\n ise there a larghe stroke; eval for intervention\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe MON 8:55 PM\n Acute stroke in the left MCA territory (< of the MCA territory) without\n evidence of hemorrhagic conversion.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GJq TUE 12:18 PM\n 1. Multiple focal acute infarcts in left MCA territory, likely secondary to\n proximal embolic source.\n\n 2. 6 mm sized multilobulated aneurysm at right MCA bifurcation.\n\n Findings discussed by dr with dr on \n at 1215 over phone\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old woman with left MCA symptoms. To evaluate for\n stroke.\n\n COMPARISON: CT head from outside hospital uploaded to PACS for comparison.\n\n TECHNIQUE: MRI and MRA of the brain was obtained without contrast per\n department protocol.\n\n FINDINGS:\n\n MRI BRAIN: There are multiple small foci of slow diffusion seen involving the\n left precentral gyrus, left centrum semiovale, left corona radiata, left\n periventricular parenchyma- medial aspect of left caudate and part of the left\n insular cortex, suggestive of acute infarcts. No abnormal susceptibility is\n seen on the gradient echo sequence to suggest hemorrhage. No other diffusion\n abnormalities are seen. There is no acute intracranial hemorrhage, edema, or\n mass effect seen. Multiple scattered FLAIr hyperintense foci are noted in the\n cerebral white matter, non-specific in appearance. Ventricles and sulci are\n normal in size and contour. Major intracranial flow voids appear normal.\n Visualized paranasal sinuses, orbits and mastoid air cells are unremarkable.\n\n MRA BRAIN: A 3.9x5.9 mm multilobulated, saccular aneurysm is seen arising at\n the right Middle Cerebral Artery bifurcation. ( se 404, im 7) Bilateral\n internal carotid arteries, vertebral, basilar arteries and their major\n branches are otherwise patent with no evidence of focal flow limiting stenosis\n or occlusion.\n\n\n (Over)\n\n 5:03 PM\n MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST\n Reason: ise there a larghe stroke; eval for intervention\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Multiple focal, small acute infarcts in left MCA territory, likely\n secondary to proximal embolic source. Correlate clinically\n\n 2. 3.9x5.9 mm sized multilobulated aneurysm at right MCA bifurcation.\n Consider Interventional neuroradiology consult.\n\n Findings discussed by Dr with Dr on \n at 1215 over phone.\n\n" }, { "category": "Radiology", "chartdate": "2152-12-25 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1215724, "text": "HAUSSEN, EU 5:03 PM\n MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST\n Reason: ise there a larghe stroke; eval for intervention\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with left mca symptoms. NO CONTARST TO BE GIVEN\n REASON FOR THIS EXAMINATION:\n ise there a larghe stroke; eval for intervention\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Multiple focal acute infarcts in left MCA territory, likely secondary to\n proximal embolic source.\n\n 2. 6 mm sized multilobulated aneurysm at right MCA bifurcation.\n\n Findings discussed by dr with dr on \n at 1215 over phone\n\n" }, { "category": "Radiology", "chartdate": "2152-12-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1215761, "text": " 3:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for CHF, infection\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with afib, stroke\n REASON FOR THIS EXAMINATION:\n Please evaluate for CHF, infection\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old female with atrial fibrillation with stroke.\n\n COMPARISON: CT .\n\n PORTABLE CHEST\n\n There is extensive pleural thickening and calcification involving the right\n lower hemithorax, with associated volume loss and increased opacity of the\n right lung. There are additional extensive pericardial calcifications. There\n is a possible parenchymal opacity at the right lung base, though it is unclear\n whether this represents additional pleural abnormality or more likely\n associated atelectasis. The right upper lung zone and left lung remain clear.\n There is no pleural effusion or pneumothorax. The heart is mildly enlarged\n and there is widening of the mediastinal contours, incompletely evaluated\n though likely reflecting adenopathy seen on chest CT. There is no pulmonary\n edema.\n\n IMPRESSION:\n\n 1. Extensive pleural thickening and pleural calcification in the right\n hemithorax with associated volume loss and pericardial calcification, as seen\n on prior chest CT, most likely the sequelae of prior pleuropericarditis.\n\n 2. Added opacity at the right lung base, which could represent additional\n pleural abnormality or atelectasis, though if there is concern for pnuemonia,\n radiographic followup is recommended.\n\n 3. Mediastinal widening, likely reflecting adenopathy seen on recent chest\n CT.\n\n" }, { "category": "Echo", "chartdate": "2152-12-26 00:00:00.000", "description": "Report", "row_id": 93885, "text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Left ventricular function.\nHeight: (in) 60\nWeight (lb): 177\nBSA (m2): 1.77 m2\nBP (mm Hg): 140/92\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 11:37\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Optison\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD or PFO by 2D, color\nDoppler or saline contrast with maneuvers. Normal IVC diameter (>2.1cm) with\n<50% decrease with sniff (estimated RA pressure (>=15 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mild-moderate\nglobal left ventricular hypokinesis. 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: Mildly thickened aortic valve leaflets (3). 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 [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\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. The\nrhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is dilated. (Transthoracic echocardiography not adequate to\nassess for atrial thrombus, particularly appendage thrombus). No atrial septal\ndefect or patent foramen ovale is seen by 2D, color Doppler or saline contrast\nwith maneuvers. The estimated right atrial pressure is at least 15 mmHg. Left\nventricular wall thicknesses are normal. The left ventricular cavity size is\nnormal. There is mild to moderate global left ventricular hypokinesis (LVEF =\n~40 %). Right ventricular chamber size and free wall motion are normal. The\naortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nNo cardiac source of embolus seen other than atrial fibrillation.\n\nNOTE: Report modified at 1:17 pm on to note that no evidence of ASD\nor PFO seen.\n\n\n" }, { "category": "ECG", "chartdate": "2152-12-25 00:00:00.000", "description": "Report", "row_id": 251046, "text": "Marked baseline artifact in the limb leads. Atrial fibrillation. Diffuse\nT wave flattening. No other diagnostic abnormality. No previous tracing\navailable for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2148-09-17 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 984557, "text": " 1:12 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: please eval for ascites and mark for paracentesis\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with worsening jaundice hx of NASH, and worsening renal\n function and weight gain.\n REASON FOR THIS EXAMINATION:\n please eval for ascites and mark for paracentesis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old woman with worsening jaundice, history of NASH and\n worsening renal function and weight gain. Assess for ascites and mark for\n paracentesis.\n\n LIMITED ABDOMEN ULTRASOUND: Limited evaluation for the assessment of ascites\n was performed. There is a moderate amount of ascites, with the largest pocket\n in the left mid-flank. The patient's skin was marked in this location.\n\n" }, { "category": "Radiology", "chartdate": "2148-09-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 984474, "text": " 7:33 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: check line placment\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with hx of CHF now with new wt gain and peripheral edema new\n central line\n REASON FOR THIS EXAMINATION:\n check line placment\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:41 P.M., \n\n HISTORY: Central line placement.\n\n IMPRESSION: AP chest compared to 1:46 p.m.:\n\n Tip of the left jugular line projects over the mid SVC. Mild pulmonary\n vascular congestion and borderline edema are probably present but not\n appreciably changed since earlier in the day. Heart size is normal. There is\n no pneumothorax, pleural effusion, or mediastinal widening.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-09-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 984435, "text": " 2:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion/infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with hx of CHF now with new wt gain and peripheral edema\n REASON FOR THIS EXAMINATION:\n eval for effusion/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP\n\n COMPARISON: None.\n\n HISTORY: Weight gain and peripheral edema.\n\n FINDINGS: The heart size is top normal. The hilar contours are indistinct.\n There is cephalization of pulmonary vasculature. There are increased\n interstitial markings. There is no evidence of pleural effusions or\n consolidations. The osseous structures are unremarkable.\n\n IMPRESSION:\n\n Mild cardiomegaly, mild pulmonary vascular congestion.\n\n" }, { "category": "Radiology", "chartdate": "2148-09-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 985133, "text": " 12:28 PM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate for acute intrapulmonary process\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old F cirrhotic with cough, hyponatremia, MS changes\n REASON FOR THIS EXAMINATION:\n please evaluate for acute intrapulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: Cough, hyponatremia, mental status changes.\n\n Comparison is made with prior study, .\n\n Cardiomediastinal contours are unremarkable. There is no pneumothorax or\n pleural effusion. Mild pulmonary vascular congestion and borderline edema are\n unchanged. Hardware is in the right arm. There is chronic dislocation of the\n right shoulder joint.\n\n jr\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2148-09-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 985464, "text": " 9:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: edema, infiltrate\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with SOB, somnolence\n REASON FOR THIS EXAMINATION:\n edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath with somnolence.\n\n FINDINGS: In comparison with the study of , there is little change.\n Again, there is mild pulmonary vascular congestion with the cardiac silhouette\n slightly enlarged. No evidence of acute focal pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-09-30 00:00:00.000", "description": "R SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT", "row_id": 986395, "text": " 2:08 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT Clip # \n Reason: Eval for new fracture\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with shoulder fracture and chronic dislocation with worsening\n shoulder pain\n REASON FOR THIS EXAMINATION:\n Eval for new fracture\n ______________________________________________________________________________\n FINAL REPORT\n SHOULDER, \n\n INDICATION: 67-year-old female with shoulder fracture and chronic\n dislocation. Worsening shoulder pain.\n\n Four views of the right shoulder are obtained and there are no prior studies\n for comparison.\n\n There is marked inferior positioning of the humeral head with respect to the\n glenoid. There is an angulated and distracted fracture through the humeral\n diaphysis. Two fixation plates are present with multiple screws in the region\n of the mid and proximal humeral diaphysis; however, the fixation plate and\n screws project outside of the proximal fracture fragment. None of the\n proximal screws appear to project over the proximal humerus. There is\n angulation of the fixation plate and the proximal fracture fragment appears\n incongruous with the distal fracture fragment. There are degenerative changes\n of the acromioclavicular joint.\n\n The right costophrenic angle is blunted and there is increased air space\n opacity in the visualized portion of the right lung which may represent\n pulmonary edema.\n\n This could be better assessed with a dedicated chest x-ray.\n\n IMPRESSION:\n 1. ORIF of humeral fracture with marked inferior positioning of the humeral\n head and angulated and distracted fracture fragments of the humeral diaphysis.\n The fixation plate projects outside of the proximal fracture fragment.\n Comparison with any old studies is recommended.\n\n 2. Probable right effusion and air space opacity. The finding could\n represent pulmonary edema. This could be better assessed with a chest x-ray.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2148-09-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 986400, "text": " 2:25 PM\n CHEST (PA & LAT) Clip # \n Reason: Eval for pulm edema, effusion or other acute process\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with CHF, critical AS, and crackles at right base with\n increasing O2 requirement\n REASON FOR THIS EXAMINATION:\n Eval for pulm edema, effusion or other acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Congestive failure with increasing oxygen requirement.\n\n FINDINGS: The current study is extremely contrast_____, making it somewhat\n difficult to compare with the previous examination of . Nevertheless,\n there appears to be some substantial increase in the degree of pulmonary\n vascular congestion.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-09-19 00:00:00.000", "description": "MRCP (MR ABD W&W/OC)", "row_id": 984804, "text": " 7:58 AM\n MRCP (MR ABD W&W/OC) Clip # \n Reason: r/o HCC, evaluate biliary tree\n Admitting Diagnosis: LIVER FAILURE\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with NASH cirrhosis. Pls evaluate for HCC\n REASON FOR THIS EXAMINATION:\n r/o HCC, evaluate biliary tree\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old female with NASH cirrhosis with concern for HCC or\n biliary abnormality.\n\n COMPARISON: Ultrasound and , CTA abdomen and pelvis .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\n Tesla magnet including dynamic imaging obtained before, during and after the\n uneventful IV administration of 0.1 mmol/kg of gadolinium-DTPA. Multiplanar\n 2D and 3D reformations and subtraction images were generated on an independent\n workstation.\n\n FINDINGS: This study is limited by motion artifact. The liver has a nodular\n contour and diffusely heterogeneous signal characteristics with relative\n larger size of the left lobe, findings consistent with cirrhosis. No focus of\n abnormal early arterial enhancement or focal mass is identified of the liver\n although a small lesion could be missed due to obscuration by motion. There is\n a moderate amount of ascites within the abdomen, predominantly surrounding the\n liver. There is evidence of portal hypertension including a recanalized\n umbilical vein and splenomegaly. The portal and splenic veins enhance with\n gadolinium, however directionality cannot be evaluated on this study. There\n is no biliary ductal dilatation. Gallbladder wall thickening is again\n demonstrated similar to the recent ultrasound study and probably secondary to\n chronic liver disease and ascites. The pancreas, adrenal glands, kidneys,\n stomach and intra-abdominal bowel are unremarkable. No significant\n lymphadenopathy is identified.\n\n Multiplanar 2D and 3D reformations and subtraction images were essential in\n providing multiple perspectives for evaluation of the dynamic series.\n\n IMPRESSION:\n 1. Cirrhosis.\n 2. Moderate ascites.\n 3. Evidence of portal hypertension with splenomegaly and recanalized\n umbilical vein.\n 4. Study is considerably due to significant motion artifact and presence of\n ascites. Allowing for this, no focal hepatic lesion or abnormal arterial\n enhancement identified. Please note that a small arterially enhancing lesion\n might not be detected on this examination.\n 5. Gallbladder wall thickening is likely secondary to chronic liver disease\n and ascites.\n (Over)\n\n 7:58 AM\n MRCP (MR ABD W&W/OC) Clip # \n Reason: r/o HCC, evaluate biliary tree\n Admitting Diagnosis: LIVER FAILURE\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2148-09-16 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 984454, "text": " 4:06 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Evaluate for swelling/obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with worsening jaundice hx of NASH, no pain\n REASON FOR THIS EXAMINATION:\n Evaluate for swelling/obstruction\n ______________________________________________________________________________\n WET READ: ARHb MON 5:13 PM\n Cirrhotic appearing liver with reversal of portal flow (new since ),\n splenomegaly, and moderate ascites consistent with worsening portal\n hypertension. Explansion of left hepatic lobe consistent with recent CTA\n findings and not well evaluated. Cholelithiasis with mild galbladder wall\n thickening likely from underlying cirrhosis/portal hypertension.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Worsening jaundice with history of NASH. No pain.\n\n COMPARISON: Multiple priors, the most recent CTA abdomen dated .\n\n FINDINGS: The liver parenchyma is shrunken, coarsened and nodular consistent\n with cirrhosis. There is expansion of the left hepatic lobe, consistent with\n recent CTA findings, though no definite focal lesion is dientified. There is\n no intra- or extra- hepatic biliary ductal dilatation. Cholelithiasis is again\n noted. Mild galbladder wall thickening likely represents edema from\n cirrhosis/portal hypertension. The main portal vein now demsontrates\n hepatofugal flow, new since . Splenomegaly and moderate perihepatic\n ascites are also consistent with portal hypertension.\n\n IMPRESSION:\n 1. Cirrhotic-appearing liver with evidence of portal hypertension including\n splenomegaly and moderate ascites. Hepatofugal portal flow is new since \n , consistent with worsenig portal hypertension. Nonspecific enlargement of\n the left hepatic lobe, which may represent relative preservation related to\n underlying cirrhosis. without focal lesion identified.\n\n 2. Cholelithiasis with evidence of mild gallbladder wall thickening likely\n representing edema secondary to underlying cirrhosis/portal hypertension.\n\n" }, { "category": "Radiology", "chartdate": "2148-09-30 00:00:00.000", "description": "MRCP (MR ABD W&W/OC)", "row_id": 986347, "text": " 9:08 AM\n MRCP (MR ABD W&W/OC) Clip # \n Reason: Eval for evidence of extrahepatic cholestasis\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with ESLD NASH, critical aortic stenosis with T Bili of\n 10.4 and no improvement over last 10 days.\n REASON FOR THIS EXAMINATION:\n Eval for evidence of extrahepatic cholestasis\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage liver disease secondary to NASH with elevated total\n bilirubin. Evaluate for extra-hepatic cholestasis.\n\n COMPARISON: MR .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images of the abdomen acquired on\n a 1.5 Tesla magnet. No intravenous contrast was administered secondary to the\n patient's inability to complete with the examination, and also due to the\n patient's borderline low EGFR.\n\n MRI OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Study is limited due to the\n patient's inability to hold her breath and lack of intravenous contrast.\n Allowing for this, no gross intra- or extra-hepatic biliary duct dilatation is\n identified. Evaluation for intraluminal filling defects, however, is limited.\n\n Again demonstrated is a shrunken and nodular liver consistent with cirrhosis.\n Moderate amount of ascites has not significantly changed in the interval.\n Small left pleural effusion is also demonstrated. No gross focal hepatic\n lesions are seen; however, evaluation is limited without the administration of\n gadolinium.\n\n Again demonstrated within the gallbladder is a single gallstone measuring 16\n mm, unchanged. The gallbladder otherwise is nondistended and demonstrates\n unchanged gallbladder wall thickening likely related to the patient's\n underlying liver disease.\n\n The spleen is stablely enlarged measuring 13.2 cm in greatest craniocaudal\n dimension.\n\n Gross visualization of the pancreas, adrenal glands, kidneys, bowel loops\n demonstrate no definite abnormalities. The abdominal aorta appears normal in\n caliber. No pathologically enlarged mesenteric or retroperitoneal lymph nodes\n are seen.\n\n IMPRESSION:\n\n 1. Limited examination secondary to patient's inability to comply with\n (Over)\n\n 9:08 AM\n MRCP (MR ABD W&W/OC) Clip # \n Reason: Eval for evidence of extrahepatic cholestasis\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n breathing instructions and to the lack of intravenous contrast.\n\n 2. No intra-hepatic or extra-hepatic biliary duct dilatation. Evaluation for\n intraluminal filling defects is limited.\n\n 3. Cirrhosis with portal hypertension. Moderate amount of ascites,\n unchanged.\n\n 4. Small left pleural effusion.\n\n 5. Cholelithiasis without cholecystitis. Unchanged gallbladder wall\n thickening secondary to the patient's underlying liver disease.\n\n DFDdp\n\n" }, { "category": "Nursing/other", "chartdate": "2148-09-17 00:00:00.000", "description": "Report", "row_id": 1637843, "text": "NURSING PROGRESS NOTE 1900-2100\nPT NOTED TO HAVE PEAKED T WAVES ON TELEMETRY MONITOR. DR. MADE AWARE, EKG OBTAINED AND K SENT. DR. REVIEWED EKG AND K RESULT 3.9. PT DENIES ANY CP. SBP STABLE IN THE LOW 100'S. TRANSFERRED TO 712 AT APPROX 2100.\n" }, { "category": "Nursing/other", "chartdate": "2148-09-17 00:00:00.000", "description": "Report", "row_id": 1637842, "text": "1900-0700 rn notes micu\n\nFULL Code\n\nAllergie: NSAID, narcotics( cause confusion)\n\n67y.o f with non-alcoholic hepatic cirrhosis presented with dyspnea worsening for past 2 days, juandice, peripheral edema nad weight gain, denies chest pain , palpitation, orthopnea. in ED prior given Lasix, pt dropped BP to 80's, given 1L fluid and transfer to unit for hypotension.\nalso in ED abd US done revealed: new reversal flow, portal hypertension nad moderatly suspicious nodule, needs CT/or MRI.\n\nneuro: A/Ox3, follows commands. pt broke her R arm 5years ago, had multiple surgeries, pt unable to move the arm.\n\nresp: NC 2L, sat 99-100%, got neb tx for wheezing. LS clear dim and crackles at bases.\n\ncv: HR 70's NSR, no ectopy, BP 97-120/50-60's, start Lasix gtt 2mg/hr,. morning labs penidng.\n\ngi/gu: foley in place daringed yeelow clear urine 40-50cc/hr. ABD obese, BS +, no stoole, cont lactalose.pt on diabetic/heart diet tollerates good.\n\naccess: 1piv 22g, LIJ.\n\nendo: at 2200 BS FS 75, d/ced Glucophage.\n\nsocial: full code, lives in . daughter-in-law visited by MD .\n\nplan: cont monitorign cardio status\n cont lasix gtt as tollerates\n ?ABD CT\n ?c/o to floor.\n" }, { "category": "Echo", "chartdate": "2148-09-18 00:00:00.000", "description": "Report", "row_id": 104691, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Congestive heart failure. Left ventricular function.\nHeight: (in) 68\nWeight (lb): 240\nBSA (m2): 2.21 m2\nBP (mm Hg): 105/57\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 15:00\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%).\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS\n(AoVA <0.8cm2). Mild (1+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral\nannular calcification. Minimally increased gradient consistent with trivial\nMS. Moderate (2+) MR. [Due to acoustic shadowing, the severity of MR may be\nsignificantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Ascites.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>65%). The aortic valve leaflets are severely thickened/deformed. There\nis severe aortic valve stenosis (area 0.7cm2). Mild (1+) aortic regurgitation\nis seen. The mitral valve leaflets and supporting structures are moderately\nthickened. There is a minimally increased gradient consistent with trivial\nmitral stenosis. Moderate (2+) mitral regurgitation is seen. [Due to acoustic\nshadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] There is moderate pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the aortic valve\ngradient and severity of mitral regurgitation have increased.\n\nCLINICAL IMPLICATIONS:\nThe patient has severe aortic stenosis. Based on ACC/AHA Valvular Heart\nDisease Guidelines, if the patient is symptomatic (angina, syncope, CHF) and a\nsurgical candidate, surgical intervention has been shown to be beneficial.\n\n\n" }, { "category": "ECG", "chartdate": "2148-10-03 00:00:00.000", "description": "Report", "row_id": 309969, "text": "Sinus rhythm. Within normal limits.\n\n" }, { "category": "ECG", "chartdate": "2148-09-17 00:00:00.000", "description": "Report", "row_id": 309970, "text": "Sinus rhythm. Normal tracing. Since previous tracing of \nno significant change.\n\n" }, { "category": "ECG", "chartdate": "2148-09-16 00:00:00.000", "description": "Report", "row_id": 309971, "text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2174-10-10 00:00:00.000", "description": "Report", "row_id": 1332456, "text": "See carevue for objective data.\n\nTx from 7 after episiode of hypotension in relation to in an attempt to wean steroids.\n\n63 year old male with PMH of chrohn's disease recently admitted to an OSH for presumed chrohn's flair and was found to be leukopenic>bone marrow biopsy>AML. Received full course of chemo(day #18 in hospital). Febrile/hypotensive. On caspo/vanco/flagyl/meripenum.\nRIJ TLC for access. Site without redness or signs of infection.\nCourse has been complicated by Chrohn's which pt has been on chronic\nsteroids and a taper was initiated. Last dose of steroids . Reportedly when pt received stress dose of steroids bradycardia ensues to the high 30's though hemodynamically stable. Tx to MICU for monitoring of steroid dosing. stim pending at this time.\n\nCt Scan done upon arrival to unit for C/O abd pain and GI relayed scan is improved from 2 weeks ago.\n\nAwake/alert/appropriate. HR/BP stable. NSR with no ectopy.\nMaintaining O2 sats on RA. Voids in urinal. NPO except for ice chips.\nRefusing pain med. Skin red-derm in to evaluate and skin biopsy done.\nTPN infusing via TLC.\n\nContinue current POC. Awaiting steroid dosing MD and monitor closely. Neutropenic precautions. Monitor and support hemodynamcis.\nEmotional support for pt and family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-10-11 00:00:00.000", "description": "Report", "row_id": 1332457, "text": "FULL CODE Universal Precautions NKDA\n\n\nNeuro: AAOx3, MAEx4 - OOB to commode w/ min assistance. No deficits.\n\nCV: HR=80s, NSR, no ectopy. BP 89-143/43-70, w/ usual range 100/50s. Pt was nauseated - Anzement 12.5 mg given w/ relief, but BP up to 143/ at this time. +periph pulses, extrems warm, no edema.\n\nResp: R/A, 02sat 98%. Lungs clear bilat, occ cough-non-productive. RR=16-23.\n\nGI/GU: Abd soft, +BS, NPO, BMx2. NPO. NO foley - voids clear yellow unrine.\n\nSkin: rash noted on back, trunk and arms - doesn't itch. Heels and coccyx intact.\n\nPain: Med x1 w. MS04 1mg IVP. Earlier in the eve, med /w tylenol w/ good effect, too.\n\nID: afebrile at 97.9. On flagyl, meropenem, vanco, Caspfungin and axithromax po added this evening.\n\nPlan: Monitor cardiac status - BP. Admin prn meds as ordered.\nMonitor neuro and resp status.\n" }, { "category": "Echo", "chartdate": "2174-09-22 00:00:00.000", "description": "Report", "row_id": 83016, "text": "PATIENT/TEST INFORMATION:\nIndication: Chemotherapy. Left ventricular function. Chemotherapy.\nHeight: (in) 68\nWeight (lb): 187\nBSA (m2): 1.99 m2\nBP (mm Hg): 122/66\nHR (bpm): 72\nStatus: Outpatient\nDate/Time: at 11:38\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. Normal LV cavity size. Overall\nnormal LVEF (>55%). TVI E/e' < 8, suggesting normal PCWP (<12mmHg).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic root. Mildly dilated ascending aorta. Normal\naortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. LV inflow\npattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Tissue velocity imaging demonstrates\nan E/e' <8 suggesting a normal left ventricular filling pressure (<12mmHg).\nRight ventricular chamber size and free wall motion are normal. The aortic\nroot is moderately dilated. The ascending aorta is mildly dilated. The aortic\nvalve leaflets are mildly thickened. The mitral valve leaflets are mildly\nthickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow\npattern suggests impaired relaxation. The estimated pulmonary artery systolic\npressure is normal. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2174-10-11 00:00:00.000", "description": "Report", "row_id": 197712, "text": "Sinus rhythm\nLateral ST-T changes are nonspecific\nLeft ventricular hypertrophy\nrsr' in lead V1\nClinical correlation is suggested\n\n" }, { "category": "ECG", "chartdate": "2174-11-04 00:00:00.000", "description": "Report", "row_id": 197711, "text": "Sinus rhythm. Slow R wave progression. Compared to the previous tracing no\nsignificant change.\n\n" }, { "category": "Radiology", "chartdate": "2174-11-01 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 930966, "text": " 10:51 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ? biliary dysfunction\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with crohn's, rising LFT's, mild abdmonal discomfort\n REASON FOR THIS EXAMINATION:\n ? biliary dysfunction\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n LIMITED ABDOMINAL ULTRASOUND\n\n HISTORY: 63-year-old male with Crohn's disease, AML status post recent\n chemotherapy. Rising LFTs, and mild abdominal discomfort. ? biliary\n dysfunction.\n\n FINDINGS: Comparison is made to CT of the torso dated .\n\n The liver exhibits a normal echotexture, without evidence of focal hepatic\n mass. The patient is status post cholecystectomy. There is no ascites. There\n is no evidence of intra- or extra-hepatic biliary ductal dilatation. The\n common bile duct is normal in diameter. The portal vein is patent with\n appropriate antegrade flow. The hepatic veins are patent. Views of the\n pancreas are limited due to overlying bowel gas, but the visualized portions\n appear unremarkable.\n\n IMPRESSION:\n\n 1. Unremarkable right upper quadrant ultrasound. S/P cholecystectomy. No\n evidence of biliary dysfunction.\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2174-11-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 931216, "text": " 7:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess line placement and for infiltrate\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with aml s/p induction, new fever, rule out pneumonia, please\n also assess R IJ tip end location\n REASON FOR THIS EXAMINATION:\n please assess line placement and for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Assessment of right internal jugular line tip\n placement and pulmonary infiltrate in patient with fever.\n\n Portable AP chest radiograph compared to .\n\n The right internal jugular line tip is 3 cm below the cavoatrial junction.\n The heart size is normal. The mediastinum contours are unremarkable. The\n lungs are clear. The pleural surfaces are smooth with no pleural effusion or\n sizable pneumothorax. The patient is after right upper lobe surgery.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-11-02 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 931223, "text": " 10:52 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please assess RIJ location\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with aml s/p induction, pulled back RIJ 3 cm, please assess\n R IJ tip end location\n REASON FOR THIS EXAMINATION:\n please assess RIJ location\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the right internal jugular tip\n placement.\n\n Portable AP chest radiograph compared to made at 19:19 p.m.\n\n The right internal jugular line tip was pulled back for almost 3 cm, now being\n at the level of cavoatrial junction.\n\n The heart size, mediastinum, and the screened portion of the lung are\n unremarkable.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-09-28 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 926874, "text": " 5:39 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please do CT abd/pelvis with contrast. Evaluate source of ab\n Admitting Diagnosis: LEUKEMIA\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with AML now day # of chemotherapy, neutropenic. On\n cefepime.\n REASON FOR THIS EXAMINATION:\n Please do CT abd/pelvis with contrast. Evaluate source of abdominal pain\n (clinically in LLQ).\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old with AML, fever, and neutropenia, also with history\n of Crohn's disease with worsening abdominal pain.\n\n TECHNIQUE: CT of the abdomen and pelvis after the administration of oral and\n 150 cc of IV Optiray. Coronal and sagittal reformatted images were obtained.\n\n Comparison is made to outside CT performed at \n Hospital, provided on film for comparison.\n\n CT OF THE ABDOMEN WITH ORAL AND IV CONTRAST: The lung bases are clear. The\n liver, spleen, pancreas, adrenals, and intra-abdominal vasculature are normal\n in appearance. The patient is post cholecystectomy with clips seen in the\n gallbladder fossa. Several small hypodensities are seen scattered in both\n kidneys which are too small to characterize, but likely represent cysts. The\n kidneys are otherwise unremarkable with symmetric enhancement and contrast\n excretion. Numerous small, less than 1 cm, lymph nodes are seen scattered\n throughout the mesentery and retroperitoneum. There is no free fluid or free\n air.\n\n The patient is post terminal ileum and proximal colonic resection with an\n anastomotic site present. There is marked inflammation and thickening of the\n wall of the distal small bowel extending from at least 15 cm proximal to the\n level of the anastomotic site . The lumen of this small bowel is narrowed\n secondary to inflammatory changes in the wall. At the proximal margin of the\n area of inflammation, there is a small stricture. The small bowel is dilated\n up to 4.4cm more proximal to this area. Contrast material is, however, seen\n to pass through the narrowed and inflamed distal small bowel into the colon.\n There are inflammatory changes also involving the proximal colon/cecal area.\n The remainder of the visualized colon is normal.\n\n CT OF THE PELVIS WITH ORAL AND IV CONTRAST: The rectum and sigmoid are normal\n in appearance. The prostate is heterogeneous in appearance, with a\n central focus of decreased attenuation seen within it. There is no\n significant periprostatic fat stranding. No free fluid or lymphadenopathy is\n present in the pelvis. The distal ureters and bladder are normal.\n\n Soft tissues are normal in appearance. Osseous structures demonstrate\n degenerative changes in the lumbar spine with Schmorl's nodes at multiple\n (Over)\n\n 5:39 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please do CT abd/pelvis with contrast. Evaluate source of ab\n Admitting Diagnosis: LEUKEMIA\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n levels.\n\n Coronal and sagittal multiplanar reformatted images confirm the above findings\n and were essential in evaluating the bowel pathology.\n\n IMPRESSION:\n 1. Inflammation and thickening of the wall of the distal small bowel up to\n the level of the anastomosis with the colon with resultant narrowing of the\n lumen. Findings are most consistent with a Crohn's disease with acute\n inflammation. There is dilation of the more proximal small bowel, though\n contrast is seen to flow into the colon, suggestive of partial obstruction.\n There is no focal abscess or fluid collection identified. Findings may be\n slightly worsened, though not significantly changed from the prior outside\n examination.\n\n 2. Heterogeneous appearance of the prostate gland with an area of slightly\n lower attenuation centrally. In the correct setting, the findings could be\n due to prostatitis or a small focal abscess. Correlation with symptoms,\n prostate exam, and urinalysis is recommended.\n\n Findings were communicated to Dr. at 7 p.m.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2174-09-22 00:00:00.000", "description": "NON-TUNNELED", "row_id": 926107, "text": " 10:49 AM\n CENTRAL LINE PLCT Clip # \n Reason: Please place triple lumen subclavian line\n Admitting Diagnosis: LEUKEMIA\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with AML admitted for chemotherapy\n REASON FOR THIS EXAMINATION:\n Please place triple lumen subclavian line\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: 7-French triple lumen central venous catheter placement via right\n internal jugular approach; ultrasound-guided venipuncture and fluoroscopic\n guided placement.\n\n CLINICAL HISTORY: 63-year-old male with acute myelogenous leukemia admitted\n for chemotherapy.\n\n INFORMED CONSENT: Procedural informed consent was obtained from the patient\n and placed in the medical record.\n\n OPERATORS: , M.D. (fellow).\n\n , M.D. (supervising staff in situ).\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, appropriate requisition,\n and appropriate informed consent. Once the above were verified, the patient\n was positioned in supine fashion on a special procedures/angiography table.\n The low right-sided neck and right upper anterior chest wall were prepped and\n draped in usual sterile fashion. Ultrasound was employed to visualize the\n right internal jugular vein, which was noted to be widely patent and\n compressible.\n\n The skin at the anticipated puncture site and subcutaneous needle tract were\n then infiltrated with approximately 3 cc of 1% Xylocaine for local anesthesia.\n Uneventful 1- wall venipuncture was achieved with a micropuncture access set\n and ultrasound guidance. Hard copy images of the son guidance were\n recorded documenting vessel patency and placed in the patient's record. A\n 0.035- inch, 1.5 mm J, wire was then advanced by way of the 4 French\n catheter of the micropuncture set, under fluoroscopic visualization to the\n inferior vena. An Life Science 7 French by a 16 mm triple lumen\n central venous catheter was then delivered over the guidewire and positioned\n at the level of the SVC right atrial junction uneventfully. The catheter was\n then sutured using 2-0 silk retention sutures. Puncture site and hub of the\n catheter was then overlaid with a Tegaderm dressing. No residual bleeding was\n encountered. The patient tolerated the procedure well. 3 lumens of the\n catheter were flushed and heparin locked per protocol.\n (Over)\n\n 10:49 AM\n CENTRAL LINE PLCT Clip # \n Reason: Please place triple lumen subclavian line\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION: Status post successful 7 French triple lumen central venous\n catheter placement via right internal jugular vein. Catheter is ready to\n employ. Post-procedural orders were written.\n\n" }, { "category": "Radiology", "chartdate": "2174-09-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 926664, "text": " 10:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for pneumonia\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new dx AML, now with neutropenia and fevers\n REASON FOR THIS EXAMINATION:\n Please evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: AML, neutropenic fever.\n\n AP PORTABLE UPRIGHT CHEST: No prior studies for comparison. Right IJ line\n with its tip in the right atrium. No pneumothorax. Heart size is normal.\n Mediastinal and hilar contours are unremarkable. The lungs are clear.\n\n IMPRESSION: No radiographic evidence of pneumonia. Right IJ tip in the right\n atrium.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-10-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 929597, "text": " 8:38 PM\n CHEST (PA & LAT) Clip # \n Reason: ? PNA\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new dx AML, now with new fevers\n REASON FOR THIS EXAMINATION:\n ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New diagnosis of acute myelogenous leukemia, with new fevers.\n Evaluate for pneumonia.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST: The right internal jugular approach central venous\n catheter is in unchanged position, with the tip in the proximal right atrium.\n Cardiac and mediastinal contours are stable. The lungs are clear, without\n vascular congestion or consolidation. No pleural effusion or pneumothorax.\n Osseous structures are unchanged. Clips in the right upper quadrant are\n redemonstrated.\n\n IMPRESSION: No evidence of pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2174-10-10 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 928314, "text": " 2:36 PM\n CT ABDOMEN W/O CONTRAST; CT CHEST W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Please evaluate abdomen and pelvis WITHOUT CONTRAST (given h\n Admitting Diagnosis: LEUKEMIA\n Field of view: 36\n ______________________________________________________________________________\n FINAL ADDENDUM\n Findings were discussed with Dr. via telephone at 5:00 p.m. on\n .\n\n\n\n 2:36 PM\n CT ABDOMEN W/O CONTRAST; CT CHEST W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Please evaluate abdomen and pelvis WITHOUT CONTRAST (given h\n Admitting Diagnosis: LEUKEMIA\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with known Crohn's disease and AML now day #18 after\n chemotherapy, neutropenic. Some belly pain, hypotension. Concern for\n perforation. On cefepime, vanco, flagyl, caspo.\n REASON FOR THIS EXAMINATION:\n Please evaluate abdomen and pelvis WITHOUT CONTRAST (given hypotension) for\n perforation, abscess, or other source of sepsis.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Crohn's disease and AML with abdominal pain, concern for\n perforation.\n\n TECHNIQUE: Non-contrast axial CT imaging of the chest, abdomen and pelvis\n without oral contrast was performed per physician .\n\n CT CHEST WITHOUT CONTRAST: Within the inferior portion of the right upper\n lobe is a 2-cm opacity containing air bronchogram that likely represents a\n focus of infection. Within the apex is a more linear opacity that may also\n represent a second focus of infection. Along the superior portion of the\n right major fissure is irregular 6-mm pulmonary nodule that may also be\n infectious. Given the above findings, three-month followup is recommended to\n demonstrate resolution. Tip of right internal jugular catheter terminates in\n the cavoatrial junction. The heart and great vessels of the mediastinum are\n otherwise unremarkable. No pathologic adenopathy is identified in the axilla,\n mediastinum, or hila.\n\n CT ABDOMEN WITH CONTRAST: No focal lesions are identified in the non-contrast\n liver. The patient is status post cholecystectomy. The pancreas, spleen,\n stomach, adrenal glands, right kidney is unremarkable. There is a\n nonobstructing 11 mm stone in the collecting system of the left kidney. There\n is no free air, free fluid, or pathologic adenopathy.\n\n CT PELVIS WITH CONTRAST: Again demonstrated is bowel wall thickening and\n inflammatory change at the distal 15 cm of neoterminal ileum. This is\n slightly improved from . Multiple adjacent likely reactive\n nodes are again identified. Dilation of small bowel loops proximal to the\n neoterminal ileum has improved. The rectum, sigmoid, and large bowel is\n unchanged in appearance. Heterogeneous appearance to the prostate is\n unchanged.\n\n BONE WINDOWS: No suspicious lesions are identified.\n\n IMPRESSION:\n 1. Multiple opacities in the right upper lobe are likely infectious. Three-\n month followup to confirm resolution is recommended.\n (Over)\n\n 2:36 PM\n CT ABDOMEN W/O CONTRAST; CT CHEST W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Please evaluate abdomen and pelvis WITHOUT CONTRAST (given h\n Admitting Diagnosis: LEUKEMIA\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. A 11-mm nonobstructing left renal collecting system stone.\n 3. Persistent and slightly improved neoterminal ileitis consistent with\n Crohns flare.\n\n" }, { "category": "Radiology", "chartdate": "2174-10-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 928182, "text": " 11:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out pneumonia, assess right IJ tip placement.\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with aml s/p induction, new fever, rule out pneumonia, please\n also assess R IJ tip end location\n REASON FOR THIS EXAMINATION:\n rule out pneumonia, assess right IJ tip placement.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: AMI status post induction, new fever, rule out pneumonia. Assess\n right IJ tip.\n\n CHEST, SINGLE AP VIEW.\n\n Rotated positioning. Allowing for this, right IJ central line is present, tip\n overlying upper right atrium, unchanged compared with . No pneumothorax\n is identified. The heart is not enlarged. There is no CHF, focal infiltrate,\n or effusion. Right hemidiaphragm is elevated, unchanged. Clips are noted in\n the right upper quadrant.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2135-08-20 00:00:00.000", "description": "Report", "row_id": 1551508, "text": "Condition Update B:\nPlease refer to careview and remarks for detials.\n\nPleasant alert and oriented gentleman who is HOH and wears a hearing aid in his (R) ear. Medicated x1 with Percocet for c/o (R) foot pain with good effect. Pox 94-99% on 4L NC, denies SOB, diff breathing. LS CTA with very faint crackles in posterior LLL. Discussed with Dr. . Pt neg 1.3L MN. Wt down. Labs WNL. Pt slept most of shift. Difficult to obtain peripheral morning labs. Dr. and Dr. aware.\n\nPt stable. Consider PICC line for labs, continued antibx therapy, possible bypass/stent. Offer pain meds for comfort. Encourage C&DB, inhalres as ordered, monitor resp status. Transfer to floor when bed available.\n" }, { "category": "Nursing/other", "chartdate": "2135-08-18 00:00:00.000", "description": "Report", "row_id": 1551502, "text": "79 year old man admitted to sicu from 11 s/p R. CEA . Tolerated procedure well , now with sudden onset resp. distress/unresponsiveness, intubated on 11. Was scheduled for fem fem bypass prior to resp. event.\n\nAgitated, MAE , PERRLA. Started on PPF gtt upon arrival. Not following commands consistently but pt. is very HOH at baseline. BP in 200s initially, then becoming hypotensive and started on Neo gtt. Now weaning Neo gtt. ST, occ PVCS. Tmax 99.7. Unable to consistently Doppler pulses to LEs, vasc. HO aware. (pt's baseline.) ABGs improved on A/C, weaning Fi02. Lung sounds dim to bases, pink frothy sputum in ETT upon arrival. Suctioned for minimal secretions. +BS, hypo. NGT placed by SICU HO and placed to suction for minimal amount bilious drainage. +placement by auscultation. Foley patent adequate amount amber urine, +diuresis after Lasix. Glucose levels elevated, SSRI PRN. Skin intact to coccxy, no breakdown. Blackened toes to R. foot as per pt's baseline, left open to air. CT done of head/chest CTA - > all negative.\nA/P: 79 year old w/mult. med. issues s/p R. CEA . Remains hypotensive s/p resp. arrest on floor , w/u negative for PE, stroke or head bleed. ABGs improved on vent. Continue to monitor closely.\n\n" }, { "category": "Nursing/other", "chartdate": "2135-08-18 00:00:00.000", "description": "Report", "row_id": 1551503, "text": "RESPIRATORY CARE\nPT REMAINS INTUBATED ON A/C MODE.ABG RESULTS IMPROVING.SUCTIONED FOR SMALL AMT OF BLOODY THK SECRETIONS.BS CLEAR B/L.MDI COMBIVENT GIVEN.PLAN TO WEAN AS TOLERATED.\nREFER CAREVUE FOR MORE INFORMATION.\n" }, { "category": "Nursing/other", "chartdate": "2135-08-18 00:00:00.000", "description": "Report", "row_id": 1551504, "text": "Please See Carevue for Specifics.\n\nExtubated this afternoon, A+Ox3, MAE, follows commands, denies pain. SR with frequent PVC's, Magnesium SUlfate and Potassium adm with minimal effect. Right hand cool and purple to touch, aline dc'd and Neo weaned off this morning, warm packs to his hand. NGT dc'd.\n" }, { "category": "Nursing/other", "chartdate": "2135-08-18 00:00:00.000", "description": "Report", "row_id": 1551505, "text": "Nursing Progress Note 1900-2300\nS: \"I am having trouble breathing\"\n\nO: Please see carevue for complete objective data.\n\nPt called for help r/t SOB. Pt sats low 80's on 2L nc and tachypneic, using accessory muscles.Tachy to 140's. EKG done. Team notified. ABG, lytes and enzymes sent. Placed on face tent with slight improvement in sats. CXR done, gave lasix 40 mg IV and gave albuterol neb. Pt verbalized improvement in breathing, sats up to 100% with neb tx. prod cough using yankauer. Pt comfortable on face tent.\n" }, { "category": "Nursing/other", "chartdate": "2135-08-19 00:00:00.000", "description": "Report", "row_id": 1551506, "text": "Nursing note: 11pm-7am\n A/Ox3, slept comfortably. Some soreness to R. toes but denies any increased pain or need for pain meds. EKG done, neb given and enzymes sent w/episode of SOB and dropping sats , now much improved. Sats 100% on FT. No further resp. issues. CXR looked wet per SICU HO. Good response to 40mg IV Lasix given.\nA/P: Improved resp. status. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2135-08-19 00:00:00.000", "description": "Report", "row_id": 1551507, "text": "Please See Carevue for Specifics.\n\nPleasantly a+ox3, oob to chair this morning to mid-afternoon. 40mg po lasix started this morning. No respir distress this shift. One percocet for moderate right foot pain with effect.\n\nPOC: pain management, OOB, lasix, transfer to floor .\n" }, { "category": "Echo", "chartdate": "2135-08-18 00:00:00.000", "description": "Report", "row_id": 60297, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 66\nWeight (lb): 125\nBSA (m2): 1.64 m2\nBP (mm Hg): 127/38\nHR (bpm): 72\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\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mildly dilated LV cavity. Moderately depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left atrium is mildly dilated.\n2. The left ventricular cavity is mildly dilated. Overall left ventricular\nsystolic function is moderately depressed. Inferior and lateral akinesis with\nanterior and septal hypokinesis are present.\n3. The aortic valve leaflets (3) are mildly thickened.\n4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n5. Compared with the prior study (images reviewed) of , LV function\nhas decreased.\n\n\n" }, { "category": "ECG", "chartdate": "2135-08-23 00:00:00.000", "description": "Report", "row_id": 107492, "text": "Sinus rhythm\nPremature ventricular contractions\nPossible right atrial abnormality\nMarked left axis deviation\nProbable old inferior infarct\nPossible right ventricular hypertrophy or inferior myocardial infarction\nposterior extension\nRV conduction delay\nSince previous tracing of , rate is decreased\n\n" }, { "category": "ECG", "chartdate": "2135-08-22 00:00:00.000", "description": "Report", "row_id": 107493, "text": "Sinus rhythm with ventricular premature beats. Incomplete right bundle-branch\nblock. Consider prior inferior (question posterior myocardial infarction).\nSince the previous tracing of precordial lead QRS voltage is less\nprominent.\n\n" }, { "category": "ECG", "chartdate": "2135-08-21 00:00:00.000", "description": "Report", "row_id": 107494, "text": "Sinus tachycardia. Ventricular premature beat. Modest right ventricular\nconduction delay. Consider prior (and question posterolateral) myocardial\ninfarction. Possible biventriculiar hypertrophy. Since the previous tracing\nof no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2135-08-18 00:00:00.000", "description": "Report", "row_id": 107495, "text": "Sinus tachycardia. Ventricular premature beats. Modest right ventricular\nconduction delay. Consider prior inferior (and question posterolateral)\nmyocardial infarction. Possible biventricular hypertrophy. Since the previous\ntracing of ventriciular ectopy is present.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2135-08-17 00:00:00.000", "description": "Report", "row_id": 107496, "text": "Sinus rhythm. Compared to the previous tracing there is now a broad R wave in\nlead VI rather than an RR' complex but the QRS interval has widened. Complete\nright bundle-branch block is now present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2135-08-17 00:00:00.000", "description": "Report", "row_id": 107497, "text": "Sinus rhythm. Narrow QRS complexes. Incomplete right bundle-branch block.\nNon-specific low amplitude T wavse in leads I, aVL and V4-V6. Compared to the\nprevious tracing of no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2135-08-16 00:00:00.000", "description": "Report", "row_id": 107498, "text": "Sinus rhythm. Right bundle-branch block. Compared to the previous tracing\nof ventricular ectopy is no longer present. T wave amplitude has\ndiminished in leads V5-V6.\n\n" }, { "category": "ECG", "chartdate": "2135-08-15 00:00:00.000", "description": "Report", "row_id": 107499, "text": "Sinus rhythm with ventricular premature beats. Incomplete right bundle-branch\nblock. Possible prior inferior and question (posterolateral) myocardial\ninfarction. Since the previous tracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2135-08-27 00:00:00.000", "description": "Report", "row_id": 107491, "text": "Sinus rhythm. Right ventricular conduction delay. Right ventricular hypertrophy\nmust be considered. Prior inferior wall myocardial infarction. Compared to the\nprevious tracing of ventricular ectopy is no longer recorded.\nOtherwise, no diagnostic interim change.\n\n" }, { "category": "Radiology", "chartdate": "2135-08-15 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 924859, "text": " 6:05 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CAROTID STENOSIS\n Admitting Diagnosis: CAROTID STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with carotid dz and PVD for carotid endartectomy\n REASON FOR THIS EXAMINATION:\n ? CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Carotid disease and peripheral vascular disease. Preop for\n carotid endarterectomy. Evaluate for failure.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST:\n\n The heart size is normal. The mediastinal and hilar contours are within\n normal limits for age. Interstitial markings within the lower lung zones are\n slightly increased compared to , suggesting mild edema. There is\n blunting of both costophrenic angles, consistent with small bilateral\n effusions. These are not significantly changed from . There are\n degenerative changes at the acromioclavicular joints bilaterally. There are\n bilateral cervical ribs, and evidence of prior thoracotomy.\n\n IMPRESSION: Evidence of mild congestive failure and small bilateral pleural\n effusions.\n\n" }, { "category": "Radiology", "chartdate": "2135-08-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 925174, "text": " 4:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval Effusions, ET position\n Admitting Diagnosis: CAROTID STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with carotid dz and PVD for carotid endartectomy\n\n REASON FOR THIS EXAMINATION:\n Eval Effusions, ET position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Followup pleural effusions.\n\n Comparison is made with prior study performed the day before.\n\n AP SINGLE VIEW OF THE CHEST.:\n There has been mild interval improvement in the mild pulmonary edema. Small\n to moderate bilateral pleural effusions are stable. ET tube remains in place\n in a standard position.\n\n" }, { "category": "Radiology", "chartdate": "2135-08-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 925157, "text": " 9:35 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: RESPITARY FAILURE; S/P CEA; EVAL FOR BLEED\n Admitting Diagnosis: CAROTID STENOSIS\n ______________________________________________________________________________\n FINAL ADDENDUM\n Both the present and several prior CT studies show soft tissue density\n material filling the right external auditory canal, with possible small\n component in the region of Prussak's space. Please correlate this observation\n by direct visualization, via ENT consultation, to determine the etiology of\n the finding.\n\n There is also continued demonstration of minimal right and mild left sided\n mastoid sinus opacification, which could be fluid, mucosal thickening, or a\n combination of the two, likely inflammatory in origin.\n\n\n\n\n 9:35 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: RESPITARY FAILURE; S/P CEA; EVAL FOR BLEED\n Admitting Diagnosis: CAROTID STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with resp failure s/p CEA\n REASON FOR THIS EXAMINATION:\n question bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old man with respiratory failure, status post right carotid\n endarterectomy.\n\n COMPARISON: Several prior head CTs, most recent dated .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no evidence of intracranial hemorrhage, mass effect,\n hydrocephalus, shift of normally midline structures, or major vascular\n territorial infarction. Hypodensity in the periventricular cerebral white\n matter bilaterally is most consistent with chronic microvascular infarction.\n Otherwise, the density values of the brain parenchyma are within normal\n limits. Nasogastric and endotracheal tubes are noted. Osseous and soft\n tissue structures are otherwise unremarkable.\n\n IMPRESSION: No acute intracranial hemorrhage or mass effect.\n\n" }, { "category": "Radiology", "chartdate": "2135-08-17 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 925158, "text": " 9:35 PM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: evaluate for PE\n Admitting Diagnosis: CAROTID STENOSIS\n Field of view: 38 Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with resp failure s/p CEA\n REASON FOR THIS EXAMINATION:\n evaluate for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure status post CEA. Evaluate for pulmonary\n embolism.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images through the chest were obtained without\n contrast. Subsequently, following the administration of 80 cc of IV Optiray,\n contiguous axial images through the chest were obtained during opacification\n of the pulmonary artery and branches. Coronal, sagittal, and oblique\n reformatted images were generated.\n\n CTA OF THE CHEST: There are no filling defects within the pulmonary arterial\n branches to suggest a pulmonary embolism. There is no thoracic aortic\n dissection. There is calcification and atherosclerotic disease of the\n thoracic aorta. There are coronary artery calcifications.\n\n CT OF THE CHEST WITHOUT AND WITH CONTRAST: An endotracheal tube is in place,\n as is a nasogastric tube. There is a fluid collection within the right side\n of the neck, presumably related to the recent carotid endarterectomy. The\n collection is not completely imaged on this examination of the chest, but at\n the superiormost images, the fluid measures roughly 2.1 x 1.7 cm in greatest\n axial dimensions. There is air within this collection. There is no\n extravasation from the adjacent visualized portion of the right carotid\n artery. There are small axillary lymph nodes bilaterally, not significantly\n changed from . These approach 10 mm in diameter in the short axis.\n There are also scattered mediastinal lymph nodes (large ones in the\n prevascular region), which are not changed from . These approach 11\n mm in the short axis dimension. Etiology of this lymphadenopathy is not\n entirely clear, but it may be related to pulmonary edema. There is a small\n right and moderate left pleural effusion, similar in degree compared to . The left effusion is perhaps slightly smaller. There is associated\n atelectasis in the lungs. There is diffuse patchy ground-glass opacities\n within the aerated portions of the lungs, consistent with pulmonary edema.\n There are some secretions within the distal trachea at the carina. Otherwise,\n the central airways are patent. The posterior wall of the left ventricle is\n calcified, as previously described. There is no pericardial effusion.\n\n Within the imaged portion of the upper abdomen, the visualized portion of the\n liver, gallbladder, and right adrenal gland are normal.\n\n (Over)\n\n 9:35 PM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: evaluate for PE\n Admitting Diagnosis: CAROTID STENOSIS\n Field of view: 38 Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONE WINDOWS: There are no suspicious osteolytic or sclerotic lesions. There\n are degenerative changes of the spine.\n\n Multiplanar reformatted images were essential in delineating the anatomy and\n pathology in this case.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism or thoracic aortic dissection.\n\n 2. Atherosclerotic disease of the aorta, and coronary artery calcifications.\n Posterior wall of the left ventricle is calcified, unchanged.\n\n 3. Bilateral pleural effusions, left greater than right, as seen previously.\n Ground-glass opacity within the lungs suggest pulmonary edema, at least\n moderate in degree.\n\n 4. Mediastinal lymphadenopathy, which is nonspecific but may be related to\n edema. The degree is not significantly changed from .\n\n 5. Fluid collection within the right neck, related to recent carotid\n endarterectomy. It is incompletely imaged.\n\n" }, { "category": "Radiology", "chartdate": "2135-08-26 00:00:00.000", "description": "ABDOMINAL AORTOGRAM", "row_id": 926285, "text": " 3:45 PM\n ABDOMINAL AORTOGRAM Clip # \n Reason: ? ILIAC STENT, CFA AND SFA PLAQUE WITH REST PAIN AND GANGRENE\n Admitting Diagnosis: CAROTID STENOSIS\n ______________________________________________________________________________\n FINAL REPORT\n Please see CareWeb Notes for the complete operative report.\n\n" }, { "category": "Radiology", "chartdate": "2135-08-23 00:00:00.000", "description": "PERSANTINE MIBI", "row_id": 925690, "text": "PERSANTINE MIBI Clip # \n Reason: PVD EVAL FOR ISCHEMIA\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 3.2 mCi Tl-201 Thallous Chloride;\n 21.3 mCi Tc-m Sestamibi;\n HISTORY: 79 yo man s/p MI x 2, 2-vessel CAD with failed PTCA of LCx in ,\n referred for CAD evaluation prior to vascular surgery.\n\n SUMMARY OF THE PRELIMINARY REPORT FROM THE EXERCISE LAB: No anginal symptoms or\n ECG changes from baseline.\n\n Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142\n milligram/kilogram/min. Two minutes after the cessation of infusion, Tc-m\n sestamibi was administered IV.\n\n INTERPRETATION:\n Image Protocol: Gated SPECT\n Resting perfusion images were obtained with thallium.\n Tracer was injected 15 minutes prior to obtaining the resting images.\n This study was interpreted using the 17-segment myocardial perfusion model.\n\n The image quality is adequate.\n\n Left ventricular cavity size is mildly enlarged.\n\n Resting and stress perfusion images reveal a severe fixed inferior and lateral\n wall defect. There is also a moderate reversible apical defect.\n\n Gated images reveal severe global hypokinesis.\n The calculated left ventricular ejection fraction is 25%.\n\n\n IMPRESSION: 1. Severe fixed inferior and lateral wall defects. 2. Moderate\n reversible apical defect. 3. Global hypokinesis. Ejection fraction is 25%.\n\n The findings were communicated to Dr. on @ 1:20 pm.\n\n\n\n , M.D.\n , M.D. Approved: TUE 4:30 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": "2135-08-27 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 926377, "text": " 2:20 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o ileus\n Admitting Diagnosis: CAROTID STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with nausea vomiting\n REASON FOR THIS EXAMINATION:\n r/o ileus\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Nausea and vomiting, rule out ileus.\n\n ABDOMEN: The patient is somewhat constipated but otherwise no dilated loops\n of bowel are seen. There is no evidence of ileus.\n\n Old healed left acetabular fracture is present. Degenerative changes in the\n lumbar spine are noted.\n\n IMPRESSION: Some constipation, no ileus.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-08-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 925153, "text": " 8:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB\n Admitting Diagnosis: CAROTID STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with carotid dz and PVD for carotid endartectomy\n\n REASON FOR THIS EXAMINATION:\n SOB\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath, patient with peripheral vascular disease, for\n carotid endarterectomy.\n\n Comparison is made with prior study dated .\n\n SINGLE AP PORTABLE VIEW OF THE CHEST:\n Interval increase in the amount of interstitial markings with worsening of the\n perihilar haziness consistent with mild pulmonary edema. Cardiac size is\n normal. The lungs are somewhat hyperinflated. Mild interval increase in size\n in the small bilateral pleural effusions. Mediastinal contour is within\n normal limits. ET tube with tip 5.3 cm above the carina.\n\n IMPRESSION: Worsening in moderate pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2135-08-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 925472, "text": " 4:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for progression of effusion/failure.\n Admitting Diagnosis: CAROTID STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with carotid dz and PVD for carotid endartectomy, with\n effusion/failure.\n REASON FOR THIS EXAMINATION:\n Please assess for progression of effusion/failure.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 79-year-old man with carotid disease and peripheral vascular\n disease, patient anticipating carotid endarterectomy.\n\n FINDINGS: Comparison is made to the previous study from .\n\n No endotracheal tube is seen. There are surgical staples seen along the right\n lower neck. The cardiac silhouette and mediastinum are within normal limits.\n There is a left-sided pleural effusion which is likely partially loculated\n along the lateral chest wall and is unchanged. Small right-sided pleural\n effusion is also identified. No overt pulmonary edema is seen. There is no\n mediastinal widening or significant cardiomegaly. There is deformity seen of\n the right chest consistent with prior thoracotomy.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2135-08-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 925310, "text": " 10:46 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: resp distress\n Admitting Diagnosis: CAROTID STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with carotid dz and PVD for carotid endartectomy\n\n REASON FOR THIS EXAMINATION:\n resp distress\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:41 P.M. ON .\n\n HISTORY: Carotid endarterectomy. Respiratory distress.\n\n IMPRESSION: AP chest compared to through :\n\n The upper margin of this film is T1, approximately 3.5 cm above the upper\n margin of the clavicles; no endotracheal tube is seen below that point.\n Moderate left pleural effusion superimposed on chronic left pleural scarring\n and mild-to-moderate pulmonary edema have both increased after previously\n improving between and 24. This could be a function of cessation of\n positive pressure ventilation if the patient has clearly been extubated.\n Right lung is small than the left, probably a function of surgery. Heart is\n normal size. There is no pneumothorax. Findings were discussed by telephone\n with Dr.\n at the time of dictation.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2114-09-12 00:00:00.000", "description": "Report", "row_id": 1314596, "text": "NEURO: ALERT, ORIENTED, PLEASANT AND COOPERATIVE. MAE, FOLLOWS COMMANDS. 2 PERCOCET FOR PAIN AT 1430, MORPHINE 2MG IV X 1 AT 1730 FOR C/O PAIN.\n\nPULM: LUNGS CLEAR, SATS >98% ON 2L N/P. GOOD COUGH, DEEP BREATH AND USE OF IS. CHEST TUBES DRAINED 50CC SEROSANGUINOUS WHEN OOB TO CHAIR.\n\nCV: NSR WITH RARE PVC. NEO GTT WEANING, MAP 60-70. 4+ PALPABLE PEDAL PULSES. R RADIAL A-LINE WITH DAMPENED WAVE FORM AT TIMES. CALCIUM AND KCL REPLACEMENT PER LABS. BS 108.\n\nGI: + BOWEL SOUNDS, ABD SOFT. TAKING CLEAR LIQUIDS WELL. C/O BRIEF NAUSEA WHEN GOTTEN OOB TO CHAIR.\n\nGU: FOLEY TO CD DRAINING QS AMTS CLEAR YELLOW URINE.\n\nSOCIAL: MANY FAMILY MEMBERS IN AND OUT.\n\nPLAN: CONTINUE TO WEAN NEO GTT TO KEEP MAP >65. PEROCET FOR PAIN. AGGRESSIVE PULM HYGIENE. INCREASE ACTIVITY.\n" }, { "category": "Nursing/other", "chartdate": "2114-09-12 00:00:00.000", "description": "Report", "row_id": 1314597, "text": "ADDENDUM: R RADIAL A-LINE HAD BEEN DAMPENED, NOW WITH SHARP WAVE FORM. 40mm difference between cuff and radial a-line bp's. Neo being weaned according arterial BP's.\n" }, { "category": "Nursing/other", "chartdate": "2114-09-13 00:00:00.000", "description": "Report", "row_id": 1314598, "text": "NEURO-COMPLETELY INTACT. PLEASANT/COOPERATIVE WITH CARE.\n\nCV-NSR.NO ECTOPY. NEO TITRATED TO SUPPORT MAP >60.CURRENTLY @ 1MCGKGMIN WITH MAP 70'S, U/O IMPROVED WITH HIGHER BP. HCT=23.3 MD NOTIFIED. WILL DISCUSS WITH TEAM DURING AM ROUNDS.\n\nRESP-2LNC-98 %. LSC ALL FIELDS. CT WITH MINIMAL SS DRG. NO AIR LEAK SEEN.\n\nG.I.- ABD SOFT. HYPOACTIVE BS.\n\nG.U.- MARGINAL U.O APPROX. 22-28CC/HR. OUTPUT INCREASED WITH INCREASING NEO SUPPORT.\n\nLABS- K+3.9. TX WITH 20 MEQ KCL IV X2. MG=1.7-> TX WITH 2GRMS MGSO4 IV X1.\n\nPLAN-TRANSFER CHAIR -> BED. WEAN NEO AS TOLERATED.ENC. I.S. PERCOCET PRN.\n" }, { "category": "Nursing/other", "chartdate": "2114-09-13 00:00:00.000", "description": "Report", "row_id": 1314599, "text": "NEURO: A&O x 3, pleasant and cooperative. MAE. dilaudid po for pain with poor effect, supplemented with 2mg Morphine IV.\n\nPulm: Lungs diminished L base, O2 at 2L with sats >95%. Good IS use, good cough and deep breath effort. Chest tubes removed today.\n\nCV: NSR with rare PVC. Epicaridal A&V wires sensing/capturing approp with atrial back-up rate 60, MA 20, V wires of. Neo gtt weaned down to 0.2mcg/kg with MAP 65-75 and adequate UO. Palpable pedal pulses. 1-2mm ST elevations noted after chest tube removed, EKG done and shown to , NP, ? mild pericarditis. no pericardial rub noted. 2+ periph edema, Lasix 10mg IV x 1.\n\nGI: taking clear liquids. + bowel sounds. No c/o nausea.\n\nGU: foley to CD draining clear yellow urine. lasix 10mg IV for low UO with 350cc response.\n\nSocial: Family called numerous times, daughter and mother visited briefly. Very supportive family.\n\nPlan: wean Neo off keeping MAP's 65-75 and adequate UO. Dilaudid po for pain. aggressive pulm Hygiene. ? transfer to Far 2 .\n" }, { "category": "Nursing/other", "chartdate": "2114-09-14 00:00:00.000", "description": "Report", "row_id": 1314600, "text": "NEURO ALERT ORIENTED NO DEFECITS NOTED MOVES ALL EXTREMTIES\n\nRESP LUNGS CLEAR USING IS APPROPRIATLY SATS 99% 2L NC 94% RA NONPRODUCTIVE\n\nC/V NSR ST NO ECT B/P STABLE EPI WIRES INTACT SET TO BACKUP OF 60 LOPRESSOR STARTED 7AM GOOD PEDAL PULSES\n\nGU/GI ABD SOFT HYPOACTIVE BOWEL SOUNDS HEARD ADEQUATE URINE OUT TOL LIQUIDS WELL\n\nPLAN CONTINUE TO INCREASE DIET AND ACTIVITY AS TRANSFER TO 2 WHEN BED AVAILABLE TODAY\n" }, { "category": "Nursing/other", "chartdate": "2114-09-11 00:00:00.000", "description": "Report", "row_id": 1314592, "text": "OP DAY S/P TISSUE MV REPLACEMENT AND MAZE\n\nAVP->AP WITH FREQUENT UNIFOCAL PVCS EARLIER. UNDERLYING RHYTHM SINUS 60S. V WIRES NOT SENSING APPROPRIATELY EARLIER POST-OP. V SIDE TURNED OFF. CI OVER 2.2. EPI WEANED TO OFF AS DISCUSSED WITH DR. . NEOSYNEPHRINE TITRATED THROUGHOUT SHIFT WITH LABILE BP. 1 LITER LR AND 1 PRBC GIVEN THIS SHIFT. ELEVATED PT/PTT/INR IMPROVED WITHOUT INTERVENTION (SEE FLOWSHEET).\n\nBREATHSOUNDS CLEAR. FAILED FIRST VENT WEAN ATTEMPT LATE AFTERNOON D/T DROWSINESS/LOW MINUTE VOLUME. EXTUBATED @ 22/HR. DEEP BREATHING AND COUGHING INSTRUCTIONS GIVEN.\n\nOGT DRAINED MINIMAL BILIOUS FLUID PRIOR TO REMOVAL. CARAFATE AND RANITIDINE GIVEN. ABSENT BOWEL SOUNDS. PT C/O THIRST. SOME ICE CHIPS GIVEN.\n\nINSULIN GTT STARTED FOR ^BS 152. CSRU BLOOD SUGAR PROTOCOL INITIATED. SEE FLOW SHEET.\n\nFOLEY CATH DRAINING ADEQUATELY.\n\n\nC/O STERNAL ACHE #7. TORADOL STARTED (NO LOAD). MSO4 GIVEN IVP. PT SLEEPING.\n\nHUSBAND IN TO VISIT AND PLANS TO RETURN AROUND 11AM TOMORROW. HE REPORTS THAT HE PLANS TO CHECK ON HIS WIFE BY PHONE AND CIRCULATE INFORMATION TO HIS FAMILY MEMBERS.\n\nPLAN TO FOLLOW BS. PLAN TO CONTINUE TO ASSESS PAIN AND MINIMIZE WITH TORADOL AND MSO4. PLAN TO MONITOR FOR LOOSE STOOL AND SIGNS OF C DIFF. NO NEED FOR PRECAUTIONS NOW (AS DISCUSSED WITH NP).\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2114-09-12 00:00:00.000", "description": "Report", "row_id": 1314593, "text": "PATIENT WITH SBP INTO THE 70'S AFTER TURING, 500CC FLUID BOLUS GIVEN, INCREASED NEO TO 1.5, IMPROVED. SVO2 CHECKED AFTER VOLUME GIVEN 66% WITH CI APPROX. 2,5. RECEIVING MSO4 2MG IV APPROX. Q2HRS. WITH GOOD RELIEF, WEANING NEO AT 1.3 MCG/KG/MIN PRESENTLY. BS 100'S DRIP AT 2U/HR..\n" }, { "category": "Nursing/other", "chartdate": "2114-09-12 00:00:00.000", "description": "Report", "row_id": 1314594, "text": "PATIENT'S DROP IN SBP TO 80'S WITH REPOSITIONING, 500CCLR BOLUS, INCREASED NEO. HCT THIS AM 25, ??TRANSFUSION. PACER OFF IN SR IN THE 80'S THIS AM. PATIENT WITH IMPROVED SBP AFTER VOLUME/NEO. GOOD CI THIS AM. U/O GOOD... RESP. BILATERAL BS CLEAR, ON 4LNP WITH SATS 97%, INSTRUCTED ON I/S MOVING VOLUMES 400-600CC. GU AS NOTED, GI FAINT BS THIS AM, TOLERATING ICE CHIPS AND SIPS. PAIN MEDIACTED WITH 2MG MSO4 APPROX. Q2-3HRS /TORADOL 15MG Q6HRS. WITH GOOD RESULTS. STERANL INCISION D/I. ENDO- BS 100'S ON 2UREG INSULIN/HR. PATIENT COOPERATIVE AND TALKATIVE THIS AM. PLAN OOB TO CHAIR, ?? ATTEMPT TO WEAN NEO ?? BETABLOCKERS THIS AM.. ?? START LASIX..\n" }, { "category": "Nursing/other", "chartdate": "2114-09-12 00:00:00.000", "description": "Report", "row_id": 1314595, "text": "NEURO ALERT ORIENTED NO DEFECITS\n\nC/V NSR NO ECT EPI WIRES INTACT A WIRES FUNCTIONAL B/P STABLE ON NEO WEANED TO 1MCG TOL WELL MAP 70S CONTINUE TO WEAN GOOD PEDAL PULSES\n\nRESP NC 2L SATS 99% LUNGS CLEAR NON PRODUCTIVE CHEST TUBE SMALL AMTS SEROSANG INTACT USING IS WELL\n\nGU/GI TOL LIQUIDS WELL ABD SOFT BOWEL SOUNDS HEARD ADEQUATE URINE OUT\n\nPLAN OOB TO CHIAR AFTER 2PM TODAY CONTINUE TO WEAN NEO AS TOL INCREASE DIET AS TOL\n" }, { "category": "Radiology", "chartdate": "2114-09-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 800783, "text": " 2:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX\n Admitting Diagnosis: MR\\MITRAL VALVE REPLACEMENT; WITH MAZE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p MVR\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST 1 VIEW:\n\n INDICATION: 55 y/o woman status post MVR.\n\n Portable AP radiograph of the chest was reviewed, and compared to the previous\n study of .\n\n The patient is status post MVR and median sternotomy.\n\n The tip of the endotracheal tube is identified at the thoracic inlet. The\n right jugular Swan-Ganz catheter terminates in the right main PA. The chest\n tube and mediastinal drain are identified. The nasogastric tube courses\n through the stomach. No pneumothorax is identified.\n\n There is mild pulmonary edema with mild cardiomegaly indicating congestive\n heart failure. No pneumothorax is identified. Minimal patchy atelectasis is\n seen in the left lung base.\n\n\n" }, { "category": "Radiology", "chartdate": "2114-09-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 801258, "text": " 7:52 PM\n CHEST (PA & LAT) Clip # \n Reason: ?fever\n Admitting Diagnosis: MR\\MITRAL VALVE REPLACEMENT; WITH MAZE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with MR s/p MVR and MAZE.\n\n REASON FOR THIS EXAMINATION:\n ?fever\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Mitral regurgitation. S/P mitral valve replacement and MAZE.\n Possible fever.\n\n AP AND LEFT LATERAL UPRIGHT VIEWS OF CHEST: The heart again shows moderate LV\n enlargement. There is evidence of the prosthetic mitral valve replacement and\n sternal sutures. There is again evidence of bilateral pleural effusions and\n bibasilar lower lobe atelectasis/infiltrate. These findings have improved\n slightly since the examination of one day earlier. The pulmonary vessels show\n minimal upper zone redistribution, consistent with slight LV failure.\n\n IMPRESSION: Slight improvement in bibasilar infiltrates and effusions since\n examination of one day earlier. Slight LV failure is still present.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2114-09-15 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 801147, "text": " 8:59 AM\n CHEST (PA & LAT) Clip # \n Reason: Fever s/p MVR. R/o atalectesis vs. infiltrate\n Admitting Diagnosis: MR\\MITRAL VALVE REPLACEMENT; WITH MAZE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with MR s/p MVR and MAZE.\n REASON FOR THIS EXAMINATION:\n Fever s/p MVR. R/o atalectesis vs. infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55 y/o female status post mitral valve replacement. Spiking a fever.\n Rule out atelectasis vs. infiltrate.\n\n PA AND LATERAL CHEST : Comparison is made to post-op chest on .\n All of the support tubing has been pulled. There is new bibasilar opacity.\n On the left side, this opacity is dense behind the heart and is obscuring the\n left hemidiaphragm consistent with effusion, infiltrate and/or atelectasis.\n The opacity at the right base blunting the right costophrenic angle and\n suggests there is an effusion at the right base.\n\n IMPRESSION: New retrocardiac density obscuring left hemidiaphragm consistent\n with effusion, consolidation and/or atelectasis. Probable right pleural\n effusion as well.\n\n" }, { "category": "ECG", "chartdate": "2114-09-13 00:00:00.000", "description": "Report", "row_id": 287813, "text": "Poor quality tracing. P wave amplitude is low and may be non-sinus. The rate is\nupper limits of normal. There is more prominent diffuse ST segment elevation\nraising the question of postoperative pericarditis. Clinical correlation is\nsuggested.\n\n" }, { "category": "ECG", "chartdate": "2114-09-12 00:00:00.000", "description": "Report", "row_id": 287814, "text": "Sinus rhythm\nBorderline first degree A-V block\nCompared to previous tracing, the rate has increased, and ventricular premature\ncomplex is absent\n\n" }, { "category": "ECG", "chartdate": "2114-09-11 00:00:00.000", "description": "Report", "row_id": 287815, "text": "Sinus bradycardia\nPremature ventricular contractions or aberrant ventricular conduction\nBorderline first degree AV block\nSince previous tracing of : there is less ectopy\n\n" } ]

[ { "category": "Nursing", "chartdate": "2193-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 695139, "text": "Pt. with polycystic kidney disease admitted from PACU at 1825 s/p\n bilateral (open) nephrectomies today. BP ran low during case and pt.\n was placed on Neo gtt intra-op, which she continued to require in\n PACU. Pt. started on midodrine and admitted to SICU service.\n Pt. arrived sleepy, VSS, NAD noted. Pain\n\n per report, on\n Dilaudid PCA. Pt. presently declines turning in bed due to pain.\n After dicussing possibility to increase PCA dose with H.O., pt.\n requested dose remain the same due to\nloopiness\n. Pt. has\nconstant\n nausea\n at baseline, at present it is stable. Plan to monitor BP/fluid\n status closely overnight and wean Neo gtt as tolerated, goal SBP>90,\n MAP>60.\n" }, { "category": "Nursing", "chartdate": "2193-09-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 695483, "text": "Pt. is POD 2 s/p open bilateral nephrectomies due to polycystic kidney\n disease. Pt. is on transplant list and underwent surgery do to\n increased cystic pain.\n S/P nephrectomy\n Assessment:\n VSS. No respiratory distress noted. Abd. soft, hypoactive BS\n denies flatus. Poor appetite. Intermittent nausea due to analgesia.\n Action:\n Pt. weaned to RA. IS encouraged and utilized Q2hrs. OOB to chair x\n 2hrs this a.m. Pt. given Zofran and Compazine for complaints of\n nausea.\n Response:\n Stable POD 2. Outstanding issues remain pain (see below) and nausea,\n fair effect of antiemetics.\n Plan:\n Transfer to floor and continue per post-surgical clinical pathway.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with surgical pain.\n Action:\n Dilaudid PCA transitioned to PO as noted. Pt. offered analgesia\n hourly. Repositioned for comfort.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2193-09-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 695484, "text": "Pt. is POD 2 s/p open bilateral nephrectomies due to polycystic kidney\n disease. Pt. is on transplant list and underwent surgery do to\n increased cystic pain.\n S/P nephrectomy\n Assessment:\n VSS. No respiratory distress noted. Abd. soft, hypoactive BS\n denies flatus. Poor appetite. Intermittent nausea due to analgesia.\n Action:\n Pt. weaned to RA. IS encouraged and utilized Q2hrs. OOB to chair x\n 2hrs this a.m. Pt. given Zofran and Compazine for complaints of\n nausea.\n Response:\n Stable POD 2. Outstanding issues remain pain (see below) and nausea,\n fair effect of antiemetics.\n Plan:\n Transfer to floor and continue per post-surgical clinical pathway.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with surgical pain.\n Action:\n Dilaudid PCA transitioned to PO as noted. Pt. offered analgesia\n hourly. Repositioned for comfort.\n Response:\n Pt. continues to have reported pain. Pt. remains calm/stable.\n Pt. is not willing to take any further meds at this time.\n Plan:\n Continue to monitor pain and offer anangesia.\n" }, { "category": "Nursing", "chartdate": "2193-09-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 695555, "text": "Pt. is POD 2 s/p open bilateral nephrectomies due to polycystic kidney\n disease. Pt. is on transplant list and underwent surgery do to\n increased cystic pain.\n Pt. is presently awaiting bed on surgical floor.\n S/P nephrectomy\n Assessment:\n VSS. No respiratory distress noted. Abd. soft, hypoactive BS\n denies flatus. Poor appetite. Intermittent nausea due to analgesia.\n Action:\n Pt. weaned to RA. IS encouraged and utilized Q2hrs. OOB to chair x\n 2hrs this a.m. Pt. given Zofran and Compazine for complaints of\n nausea.\n Response:\n Stable POD 2. Outstanding issues remain pain (see below) and nausea,\n fair effect of antiemetics. Required nasal cannula back as she fell\n asleep after receiving IV dilaudid.\n Plan:\n Transfer to floor and continue per post-surgical clinical pathway.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with surgical pain.\n Action:\n Dilaudid PCA transitioned to PO as noted. Pt. offered analgesia hourly\n (initially refusing.) Repositioned for comfort.\n Response:\n Pt. continued to report severe pain. Pt. remains calm/stable. Pt. was\n not willing to take PO dilaudid until second part of shift. Eventually\n 4mg given, ineffective\n given .8mg total IV dilaudid for\nbreakthrough\n pain and pain finally resolved.\n Plan:\n Continue to monitor pain and offer anangesia. Try to give didaudid\n Q3hr until pain becomes more tolerable.\n" }, { "category": "Nursing", "chartdate": "2193-09-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 695557, "text": "Pt. is POD 2 s/p open bilateral nephrectomies due to polycystic kidney\n disease. Pt. is on transplant list and underwent surgery do to\n increased cystic pain.\n Pt. is presently awaiting bed on surgical floor.\n S/P nephrectomy\n Assessment:\n VSS. No respiratory distress noted. Abd. soft, hypoactive BS\n denies flatus. Poor appetite. Intermittent nausea due to analgesia.\n Action:\n Pt. weaned to RA. IS encouraged and utilized Q2hrs. OOB to chair x\n 2hrs this a.m. Pt. given Zofran and Compazine for complaints of\n nausea.\n Response:\n Stable POD 2. Outstanding issues remain pain (see below) and nausea,\n fair effect of antiemetics. Required nasal cannula back as she fell\n asleep after receiving IV dilaudid.\n Plan:\n Transfer to floor and continue per post-surgical clinical pathway.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with surgical pain.\n Action:\n Dilaudid PCA transitioned to PO as noted. Pt. offered analgesia hourly\n (initially refusing.) Repositioned for comfort.\n Response:\n Pt. continued to report severe pain. Pt. remains calm/stable. Pt. was\n not willing to take PO dilaudid until second part of shift. Eventually\n 4mg given, ineffective\n given .8mg total IV dilaudid for\nbreakthrough\n pain and pain finally resolved.\n Plan:\n Continue to monitor pain and offer anangesia. Try to give didaudid\n Q3hr until pain becomes more tolerable.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n POLYCYSTIC KIDNEY DISEASE/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 57 kg\n Daily weight:\n 56.7 kg\n Allergies/Reactions:\n Motrin (Oral) (Ibuprofen)\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Unknown;\n Protonix (Oral) (Pantoprazole Sodium)\n Unknown;\n Iron Dextran Complex\n Rash;\n Statins: Hmg-Coa Reductase Inhibitors\n Rash;\n Ceftriaxone\n Rash;\n Methadone\n Hives;\n Precautions:\n PMH: Renal Failure\n CV-PMH: Hypertension\n Additional history: Polcystic kidney disease, RUE fistula/home HD, s/p\n spinal fusion ', s/p hysterectomy, rectocele, HX low platlets - needs\n DDAVP prior to surgeries (received today.)\n Surgery / Procedure and date: above\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:53\n Temperature:\n 97.9\n Arterial BP:\n S:133\n D:50\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 90 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,160 mL\n 24h total out:\n 75 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 04:24 AM\n Potassium:\n 4.2 mEq/L\n 04:24 AM\n Chloride:\n 101 mEq/L\n 04:24 AM\n CO2:\n 29 mEq/L\n 04:24 AM\n BUN:\n 28 mg/dL\n 04:24 AM\n Creatinine:\n 4.3 mg/dL\n 04:24 AM\n Glucose:\n 71 mg/dL\n 04:24 AM\n Hematocrit:\n 28.2 %\n 04:24 AM\n Finger Stick Glucose:\n 92\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Sicu B\n Transferred to: \n Date & time of Transfer: 12:00 AM\n" }, { "category": "Physician ", "chartdate": "2193-09-05 00:00:00.000", "description": "Intensivist Note", "row_id": 695455, "text": "SICU\n HPI:\n 65yo F c ESRD PCKD now s/p B nephrectomy for symptomatic renal\n cysts, liver cyst fenestration \n Chief complaint:\n PMHx:\n ESRD PKD, Nephrolithiasis, History of HTN (no longer on meds),\n Chronic sinusitis, pancreatic/hepatic cysts, breast CA, toxoplasmosis,\n rectocele and rectal prolapse\n PSH: L mastectomy and LAD, spinal fusion, TAH, Mesenteric LN bx, RUE\n AVF s/p multiple interventions over last 2 years\n Current medications:\n 24 Hour Events:\n ARTERIAL LINE - STOP 03:30 PM\n : off pressors 0600. HD.\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Unknown;\n Protonix (Oral) (Pantoprazole Sodium)\n Unknown;\n Iron Dextran Complex\n Rash;\n Statins: Hmg-Coa Reductase Inhibitors\n Rash;\n Ceftriaxone\n Rash;\n Methadone\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:47 PM\n Other medications:\n : Doxepin 25, Epogen qweek, Dilaudid PRN, Plaquenil 400, Iron\n Sucrose 100mg w/ clinic visits, Ativan 1mg w/procedures, Nitroglycerin\n 0.3 SL PRN, Omeprazole 40, Zofran 4prn, Citrucel 500\", CA-D3\n 500-200tab\n Flowsheet Data as of 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 36.7\nC (98\n HR: 98 (88 - 106) bpm\n BP: 128/40(61) {112/33(56) - 142/84(74)} mmHg\n RR: 19 (9 - 20) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 56.7 kg (admission): 57 kg\n CVP: 4 (0 - 6) mmHg\n Total In:\n 1,234 mL\n 510 mL\n PO:\n 160 mL\n 180 mL\n Tube feeding:\n IV Fluid:\n 1,074 mL\n 330 mL\n Blood products:\n Total out:\n 1,175 mL\n 25 mL\n Urine:\n NG:\n Stool:\n Drains:\n 175 mL\n 25 mL\n Balance:\n 59 mL\n 485 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic), RUE fistula\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 3)\n Labs / Radiology\n 134 K/uL\n 8.7 g/dL\n 71 mg/dL\n 4.3 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 28 mg/dL\n 101 mEq/L\n 142 mEq/L\n 28.2 %\n 12.1 K/uL\n [image002.jpg]\n 03:18 AM\n 02:23 PM\n 02:24 PM\n 04:24 AM\n WBC\n 18.6\n 11.0\n 12.1\n Hct\n 33.7\n 30.4\n 28.2\n Plt\n 168\n 129\n 134\n Creatinine\n 6.1\n 1.9\n 4.3\n Glucose\n 117\n 119\n 71\n Other labs: PT / PTT / INR:13.8/28.0/1.2, Ca:7.3 mg/dL, Mg:1.8 mg/dL,\n PO4:6.8 mg/dL\n Assessment and Plan\n .H/O RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPOTENSION (NOT\n SHOCK)\n Assessment and Plan: 65yo F c ESRD PCKD now s/p B nephrectomy for\n symptomatic renal cysts, liver cyst fenestration \n Neurologic: Stable. Dilaudid for pain control w/o good relief. States\n no particular med works. Prefers Tylenol.\n Cardiovascular: Off Neo 24h and s/p dialysis. Goal MAP >60 or SBP >90.\n Midodrine increased 10 mg PO TID\n Pulmonary: Stable on RA.\n Gastrointestinal / Abdomen: Clears and advance as tolerated\n Nutrition: PO. Nausea treated w/ zofran. Pt states zofran 'stops her\n bowels'.\n Renal: S/p B nephrectomy. Dialysis Following. HD . Next HD .\n Hematology: Checking iron studies. Epogen. Follow HCT, recent drop. No\n signs of active bleed.\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: , RUE AV Fistula\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Nephrology, Transplant\n Billing Diagnosis: Other: PCKD\n ICU Care\n Glycemic Control:\n Lines:\n Multi Lumen - 06:41 PM\n Prophylaxis:\n DVT: Boots, SC Heparin\n Stress ulcer: Omeprazole\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 minutes\n" }, { "category": "Nursing", "chartdate": "2193-09-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 695363, "text": "S/P bilateral nephrectomies (polycystic kidney disease)\n Assessment:\n All vitals stable, see flowsheet for details\n Abdominal incision with staples\necchymotic, no drainage\n Jp with small amount serosang output\n Lung sounds clear, breathing unlabored\n IVF infusing, patient just taking sips\n Action:\n Routine post-op care.\n Encouraged IS, assisted with dangling @ edge of bed\n Response:\n Stable POD 2\n Plan:\n OOB today\n Transfer to floor\n Provide support\n Advance diet\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient rating abdominal/incisional pain approx .\n Guarding with any movement\n Sleeping on/off throughout the night\n Action:\n Encouraged Dilaudid pca use\n Encouraged/assisted with repositioning for comfort\n Response:\n Patient currently content with pain regimen (Dilaudid pca).\n C/O nausea related to Dilaudid\n Plan:\n ? change to po Dilaudid when patient taking po\n Given Zofran for nausea\n" }, { "category": "Nursing", "chartdate": "2193-09-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 695544, "text": "Pt. is POD 2 s/p open bilateral nephrectomies due to polycystic kidney\n disease. Pt. is on transplant list and underwent surgery do to\n increased cystic pain.\n Pt. is presently awaiting bed on surgical floor.\n S/P nephrectomy\n Assessment:\n VSS. No respiratory distress noted. Abd. soft, hypoactive BS\n denies flatus. Poor appetite. Intermittent nausea due to analgesia.\n Action:\n Pt. weaned to RA. IS encouraged and utilized Q2hrs. OOB to chair x\n 2hrs this a.m. Pt. given Zofran and Compazine for complaints of\n nausea.\n Response:\n Stable POD 2. Outstanding issues remain pain (see below) and nausea,\n fair effect of antiemetics. Required nasal cannula back as she fell\n asleep after receiving IV dilaudid.\n Plan:\n Transfer to floor and continue per post-surgical clinical pathway.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with surgical pain.\n Action:\n Dilaudid PCA transitioned to PO as noted. Pt. offered analgesia hourly\n (initially refusing.) Repositioned for comfort.\n Response:\n Pt. continued to report severe pain. Pt. remains calm/stable. Pt. was\n not willing to take PO dilaudid until second part of shift. Eventually\n 4mg given, ineffective\n given .8mg total IV dilaudid for\nbreakthrough\n pain and pain finally resolved.\n Plan:\n Continue to monitor pain and offer anangesia. Try to give didaudid\n Q3hr until pain becomes more tolerable.\n" }, { "category": "Physician ", "chartdate": "2193-09-04 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 695167, "text": "24 Hour Events: OR for b/l nephrectomies, extubated post-op. SICU for\n hypotension/pressor requirement. Phenylephrine weaned but still\n required.\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Unknown;\n Protonix (Oral) (Pantoprazole Sodium)\n Unknown;\n Iron Dextran Complex\n Rash;\n Statins: Hmg-Coa Reductase Inhibitors\n Rash;\n Ceftriaxone\n Rash;\n Methadone\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.7 mcg/Kg/min\n Other ICU medications:\n Other medications:\n 10. Heparin 5000 UNIT SC BID Order date: @ \n 3. 1000 mL NS\n Continuous at 50 ml/hr Order date: @ 12. Hydroxychloroquine\n Sulfate 400 mg PO DAILY Order date: @ \n 4. DiphenhydrAMINE 25-50 mg PO Q12H OR QHS PRN sleep Order date: \n @ 13. Midodrine 5 mg PO TID Order date: @ \n 5. Docusate Sodium 100 mg PO BID Order date: @ 14.\n Omeprazole 40 mg PO DAILY Order date: @ \n 6. Doxepin HCl 25 mg PO HS Order date: @ 15. Ondansetron 4\n mg IV Q8H:PRN nausea/vomiting Order date: @ \n 7. Epoetin Alfa\n To be administered during dialysis and dosed according to the \n Epoetin Alfa P&T Guidelines. Order date: @ 16.\n Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO maintain MAP >60 or\n SBP>90 Order date: @ \n 8. HYDROmorphone (Dilaudid) 0.12 mg IVPCA Lockout Interval: 6 minutes\n Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 1.2 mg(s) Order date: @\n 17. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: \n @ 1115\n Flowsheet Data as of 03:10 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: 83 (76 - 83) bpm\n BP: 112/49(72) {91/42(61) - 122/53(77)} mmHg\n RR: 9 (7 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 6 (3 - 7)mmHg\n Total In:\n 2,011 mL\n 192 mL\n PO:\n 60 mL\n TF:\n IVF:\n 1,951 mL\n 192 mL\n Blood products:\n Total out:\n 530 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n 50 mL\n Balance:\n 1,481 mL\n 192 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Diminished: bases b/l ), Poor air\n entry\n Abdominal: Soft, Tender: appropriately, Midline surgical dressing with\n sang/serosang drainage. JP LUQx1 sanguinous drainage\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n .H/O RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPOTENSION (NOT\n SHOCK)\n Assessment And Plan: 65F c ESRD PCKD now s/p B nephrectomy for\n symptomatic renal cysts, liver cyst fenestration \n Neuro: Dilaudid PCA for Pain control\n CV: Wean Phenylephrine as tolerated (MAP >60 or SBP >90), Midodrine 5mg\n PO TID\n Resp: Extubated post-op, no active issues\n GI/GU: Sips, ARBF\n Renal: Nephrology Dialysis Following. HD if pressures will\n tollerate\n Endo: Procrit\n Prophylaxis: SQH, PPI, SCDs\n FEN: NS@50cc/hr\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 06:41 PM\n Arterial Line - 06:43 PM\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:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2193-09-05 00:00:00.000", "description": "Intensivist Note", "row_id": 695427, "text": "SICU\n HPI:\n 65yo F c ESRD PCKD now s/p B nephrectomy for symptomatic renal\n cysts, liver cyst fenestration \n Chief complaint:\n PMHx:\n ESRD PKD, Nephrolithiasis, History of HTN (no longer on meds),\n Chronic sinusitis, pancreatic/hepatic cysts, breast CA, toxoplasmosis,\n rectocele and rectal prolapse\n PSH: L mastectomy and LAD, spinal fusion, TAH, Mesenteric LN bx, RUE\n AVF s/p multiple interventions over last 2 years\n Current medications:\n 24 Hour Events:\n ARTERIAL LINE - STOP 03:30 PM\n : off pressors 0600. HD.\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Unknown;\n Protonix (Oral) (Pantoprazole Sodium)\n Unknown;\n Iron Dextran Complex\n Rash;\n Statins: Hmg-Coa Reductase Inhibitors\n Rash;\n Ceftriaxone\n Rash;\n Methadone\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:47 PM\n Other medications:\n : Doxepin 25, Epogen qweek, Dilaudid PRN, Plaquenil 400, Iron\n Sucrose 100mg w/ clinic visits, Ativan 1mg w/procedures, Nitroglycerin\n 0.3 SL PRN, Omeprazole 40, Zofran 4prn, Citrucel 500\", CA-D3\n 500-200tab\n Flowsheet Data as of 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 36.7\nC (98\n HR: 98 (88 - 106) bpm\n BP: 128/40(61) {112/33(56) - 142/84(74)} mmHg\n RR: 19 (9 - 20) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 56.7 kg (admission): 57 kg\n CVP: 4 (0 - 6) mmHg\n Total In:\n 1,234 mL\n 510 mL\n PO:\n 160 mL\n 180 mL\n Tube feeding:\n IV Fluid:\n 1,074 mL\n 330 mL\n Blood products:\n Total out:\n 1,175 mL\n 25 mL\n Urine:\n NG:\n Stool:\n Drains:\n 175 mL\n 25 mL\n Balance:\n 59 mL\n 485 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic), RUE fistula\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 3)\n Labs / Radiology\n 134 K/uL\n 8.7 g/dL\n 71 mg/dL\n 4.3 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 28 mg/dL\n 101 mEq/L\n 142 mEq/L\n 28.2 %\n 12.1 K/uL\n [image002.jpg]\n 03:18 AM\n 02:23 PM\n 02:24 PM\n 04:24 AM\n WBC\n 18.6\n 11.0\n 12.1\n Hct\n 33.7\n 30.4\n 28.2\n Plt\n 168\n 129\n 134\n Creatinine\n 6.1\n 1.9\n 4.3\n Glucose\n 117\n 119\n 71\n Other labs: PT / PTT / INR:13.8/28.0/1.2, Ca:7.3 mg/dL, Mg:1.8 mg/dL,\n PO4:6.8 mg/dL\n Assessment and Plan\n .H/O RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPOTENSION (NOT\n SHOCK)\n Assessment and Plan: 65yo F c ESRD PCKD now s/p B nephrectomy for\n symptomatic renal cysts, liver cyst fenestration \n Neurologic: Stable. Dilaudid for pain control w/o good relief. States\n no particular med works. Prefers Tylenol.\n Cardiovascular: Off Neo 24h and s/p dialysis. Goal MAP >60 or SBP >90.\n Midodrine increased 10 mg PO TID\n Pulmonary: Stable on RA.\n Gastrointestinal / Abdomen:\n Nutrition: PO. Nausea treated w/ zofran. Pt states zofran 'stops her\n bowels'.\n Renal: S/p B nephrectomy. Dialysis Following. HD . Next HD .\n Hematology: Checking iron studies. Epogen. Follow HCT, recent drop. No\n signs of active bleed.\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains: , RUE AV Fistula\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Nephrology, Transplant\n Billing Diagnosis: Other: PCKD\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 06:41 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 22 minutes\n" }, { "category": "Nursing", "chartdate": "2193-09-04 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 695240, "text": "Pt. with polycystic kidney disease admitted from PACU at 1825 s/p\n bilateral (open) nephrectomies. BP ran low during case and pt. was\n placed on Neo gtt intra-op, which she continued to require in PACU.\n Pt. started on midodrine and admitted to SICU service.\n Pt. arrived sleepy, VSS, NAD noted. Pain\n\n per report, on\n Dilaudid PCA. Pt. presently declines turning in bed due to pain.\n After dicussing possibility to increase PCA dose with H.O., pt.\n requested dose remain the same due to\nloopiness\n. Pt. has\nconstant\n nausea\n at baseline, at present it is stable. Plan to monitor BP/fluid\n status closely overnight and wean Neo gtt as tolerated, goal SBP>90,\n MAP>60.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt remains on Dilaudid PCA with no increase in dosage\n overnight\n Pressors off early this am\n Pt states abd is painful to touch but at rest pain is\n tolerabe\n Pt guards abd with movement\n C/O nausea this am\n Action:\n Repositioned as tolerated\n Zofran for pain with effect\n Using PCA appropriately\n Response:\n State pain with movement and to touch\n Pt states she does not need to have dose increased\n Plan:\n Cont to monitor resp to pain\n .H/O renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n s/p Bilateral nephrectomies for PKD\n HD done at bedside today\n K 6.2 early am (prior to HD)\n Action:\n HD at bedside\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2193-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 695160, "text": ".H/O renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Patient POD 1 bilateral nephrectomy due to chronic pain & PKD.\n Abdominal dressing intact, old serosang drainage noted. JP with small\n amounts sang output. Afebrile.\n Action:\n Routine post-operative care. Provided support.\n Response:\n Patient stable.\n Plan:\n IS teaching. Encourage ambulation.\n Hypotension (not Shock)\n Assessment:\n Patient on low dose neo since beginning of the shift. MAP occasionally\n dipping to ~ 60 with SBP occasionally high 80\ns. CVP 3-6. Maintenance\n IVF infusing. Patient does not make any urine.\n Action:\n Attempted to wean and turn neo gtt off.\n Response:\n Neo resumed & Patient remains on low dose for goal sbp 160-180. Dr.\n aware that neo gtt remains on.\n Plan:\n Wean off when possible.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient rating abdominal/incisional pain . Patient also stating\n she has chronic pain issues due to PKD and osteoarthritis. Has\n attempted several different narcotics in past for pain relief. Patient\n currently on Dilaudid PCA. Patient grimaces & guards with any\n movement.\n Action:\n Encourage PCA use. Discussed with patient what she thinks best\n possible pain management is.\n Response:\n Patient using pca frequently. Occasionally appears lethargic, but\n easily arousable and able to answer all questions.\n Plan:\n Patient states she believes PCA is working better than anything elso\n would.\n" }, { "category": "Nursing", "chartdate": "2193-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 695210, "text": ".H/O renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Patient POD 1 bilateral nephrectomy due to chronic pain & PKD.\n Abdominal dressing intact, old serosang drainage noted. JP with small\n amounts sang output. Afebrile.\n Action:\n Routine post-operative care. Provided support.\n Response:\n Patient stable.\n Plan:\n IS teaching. Encourage ambulation.\n Hypotension (not Shock)\n Assessment:\n Patient on low dose neo since beginning of the shift. MAP occasionally\n dipping to ~ 60 with SBP occasionally high 80\ns. CVP 3-6. Maintenance\n IVF infusing. Patient does not make any urine.\n Action:\n Attempted to wean and turn neo gtt off.\n Response:\n Neo resumed & Patient remains on low dose for goal sbp >90 or map >60.\n Dr. aware that neo gtt remains on.\n Plan:\n Wean off when possible.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient rating abdominal/incisional pain . Patient also stating\n she has chronic pain issues due to PKD and osteoarthritis. Has\n attempted several different narcotics in past for pain relief. Patient\n currently on Dilaudid PCA. Patient grimaces & guards with any\n movement.\n Action:\n Encourage PCA use. Discussed with patient what she thinks best\n possible pain management is.\n Response:\n Patient using pca frequently. Occasionally appears lethargic, but\n easily arousable and able to answer all questions.\n Plan:\n Patient states she believes PCA is working better than previous pain\n regimens. ? Chronic pain consult if needed (Unknown @ this time if\n patient\ns pain will resolve due to kidney removal).\n" }, { "category": "Nursing", "chartdate": "2193-09-04 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 695309, "text": "Pt. with polycystic kidney disease admitted from PACU at 1825 s/p\n bilateral (open) nephrectomies. BP ran low during case and pt. was\n placed on Neo gtt intra-op, which she continued to require in PACU.\n Pt. started on midodrine and admitted to SICU service.\n Pt. arrived sleepy, VSS, NAD noted. Pain\n\n per report, on\n Dilaudid PCA. Pt. presently declines turning in bed due to pain.\n After dicussing possibility to increase PCA dose with H.O., pt.\n requested dose remain the same due to\nloopiness\n. Pt. has\nconstant\n nausea\n at baseline, at present it is stable. Plan to monitor BP/fluid\n status closely overnight and wean Neo gtt as tolerated, goal SBP>90,\n MAP>60.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt remains on Dilaudid PCA with no increase in dosage\n overnight\n Pressors off early this am\n Pt states abd is painful to touch but at rest pain is\n tolerabe\n Pt guards abd with movement\n C/O nausea this am\n Action:\n Repositioned as tolerated\n Zofran for pain with effect\n Using PCA appropriately\n Response:\n State pain with movement and to touch\n Pt states she does not need to have dose increased\n Plan:\n Cont to monitor resp to pain\n .H/O renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n s/p Bilateral nephrectomies for PKD\n HD done at bedside today\n K 6.2 early am (prior to HD)\n Action:\n HD at bedside\n 1 liter of fluid removed during dialysis\n Response:\n Post dialysis pt tachy to 110\n Temp also 100 which pt states is fever for her\n ICU resident aware\n Tylenol given and fluid bolus given X 1 for HR.\n Plan:\n Monitor response to fluid bolus\n F/U on post dialysis labs\n Cont to monitor pain mmgt\n Cont with current plan of care\n" }, { "category": "Nursing", "chartdate": "2193-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 695310, "text": "Pt. with polycystic kidney disease admitted from PACU at 1825 s/p\n bilateral (open) nephrectomies. BP ran low during case and pt. was\n placed on Neo gtt intra-op, which she continued to require in PACU.\n Pt. started on midodrine and admitted to SICU service.\n Pt. arrived sleepy, VSS, NAD noted. Pain\n\n per report, on\n Dilaudid PCA. Pt. presently declines turning in bed due to pain.\n After dicussing possibility to increase PCA dose with H.O., pt.\n requested dose remain the same due to\nloopiness\n. Pt. has\nconstant\n nausea\n at baseline, at present it is stable. Plan to monitor BP/fluid\n status closely overnight and wean Neo gtt as tolerated, goal SBP>90,\n MAP>60.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt remains on Dilaudid PCA with no increase in dosage\n overnight\n Pressors off early this am\n Pt states abd is painful to touch but at rest pain is\n tolerabe\n Pt guards abd with movement\n C/O nausea this am\n Action:\n Repositioned as tolerated\n Zofran for pain with effect\n Using PCA appropriately\n Response:\n State pain with movement and to touch\n Pt states she does not need to have dose increased\n Plan:\n Cont to monitor resp to pain\n .H/O renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n s/p Bilateral nephrectomies for PKD\n HD done at bedside today\n K 6.2 early am (prior to HD)\n Action:\n HD at bedside\n 1 liter of fluid removed during dialysis\n Response:\n Post dialysis pt tachy to 110\n Temp also 100 which pt states is fever for her\n ICU resident aware\n Tylenol given and fluid bolus given X 1 for HR.\n Plan:\n Monitor response to fluid bolus\n F/U on post dialysis labs\n Cont to monitor pain mmgt\n Cont with current plan of care\n" } ]

[ { "category": "Radiology", "chartdate": "2180-02-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 997060, "text": " 12:01 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: IJ placement\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with new r IJ pulled back\n REASON FOR THIS EXAMINATION:\n IJ placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: IJ line placement.\n\n One portable view. Comparison with the previous study done . Streaky\n density consistent with subsegmental atelectasis or scarring at the lung bases\n persists. Mediastinal structures are unchanged. An endotracheal tube and\n nasogastric tube remain in place. A right internal jugular catheter has been\n pulled back and now terminates in the inferior portion of the superior vena\n cava near the cavoatrial junction.\n\n IMPRESSION: Line placement as described.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-02-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 997888, "text": " 2:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pna or chf\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with rales and crackles\n REASON FOR THIS EXAMINATION:\n ? pna or chf\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Rales and crackles.\n\n FINDINGS: In comparison with the study of , there has been the\n development of substantial pleural effusions bilaterally. The pulmonary\n vessels are less sharply seen, consistent with increasing pulmonary venous\n pressure.\n\n The endotracheal tube has been removed and the right IJ catheter remains.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-02-18 00:00:00.000", "description": "R FOOT AP,LAT & OBL RIGHT", "row_id": 998056, "text": " 2:21 PM\n FOOT AP,LAT & OBL RIGHT Clip # \n Reason: please perform 3 views\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p Ex lap w/ pain 3th/4th toes R foot\n REASON FOR THIS EXAMINATION:\n please perform 3 views\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT FOOT\n\n INDICATION: -year-old female with pain in the third and fourth right toes.\n\n Three radiographs of the right foot are obtained and compared to .\n\n Evaluation is limited due to positioning. There is dislocation/subluxation of\n the second metatarsophalangeal joint. Deformity of the proximal phalanx of\n the second digit is noted which may represent old fracture deformity. There\n is dislocation of the third proximal interphalangeal joint with lateral\n displacement of the proximal phalanx. There is dislocation of the fourth\n proximal interphalangeal joint with lateral displacement of the fourth\n proximal phalanx. An osseous density is seen projecting adjacent to the base\n of the middle phalanx of the fourth toe. It is unclear whether this\n represents a fracture fragment. There is a deformity of the fifth proximal\n phalanx at the metatarsophalangeal joint, likely representing subluxation. The\n bones are diffusely demineralized which limits evaluation.\n\n Degenerative changes of the interphalangeal joint and metatarsophalangeal\n joint of the first toe are also noted. There is a corticated density anterior\n to the tibiotalar joint. This may represent sequelae of old trauma. Diffuse\n vascular calcification is present.\n\n IMPRESSION: Overall unchanged appearance when compared to .\n Dislocation of the third and fourth proximal interphalangeal joint.\n Subluxation/dislocation of the second and fifth metatarsophalangeal joint. A\n fracture at the base of the fourth middle phalanx cannot reliably be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2180-02-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 998967, "text": " 10:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulm edema, ? increasing effusions\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman expiratory wheezes, crax in bases\n REASON FOR THIS EXAMINATION:\n pulm edema, ? increasing effusions\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: \n\n INDICATION: Followup.\n\n FINDINGS: As compared to the previous examination of , the\n extent of the pleural effusions is unchanged. The bibasilar parenchymal\n opacities are also unchanged. No newly appeared opacities.\n\n IMPRESSION: No relevant changes as compared to .\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2180-02-25 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 999194, "text": " 2:47 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: ? clot from PICC\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with\n REASON FOR THIS EXAMINATION:\n ? clot from PICC\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: -year-old female referred for evaluation of DVT.\n\n RIGHT UPPER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler son of\n the right internal jugular, subclavian, axillary, brachial, basilic, and\n cephalic veins were performed. Normal waveform, compressibility,\n augmentation, and flow are demonstrated. A PIC catheter is seen extending\n from the brachial to the subclavian vein.\n\n IMPRESSION: No evidence of DVT.\n\n" }, { "category": "Radiology", "chartdate": "2180-02-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 998700, "text": " 5:52 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pt had a right sided picc line placed,43cm, and needs tip co\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with SBO who needs picc line for TPN.\n REASON FOR THIS EXAMINATION:\n Pt had a right sided picc line placed,43cm, and needs tip confirmation please\n page at with wet read,thanks.\n ______________________________________________________________________________\n WET READ: ARHb TUE 7:11 PM\n Right PICC tip projects low, near right hemidiaphragm. Partial withdrawal\n recommended. No other significant change. D/W (IV nurse).\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable for line placement on .\n\n COMPARISON: Chest portable AP on .\n\n HISTORY: A -year-old woman with shortness of breath, who needs a PICC line\n for total parenteral nutrition. The patient had a right-sided PICC line\n placed, confirmation for the location of its tip is recommended.\n\n FINDINGS: The right subclavian PICC line distal tip is projected along the\n inferior most portion of the right atrium and thus needs to be pulled back by\n at least 7.5 cm.\n\n There is persistent cardiomegaly. Bilateral small-to-moderate pleural\n effusions are again seen with small loculated right minor fissure effusion. On\n today's examination, the lungs are clear, demonstrating no edema. The patient\n is status post abdominal surgery with multiple surgical clips.\n\n IMPRESSION:\n 1. The right subclavian PICC line distal tip is in the inferior most portion\n of the right atrium and needs to be pulled back by approximately 7.5 cm.\n 2. Bilateral moderate pleural effusion with right-sided pleural loculation in\n the right minor fissure.\n 3. No pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2180-02-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 998319, "text": " 11:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: increased white count, please eval for acute pulmonary proce\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p lysis of adhesions for SBO\n REASON FOR THIS EXAMINATION:\n increased white count, please eval for acute pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Increased white count.\n\n FINDINGS: Again noted are large bilateral pleural effusions and right IJ line\n with tip in the SVC. The upper lungs are clear. The lower lungs cannot be\n assessed due to the overlying effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-02-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 998714, "text": " 9:00 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: picc repositioned, please verify tip location, could you ple\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with\n REASON FOR THIS EXAMINATION:\n picc repositioned, please verify tip location, could you please page beeper\n with wet read, thanks.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable for line placement on .\n\n COMPARISON: chest radiograph at 18:12.\n\n HISTORY: PICC line repositioned. Evaluate for the new location.\n\n FINDINGS: In the interim, the right PICC line has been pulled back now with\n distal tip located at the SVC/atrial junction. Persistent moderate bilateral\n pleural effusion is again seen with loculation in the right minor fissure. On\n today's examination, there is indistinctness of the pulmonary parenchyma\n indicative of a newly developing bilateral pulmonary edema.\n\n IMPRESSION:\n 1. Right PICC line in a fairly satisfactory location at the SVC/atrial\n junction.\n 2. New bilateral mild interstitial pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2180-02-21 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 998532, "text": " 7:47 PM\n PORTABLE ABDOMEN Clip # \n Reason: now with N/V, very distended abdomen, low UOP. Difficult to\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with recent SBO, s/p exlap LOA\n REASON FOR THIS EXAMINATION:\n now with N/V, very distended abdomen, low UOP. Difficult to ascertain if pt is\n constipated or obstructed, please evaluate, thanks. call with results\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable abdomen.\n\n INDICATION: -year-old female with recent small bowel obstruction status\n post LOA, presenting with nausea and vomiting.\n\n FINDINGS: Multiple clips overlie the midline of the abdomen. The right\n lateral aspect of the patient is excluded from the film. High-density\n material is identified within the colon, which is probably from the previous\n CT evaluation of . No definite air-distended loops of small bowel.\n\n IMPRESSION: Limited examination. Recommend upright and supine views to\n further assess bowel as indicated. No definite evidence of obstruction. Dense\n material of the colon is probably from CT evaluation nine days prior.\n\n" }, { "category": "Radiology", "chartdate": "2180-02-22 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 998628, "text": " 11:52 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ? abscess\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p exp. lap , now wbc 26\n REASON FOR THIS EXAMINATION:\n ? abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post exploratory laparotomy, , now with elevated\n white blood cell count. Evaluate for abscess.\n\n COMPARISON: .\n\n TECHNIQUE: Axial MDCT images were obtained from the lung bases to the pubic\n symphysis after the intravenous administration of Optiray. Coronal and\n sagittal reformatted images are provided.\n\n CONTRAST: Oral and intravenous nonionic contrast.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Moderate bilateral pleural\n effusions are increased from , along with increasing compressive\n atelectasis in the lower lobes and right middle lobe. Coronary artery,\n aortic, and mitral annular calcifications are again noted. The liver, spleen,\n pancreas appear unremarkable. Slight fullness of the left adrenal gland is\n present without a definite nodule. Two cysts in the left kidney appear\n unchanged. There is no hydronephrosis.\n\n Multiple loops of distended small bowel containing air-fluid levels are seen\n throughout the abdomen without a clear transition point. The patient is\n status post prior right hemicolectomy. A large amount of stool and retained\n contrast is seen within the residual portion of the colon, particularly its\n most proximal segment near the ileocolic anastomosis. Just adjacent to the\n anastomosis, an approximately 3- cm long segment of colon shows\n circumferential peripheral tiny foci of gas. This most likely represents\n trapped bubbles of gas surrounding luminal contents, although pneumatosis\n could have a similar appearance. There is no free intraperitoneal air and no\n mesenteric or portal venous gas. The aorta is normal in caliber with mural\n calcification consistent with atheromatous disease, and the proximal celiac\n and superior mesenteric arteries are patent. Surgical clips in the anterior\n midline are consistent with patient's recent laparotomy.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder and distal ureters\n appear unremarkable. A moderate amount of gas and a small amount of fecal\n material are seen in the colon, along with peripheral hyperdensity coating the\n mucosa thought to relate to barium residual from the previous CT examination\n of several days ago. There has been right salpingo-oophorectomy and a small\n amount of fluid without a clear enhancing rim seen in the right adnexal fossa\n (2:62). Another small pocket of fluid is seen just adjacent to the left\n adnexum (2:63), which appears to be free within the pelvis and shows no\n (Over)\n\n 11:52 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ? abscess\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n enhancing rim. Central hypodensity in the uterus could relate to a uterine\n fibroid. A couple of punctate calcifications are again seen within the\n uterus. There are no pathologically enlarged pelvic or inguinal lymph nodes.\n Subcutaneous tissue stranding is consistent with anasarca.\n\n BONE WINDOWS: Bone windows show degenerative change of the thoracolumbar\n spine and no lesions worrisome for osseous metastatic disease.\n\n IMPRESSION:\n 1. Dilated loops of small bowel and moderate amount of stool in the colon.\n Findings are most suggestive of ileus.\n 2. Focal area of peripheral circumferential gas within the colon, just\n adjacent to the ileocolic anastomosis, most likely represents gas trapped\n around luminal contents, as no other signs to suggest bowel ischemia are\n present.\n 3. Increased bilateral pleural effusions and atelectasis.\n 4. Small amount of fluid in the pelvis without evidence of abscess.\n 5. Left adrenal gland prominence could relate to adenoma as previously\n suggested, although a focal nodule is not definitely visualized on today's\n examination.\n\n" }, { "category": "Radiology", "chartdate": "2180-02-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 998469, "text": " 1:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pna\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p exp. lap\n REASON FOR THIS EXAMINATION:\n ? pna\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: chest radiograph.\n\n HISTORY: -year-old woman status post exploratory laparotomy, rule out\n pneumonia.\n\n FINDINGS: In the interim, the lungs congestion has cleared with persistent\n bilateral moderate significant pleural effusion. The lung bases cannot be\n evaluated due to the presence of the pulmonary effusion. The visualized\n portions of the lungs do not show any abnormal masses. The visualized osseous\n structures do not show any lesions suspicious for malignancy.\n\n IMPRESSION:\n 1. The lungs are better aerated when compared to the previous examination.\n 2. Persistent moderate significant pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2180-02-17 00:00:00.000", "description": "R FOOT 2 VIEWS RIGHT", "row_id": 997920, "text": " 6:29 PM\n FOOT 2 VIEWS RIGHT Clip # \n Reason: r/o fracture\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with R foot pain and bruising\n REASON FOR THIS EXAMINATION:\n r/o fracture\n ______________________________________________________________________________\n WET READ: 8:42 PM\n No definite fx. Dislocated 3rd PIP and subluxed 4th PIP with ?bone fragment\n at distal 4th prox. phalanx, age indeterminate.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Rule out fracture.\n\n FINDINGS: No previous images. Frontal and lateral view show no definite\n fracture. There is apparent dislocation of the third PIP and subluxed fourth\n PIP. Question of a well-corticated bone fragment at the distal fourth\n proximal phalanx. This could be a sequela of previous injury, though an acute\n fracture cannot be unequivocally excluded.\n\n\n" }, { "category": "Echo", "chartdate": "2180-02-18 00:00:00.000", "description": "Report", "row_id": 69449, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 64\nWeight (lb): 120\nBSA (m2): 1.58 m2\nBP (mm Hg): 125/75\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 11:48\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). Transmitral Doppler and TVI c/w Grade I (mild)\nLV diastolic dysfunction.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Moderately dilated ascending\naorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Moderate AS (AoVA\n1.0-1.2cm2) Mild to moderate (+) AR.\n\nMITRAL VALVE: Moderate mitral annular calcification. Mild thickening of mitral\nvalve chordae. Calcified tips of papillary muscles. No MS. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent\nwith Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size\nand free wall motion are normal. The ascending aorta is moderately dilated.\nThe aortic valve leaflets are moderately thickened. There is moderate aortic\nvalve stenosis (area 1.0-1.2cm2). Mild to moderate (+) aortic regurgitation\nis seen. Moderate (2+) mitral regurgitation is seen. There is moderate\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nand regional biventricular systolic function. Moderate aortic stenosis.\nMild-moderate aortic regurgitation. Moderate mitral regurgitation. Moderate\npulmonary hypertension. Dilated thoracic aorta.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-02-12 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 997051, "text": " 9:46 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess line placement, for PTX\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with RIJ CVL\n REASON FOR THIS EXAMINATION:\n assess line placement, for PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Right IJ line. Assess placement, evaluate for pneumothorax.\n\n One view. Comparison with the previous study done . Streaky density\n at the lung bases consistent with subsegmental atelectasis or scarring\n persists. The cardiac silhouette is prominent as before. The aorta is\n tortuous and calcified. The mediastinal structures are unchanged. An\n endotracheal tube has been inserted and ends at the thoracic inlet. A\n nasogastric tube has been inserted and terminates below the diaphragm in the\n region of the stomach. A right internal jugular line has been placed and\n terminates at the level of the right atrium.\n\n IMPRESSION: Tube and line placement as described.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-02-12 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 996964, "text": " 4:50 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for sbo\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with h/o colon ca s/p resection in ed with abd distention,\n nausea, po.\n REASON FOR THIS EXAMINATION:\n eval for sbo\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: BTCa SAT 5:53 AM\n Severely dilated loops of small bowel and collapsed loops of distal colon\n consistent with high grade small bowel obstruction. No free air. Surgical\n consult needed.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old female with history of colon CA status post\n resection, presenting with abdominal distention and nausea.\n\n COMPARISONS: None.\n\n TECHNIQUE: MDCT axial images are obtained from the lung bases through the\n pubic symphysis following administration of oral and intravenous Optiray\n contrast. Multiplanar reconstructions were performed.\n\n CT ABDOMEN WITH IV CONTRAST: There is dilatation of the imaged aortic root\n measuring up to 4.5 cm. Main pulmonary artery enlargement suggests underlying\n pulmonary arterial hypertension. Calcifications are seen within the coronary\n vessels. There are small bilateral pleural effusions, left greater than right\n with airspace consolidation at the left lung base. Multiple dilated loops of\n small bowel measuring up to 4.6 cm are seen throughout the abdomen with\n fecalization of small bowel contents seen to the level of the ileocolonic\n anastomosis in the mid-abdomen. The proximal colon which is moderately\n distended with fecalized material. Distal loops of colon are decompressed.\n There is no evidence for free intraperitoneal air or abscess collection. The\n liver enhances homogeneously without mass. The gallbladder is slightly\n distended without evidence for wall edema or adjacent stranding to suggest\n acute cholecystitis. The pancreas and right adrenal gland appear unremarkable.\n The left adrenal gland appears bulky and contains a fat density nodule, likely\n an adenoma. The spleen is small in size. Kidneys enhance symmetrically and\n excrete contrast normally. Several simple cysts are present in the mid and\n lower poles of the left kidney. The ureters are not dilated. No\n pathologically enlarged mesenteric or retroperitoneal lymph nodes are seen.\n Multiple sutures are present in the midline abdominal musculature.\n\n CT PELVIS WITH IV CONTRAST: A Foley catheter is seen within the bladder. Air\n within the bladder is likely iatrogenic. The uterus contains hypodense fluid\n within the endometrial cavity. Several large cystic structures measuring up\n to 3 cm are seen in the right adnexa. There is no free pelvic fluid or air.\n No inguinal or pelvic lymphadenopathy is seen.\n\n (Over)\n\n 4:50 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for sbo\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONE WINDOWS: There are no suspicious osteolytic or sclerotic lesions. There\n are marked degenerative changes in the thoracolumbar spine with multiple\n compression deformities including a severe wedge deformity of the T9 vertebral\n body.\n\n IMPRESSION:\n 1. Multiple dilated loops of fluid-filled small bowel with fecalized material\n in the distal ileum extending to the ileocolonic anastomosis in the mid\n abdomen. Findings are consistent with partial small- bowel obstruction. No\n evidence for free intraperitoneal fluid or air.\n\n 2. Cystic mass in the right adnexa and fluid filled endometrial cavity are\n both concerning findings given the patient's age. Further characterization\n with pelvic ultrasound is recommended on a non-emergent basis if additional\n followup is warranted.\n\n 3. Small bilateral pleural effusions and bibasilar atelectasis.\n 4. Dilatation of the aortic root to 4.5 cm. Coronary artery calcifications\n and enlargement of the pulmonary artery suggestive of pulmonary arterial\n hypertension.\n\n 5. Left adrenal adenoma.\n\n 6. Severe degenerative changes in the thoracolumbar spine with numerous wedge\n compression deformities of unknown chronicity.\n\n Findings were discussed with Dr. at 6:00 a.m. on the date of\n dictation.\n\n" }, { "category": "Nursing/other", "chartdate": "2180-02-13 00:00:00.000", "description": "Report", "row_id": 1668128, "text": "Respiratory Care:\nPt recieved orally intubated and vneted form PACU S/P exploratory lap. Pt weaned to PSV, Vt 450-550, RR 14-24, SpO2 100%. Lung sounds clear. Suctioned for none. Plan is to wean as tolerated to possibly extubate in am.\n" }, { "category": "Nursing/other", "chartdate": "2180-02-13 00:00:00.000", "description": "Report", "row_id": 1668129, "text": "T-SICU NPN 1230-1900\n\nUniversal precautions\n\nAllergies: PCN, unsure of reaction per dtr/HCP \n\nPMH: depression, shortnes of breath associated with pectus carinatum and age appropriate obstructive ventilatory deficit (seen in pulmonary clinic @ ), colon ca and sm. bowel ca (resected in past), history of falls, hypothyroidism, glaucoma, cataracts, ? some short term memory loss, AS, EF 55%. Pt had been DNR/DNI. Family to re-address code status in am.\n\nMeds: asa, heparin, mirtazapine, hexavitamin, dorzolamide 2% gtts, clonazepam, lisinopril, metoprolol, diltiazem, levothyroxine, colace, senna, bisacodyl (per last discharge summary).\n\nDaughter is HCP. cell , home \nSon \n\nPt lives at . , independent living facility with 24hr caretaker. Pt had recent stay at after last admission to .\n\n ? SBO, s/p exp. lap. with LOA, R oophorectomy.\nExtubated post-op in PACU. Pt became tachycardic, drop in O2sats, re-intubed by anesthesia. Transferred to TSICU for further management.\n\nROS\nNeuro: Easily arousable to voice, MAE's, follows commands. Trying to mouth words around ett. Nodding head yes/no appropriately to simple questions. c/o throat pain, denies abd. pain, medicated with 0.5mg morphine x2 for suspected discomfort prior to turning with effect.\nCV: HR 90'S SR with rare PVC's, goal SBP MAP >60, SBP >100, CVP 8. Arrived on 1.5mcg/kg/min neo, weaned, currently off. Skin warm, dry. Pedal pulses palpable. PB's and sc heparin for DVT prophylaxis.\nCK 68 (74), 3rd due after 2200.\n\nAccess: L radial a-line and RIJ TLCL wnl.\n\nResp: LS clear, diminished at bases. Denies difficulty. Vent weaned to CPAP, Vt 450-550, RR teens-20's, O2sats 98%. Abg acceptable, see flowsheet. ? possible extubation in am.\n\nGI: abd firm, distended, BS faint, hypoactive, NPO, no stool. NGT to LCWS with bilious drainage. Pepcid for prophylaxis.\n\nGU: foley patent draining 25-40cc/hr. 500cc LR bolus x1 for low uo. Calcium repleted.\nEndo: coverage per sliding scale.\n\nID: afebrile; no current abx.\n\nSkin: back/buttocks intact. Abd incision with primary dsg intact, serosang. staining to lower aspect of dsg, no advancement noted. Skin tear noted to R forearm, OTA.\n\nPsych/social: pt's daughter/HCP and son in this afternoon and this eve. Updated by Dr. and also spoke with covering PCP. /questions appropriate. Update given, emotional support provided.\n\nA: yo s/p exp. lap. LOA, R oophorectomy, tol. slow vent wean, neo currently off\n\nP: Monitor VS, I/O, labs/ck's. Cont. aggressive pulmonary hygiene/skin care. Assess pain, med. prn. ? wean to extubate in am. Plan for family meeting in am to address pt's wishes regarding code status. Cont. ongoing open communication, comfort and support to pt and family.\n\n" }, { "category": "Nursing/other", "chartdate": "2180-02-14 00:00:00.000", "description": "Report", "row_id": 1668130, "text": "Resp Care: Pt continues on mechanical ventilation: PSV 10/5 50%. VE 7.0-8.0 LPM. LS clear/diminished bilaterally. Sxn'd for small to moderate amounts of thick yellow secretions. RSBI this am: 43. PLAN: wean to extubate.\n" }, { "category": "Nursing/other", "chartdate": "2180-02-14 00:00:00.000", "description": "Report", "row_id": 1668131, "text": "focus hemodynmics\ndata: neuro: intubated. opens eyes to verbal stimuli. moves arms off the bed. wiggles toes to command. having difficult time moving legs up and down due to painful abd incision. follows simple commands. mouthing words and very difficult understanding her. call light at her side.\n\nresp: remains intubated. suctioned for scant amt of white sputum. o2sats 100%. rsbi 42. ? extubate today. mouth care done q4hrs. breath sounds clear in the upper lobes and diminished in the lower lobes. at 0600 placed on cpap 5/5 and tol well.\n\ncardiac: remains in nsr. bp > 100syst. lopressor 5mg iv q6hrs given as ordered. k 4.3, hct 33.4. magnesium 1.9 and repleted with 2gms of magnesium sulfate iv. ''\n\ngu: foley patent and draining yellow-ambercolored urine. u/0 20-50cc/hr. dr notified. 500cc lactated ringer iv bolus given.\n\ngI abd firm distended. dr aware. unable to hear bowel sounds. ngt to lcws and draining rown drainage. abd incision intact. original dsg\n in place. iv lactated ringers at 125cc/hr.\n\nsocial: daughter in to visit today and update given to her.\n\naction: labs done as ordered. suctioned prn. morphine sulfate 2mg iv x2 given for pain control and effective. ngt to lcws and draining brown drainage. iv lopressor 5mg iv q6hrs given. iv lactated ringers at 125cc/hr. 500cc lactated ringers bolus given for low u.o. mouth care q4hrs.\n\nresponse: monitor closely\n" }, { "category": "Nursing/other", "chartdate": "2180-02-14 00:00:00.000", "description": "Report", "row_id": 1668132, "text": "***TSICU NURSING PROGRESS NOTE 7A-7P**\n--please ssee carevue for exact data--\n\n*EVENTS: pt extubated this AM. currently w/ Face tent 50% FiO2\n\n*ROS:\n\n*NEURO: pt A&Ox3, pt slightly confused at times & upon awakening-easily reoriented. communicates & answers questions appropriately. follows all commands. MAE's purposefully. =strength/sensation. PERRLA. +cough/gag. pt comfortable, dozing off/on. denies pain. PRN Morphine available for pain control. PT Consult ordered, pt ok OOB-chair as tolerated.\n\n*CV: SR-ST. occ PACs. HR 80-100s. ABP 100-120s/50-60s. CVP 9-15. sharp waveforms. A-line positional. skin warm/dry/intact. +pedal pulses. SC Heparin & compression sleeves for prophylaxis. RIJ TLC for access-site ecchymotic, DSD intact. L Radial A-line, dsg intact, unable to draw blood.\n\n*RESP: pt w/ face tent @ 50% FiO2. RR teens. SaO2 96-100%. LS coarse w/ diminished bases bilaterally. pt w/ productive cough. expectorates moderate amts thick white/tan secretions. IS & C/DB performed. oral care provided.\n\n*GI: pt NPO. NGT to LCWS. moderate amts brown drainage. midline abdominal incision s/p ex lap, primary DSD intact, UTA, small amt s/s drainage. abdomen firm & distended, absent BS. MDs aware. -BM. H2blocker for prophylaxis.\n\n*GU: Foley w/ adequate clear yellow urine. pt + approx 10L. 10mg Lasix given x1. LR KVO.\n\n*ENDO: RISS. no coverage needed.\n\n*ID: pt afebrile. no antibiotics ordered.\n\n*SOCIAL: pts family in throughout shift. all questions RE: pts status & POC answered & understood.\n\nPLAN: ? transfer to flr. OOB-chair tmrw as tolerated. cont to monitor/control hemodynamics, respiratory status, BS, urine output & fluid status. assess abdomen for further distension, bowel sounds, pain. encourage C&DB & IS. cont to support pt & family.\n" }, { "category": "Nursing/other", "chartdate": "2180-02-14 00:00:00.000", "description": "Report", "row_id": 1668133, "text": "Respiratory CAre:\nPt recieved orally intubated and vented. Placed on SBT this am, passed SBT. AbG showed acid base within normal with hyperoxymea. Pt then extubated, good cuff leak heard prior to extubation. placed on face tent cool areosol with 50% FiO2. Lung sounds clear prior to extubation, post extubation coarse. Given albuterol neb. Pt tolerated well. Currently on face tent SpO2 96%, RR 21.\n" }, { "category": "Nursing/other", "chartdate": "2180-02-15 00:00:00.000", "description": "Report", "row_id": 1668134, "text": "t-sicu nsg note:\nneuro-awakens slightly confused to time but reorients easily, follows commands, mae's. no pain per pt report.\n\nresp- spo2 96-98% on 4lnc, rr 16-20, strong cough productive for sm amt thick yellow secretions., bs cta. diminished bibasilar.\n\ncvs- hr 90's nsr w/ occ apc and pvc, lytes pnd. lopressor given as ordered, sbp 110-130's. afeb.\n\ngi- ngt patent for dk brown-maroon drainage, md aware, hct stable @32, abd slightly firm and distended, no bs.\n\ngu- foley draining clear yellow urine ~30cc/hr\n\nskin- abd dsg intact w/ old staining, ecymotic surrounding r neck cvl.\n\nendo- bs wnl no riss required.\n\nsocial- family very supportive, visit in eve.\n\na:stable night\n\nP: monitor cvs per routine, enc c+db, reposition q2, med prn for pain, monitor ngt drainage.\n" }, { "category": "ECG", "chartdate": "2180-02-23 00:00:00.000", "description": "Report", "row_id": 165989, "text": "Sinus rhythm. Diffuse non-specific ST-T wave changes. Compared to the\nprevious tracing of atrial ectopy is no longer recorded.\n\n" }, { "category": "ECG", "chartdate": "2180-02-12 00:00:00.000", "description": "Report", "row_id": 165990, "text": "Sinus rhythm with premature atrial contractions. Baseline artifact.\nDiffuse ST-T wave flattening which may be non-specific. Compared to the\nprevious tracing of there is no significant change.\n\n" } ]

[ { "category": "Echo", "chartdate": "2105-03-09 00:00:00.000", "description": "Report", "row_id": 81823, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. V-fib arrest. S/p stent? Unable to move\nHeight: (in) 73\nWeight (lb): 190\nBSA (m2): 2.11 m2\nBP (mm Hg): 94/59\nHR (bpm): 54\nStatus: Inpatient\nDate/Time: at 15:46\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. Overall normal LVEF (>55%). False LV tendon (normal\nvariant).\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: septal apex -\nhypo; remaining LV segments contract normally.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Mildly\ndilated aortic arch. No 2D or Doppler evidence of distal arch coarctation.\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. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views. Based on\n AHA endocarditis prophylaxis recommendations, the echo findings indicate\na low risk (prophylaxis not recommended). Clinical decisions regarding the\nneed for prophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size.\nThere is mild regional left ventricular systolic dysfunction with focal\nhypokinesis of the distal septum. The remaining left ventricular segments\ncontract normally. Right ventricular chamber size and free wall motion are\nnormal. The aortic arch is mildly dilated. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic\nregurgitation. The mitral valve appears structurally normal with trivial\nmitral regurgitation. There is mild pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with very mild\nregional left ventricular systolic dysfunction c/w CAD (distal LAD lesion).\nMild pulmonary artery systolic hypertension. Dilated aortic arch.\nCompared with the prior study of (images reviewed), left ventricular\nsystolic function has improved.\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": "2105-03-08 00:00:00.000", "description": "Report", "row_id": 81824, "text": "PATIENT/TEST INFORMATION:\nIndication: VF ARREST sp resuscitation\nHeight: (in) 73\nWeight (lb): 190\nBSA (m2): 2.11 m2\nBP (mm Hg): 96/60\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 12:48\nTest: Portable TTE (Focused views)\nDoppler: Limited 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: Dilated IVC (>2.5 cm).\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild regional LV\nsystolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; mid anteroseptal - hypo; anterior apex - hypo; remaining LV segments\ncontract normally.\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. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nThe left atrium is mildly dilated. The inferior vena cava is dilated (>2.5\ncm). Left ventricular wall thicknesses and cavity size are normal. There is\nmild regional left ventricular systolic dysfunction with hypokinesis of the\ndistal half of the anterior septum and anterior wall. The remaining left\nventricular segments contract normally and overall systolic function is low\nnormal. Right ventricular chamber size and free wall motion are normal. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. The mitral valve leaflets are\nstructurally normal. Mild to moderate (+) mitral regurgitation is seen. The\npulmonary artery systolic pressure could not be determined. There is no\npericardial effusion.\n\nIMPERSSION: Mild left ventricular systolic dysfunction. Mild-moderate mitral\nregurgitation.\n\n\n" }, { "category": "ECG", "chartdate": "2105-03-10 00:00:00.000", "description": "Report", "row_id": 203429, "text": "Atrial fibrillation with a slow ventricular response. No change since the\nprevious tracing of .\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2105-03-09 00:00:00.000", "description": "Report", "row_id": 203430, "text": "Atrial fibrillation. No change compared to tracing #2.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2105-03-09 00:00:00.000", "description": "Report", "row_id": 203431, "text": "Atrial fibrillation with a slow ventricular response. No change since the\nprevious tracing of .\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2105-03-09 00:00:00.000", "description": "Report", "row_id": 203432, "text": "Atrial fibrillation with a slow ventricular response. since the previous\ntracing of further evolution of the anterior myocardial infarction is\nseen.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2105-03-08 00:00:00.000", "description": "Report", "row_id": 203433, "text": "Atrial fibrillation\nAnteroseptal myocardial infarct, age indeterminate - possible acute/recent/in\nevolution\nLeft ventricular hypertrophy\nSince previous tracing of the same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2105-03-08 00:00:00.000", "description": "Report", "row_id": 203434, "text": "Baseline artifact\nAtrial fibrillation\nAnteroseptal myocardial infarct, age indeterminate - possible acute/recent/in\nevolution\nLeft ventricular hypertrophy\nNo previous tracing available for comparison\n\n" }, { "category": "ECG", "chartdate": "2105-03-08 00:00:00.000", "description": "Report", "row_id": 203435, "text": "Baseline artifact\nAtrial fibrillation\nAnteroseptal myocardial infarct, age indeterminate - possible acute/recent/in\nevolution\nLeft ventricular hypertrophy\nSince previous tracing of the same date, no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2105-03-08 00:00:00.000", "description": "Report", "row_id": 1402165, "text": "Nursing Adm note\n55 yr old with h/o no pmh other than^chol had v.fib/tach arrest while running in marathon in today, went down in front of EMT station, CPR, shocked with 360J, intubated and extubated in the field. Brought to EW, HR 50-60 a.fib, BP 110's/50. Intermittent CP in EW, ECG's without changes. Trop<.01\n\nCV: c/o chest soreness, given 400mg ibuprophen, HR 45-60 a.fib, no ectopy, BP 100-110's/60-70, on Hep at 1050units/hr, PTT due at 9pm. Repeat lytes, K+ 3.9, ordered for 20 mEq KCL(needs to get), Mag 1.9\n\nResp: LS clear, 2L NC, no sob.\n\nID: afebrile.\n\nNeuro: head CT neg for bleed. Pt A&Ox3.\n\nGI: heart healthy diet, ate dinner.\n\nSoc: wife and daughter in, daughter works in SICU at B&W hosp. Health Care Proxy form completed.\n\nA/P: pt with vf/vt defibrilated in field, now in a.fib, on hep gtt, to go to cath tomorrow, possible ICD at some point.\n" }, { "category": "Radiology", "chartdate": "2105-03-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 904162, "text": " 10:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cardiopulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p vtach/vfib arrest\n REASON FOR THIS EXAMINATION:\n eval for cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post ventricular tachycardia/fibrillation arrest.\n\n COMPARISON: None.\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: The heart is at the upper limits of normal\n size. The mediastinal and hilar contours are within normal limits. The\n pulmonary vascularity is normal. Patchy bibasilar opacities are present less\n likely representing atelectasis. No definite pleural effusions are seen,\n however, the left costophrenic angle was excluded from the study. There is no\n pneumothorax. The osseous structures are unremarkable.\n\n IMPRESSION: Bibasilar atelectasis. No evidence of congestive heart failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-08 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 904170, "text": " 12:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P ARREST, FELL, ABRASIONS TO HEAD, EVALUATE FOR ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man s/p arrest, fell abrasions to head, no neck pain\n REASON FOR THIS EXAMINATION:\n eval for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KMcd SUN 2:22 PM\n no intracranial hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post arrest, fall, abrasions to head, evaluate for\n intracranial hemorrhage.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: No hemorrhage is seen. No mass lesion, hydrocephalus, shift of\n normally midline structures, minor or infarct is apparent. The density values\n of the brain parenchyma are within normal limits. The surrounding osseous and\n soft tissue structures are unremarkable. There is minimal mucosal thickening\n in the maxillary and ethmoid sinuses.\n\n IMPRESSION: Paranasal sinus mucosal thickening, otherwise normal study.\n\n" }, { "category": "Nursing/other", "chartdate": "2105-03-09 00:00:00.000", "description": "Report", "row_id": 1402166, "text": "ccu nsg progress note.\no:slow af rhythm wo ectopy-lopressor held. stable bp. heparin gtt sub- theraputic--rebolused (1700u) & increased to 1200u/hr @ approx 0100-- reck ptt pending. k & mg replaced. am lab sent.\n\na:hemody stable over night-despite slow (30's) af.\n\np:contin present management. cardiac cath & ?icd placement. support as indicated.\n" } ]

[ { "category": "ECG", "chartdate": "2198-03-14 00:00:00.000", "description": "Report", "row_id": 140227, "text": "Sinus rhythm and occasional atrial ectopy. Compared to the previous tracing\nof the atrial morphology has changed and the rate has slowed. Atrial\nectopy has appeared. Otherwise, no diagnotic interim change.\n\n" }, { "category": "Nursing/other", "chartdate": "2198-03-14 00:00:00.000", "description": "Report", "row_id": 1479308, "text": "MICU NRSG ADMIT NOTE\n86yo with past med hx of osteoarthritis, divericulosis with admit in ' for lower GIB, HTN, CAD, hepatic cyst, hypothrroid, spinal stenosis and neuropathy. At home had 3 episodes of BRBPR therefore she came to where she was hemodynamically stable with first hct 29.7, after 2l ns repeat hct 24.4 and she had 2 more episodes of BRBPR therefore she was trnansfused 1 unit PRBC and transferred to MICU for further management.\n She is afebrile. Hr 50-60's SB/SR with no vea noted, all antihypertensives are currently on hold. BP 120-160's/50-70's. She is on room air with sats in the upper 90's. Lungs are clear throughout. She is able to get oob to BSC to void mod amts clear yellow urine. She has had no further episodes of BRBPR. Her unit of blood finished shortly after she arrived and her repeat hct 2 hours later was 25.7. She will need more labs at 8am. She is alert and oriented x 3. She speaks Chinese but is also able to speak English. She is DNR per self. She is very HOH in her r ear. No family accompanied her to the unit but she states that she had sent them home.\nA: s/p BRBPR requiring 1 unit PRBC\n hemodynamically stable\nP: please draw labs at 8am\n cont to assess for further bleeding\n\n" }, { "category": "Nursing/other", "chartdate": "2198-03-14 00:00:00.000", "description": "Report", "row_id": 1479309, "text": "this 86y/0 chinese/english speaking women admitted for lower GIB remains hemodynamically stable with serial monitoring of hct, last @2pm 26.3 down from 27. pt continues with frequent small to moderate stool with visible streaks of blood noted. GI service is following pt who is known to their service. No plan for colonscopy or EGD @ this time. She has hx of diverticulosis and GIB in past and they will continue to follow her. She is a call out and her transfer note is done.\n\nNeuro: A&OX3 speaks english, responds & follow commands appropriately\nResp: Ra sats 97-99%, lungs clear (B), no cough, no sob\nCV: nsr hr 60-80's no ectopy noted, (+) peripheral pulses\nGI/GU: diet advanced to clear liqs today, tolerating well, denies abdominal pain/cramping. Voids on bedside commode - oob with assistance, minimal weight bearing\nSkin: (L) UE with small ecchymotic area above (L)ac #18ghl\notherwise warm, dry & intact\nPlan: transfer to floor - restart all antihypertensives as necessary\n" } ]

[ { "category": "Echo", "chartdate": "2133-11-10 00:00:00.000", "description": "Report", "row_id": 81869, "text": "PATIENT/TEST INFORMATION:\nIndication: Mitral valve disease.\nWeight (lb): 140\nBP (mm Hg): 135/65\nHR (bpm): 103\nStatus: Inpatient\nDate/Time: at 09:33\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Hyperdynamic\nLVEF. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\nNormal ascending aorta diameter. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate/severe MVP.\nPartial mitral leaflet flail. Moderate mitral annular calcification. Mild\nthickening of mitral valve chordae. Calcified tips of papillary muscles. No\nMS. (4+) MR. Eccentric MR jet.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. TVP. Normal\ntricuspid valve supporting structures. No TS. Severe [4+] TR. Severe PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: Small to moderate pericardial effusion. Effusion is loculated.\nBrief RA diastolic collapse. Sgnificant, accentuated respiratory variation in\nmitral/tricuspid valve inflows, c/w impaired ventricular filling.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Left ventricular systolic\nfunction is hyperdynamic (EF 80%). There is no ventricular septal defect.\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present.\nMild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is severe mitral valve prolapse. There is partial mitral\nleaflet flail. Severe (4+) mitral regurgitation is seen. The mitral\nregurgitation jet is eccentric. The tricuspid valve leaflets are mildly\nthickened. Tricuspid valve prolapse is present. Severe [4+] tricuspid\nregurgitation is seen. There is severe pulmonary artery systolic hypertension.\nThere is a small to moderate sized pericardial effusion. The effusion appears\nloculated. There is brief right atrial diastolic collapse. There is\nsignificant, accentuated respiratory variation in mitral/tricuspid valve\ninflows, consistent with impaired ventricular filling.\n\nImpression: mitral and tricuspid valve prolapse with flail mitral leaflets;\nsevere mitral and tricuspid regurgitation with hyperdynamic left ventricular\ncontractile function\n\n\n" }, { "category": "ECG", "chartdate": "2133-11-10 00:00:00.000", "description": "Report", "row_id": 208041, "text": "Sinus tachycardia\nNonspecific ST-T wave changes\nSince previous tracing of , ST-T wave changes slightly more prominent\n\n" }, { "category": "ECG", "chartdate": "2133-11-09 00:00:00.000", "description": "Report", "row_id": 208042, "text": "Sinus tachycardia\nNonspecific ST-T wave changes\nNo previous tracing available for comparison\n\n" }, { "category": "Nursing/other", "chartdate": "2133-11-11 00:00:00.000", "description": "Report", "row_id": 1434214, "text": "Respiratory Care:\n\nPatient sedated/intubated on mechanical support. Fio2 weaned to 50% with good Abg's. PaO2 116. Pt. hypotensive. Further weaning held at this time. Current vent settings Vt 500, A/c rate 16, Fio2 50% and Peep 7cm. ETT retaped 19Cm/lip and rotated to L side. BS clear/equal bilaterally. Sx'd for sm amounts of blood tinged secretions. Bilateral CT's in place secondary to effusions. No air leaks noted. Pt. transported to CT. Tolerated well. Chest CT revealed bilateral lower lobe consolidations, sm R effusion, ? pulmonary edema. No further changes made.\nPlan: Continue with mechanical support and wean Fio2 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2133-11-11 00:00:00.000", "description": "Report", "row_id": 1434215, "text": "addendum:Skin: pt's heals and toes of feet are red. legs have been elevated and heals are not touching surface.\nHct was low 23.6 from 27.7. pt is currently receiving 1st unit of PRBC. consent was obtained over the phone by daughter.\n" }, { "category": "Radiology", "chartdate": "2133-11-10 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 935907, "text": " 9:43 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: pre-op evaluation, effusions/infiltrate, COPD severity, pulm\n Admitting Diagnosis: PULMONARY EDEMA\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with COPD, ?RLL infiltrate, presenting with mitral valve\n prolapse\n REASON FOR THIS EXAMINATION:\n pre-op evaluation, effusions/infiltrate, COPD severity, pulmonary edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of COPD, possible right lower lobe infiltrate, and\n presented with mitral valve prolapse.\n\n COMPARISON: Chest radiograph obtained on the same day.\n\n TECHNIQUE: Non-contrast images of the chest were obtained.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: There is an endotracheal tube that\n terminates above the carina. There is a nasogastric tube that terminates in\n the stomach. Swan-Ganz catheter enters from below and terminates in the\n distal portions of the right main pulmonary artery. Bilateral chest tubes are\n in place, with the chest tube on the right with distal tip in the posterior\n costophrenic sulcus. The left chest tube distal tip projects in the region of\n the more anterior lower thorax with images of the stomach nearly superimposed,\n probably due to volume averaging. There is a right-sided pleural effusion and\n possibly a small left-sided pleural effusion. There is bilateral lower lobe\n dense consolidation, right worse than left. There are emphysematous changes\n of the lungs. There are scattered patchy areas of ground-glass opacity, right\n worse than left.\n\n Limited images of the upper abdomen demonstrate atherosclerosis of the aorta.\n Contrast is seen within the collecting systems of the kidneys, probably from\n the patient's recent cardiac catheterization. There may be a malrotated right\n kidney.\n\n Bone windows reveal degenerative changes with no suspicious lytic or sclerotic\n lesions.\n\n IMPRESSION:\n\n 1. Bilateral lower lobe consolidation.\n 2. Small right-sided pleural effusion and patchy bilateral areas of ground-\n glass opacity and interlobular septal thickening, right worse than left may\n represent a component of mild pulmonary edema.\n 3. Lines and tubes as described above.\n (Over)\n\n 9:43 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: pre-op evaluation, effusions/infiltrate, COPD severity, pulm\n Admitting Diagnosis: PULMONARY EDEMA\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2133-11-11 00:00:00.000", "description": "Report", "row_id": 1434216, "text": "CCU NPN 0700-1900\nS: \"Just shut the machines off.\"\n\nO: Please see careview for VS and additional data.\n\nEvents: Pt with wide open MR, pt family declined surgery, pt medicall managed with IV nipride, attempted to wean vent with subsequent poor ABGs, decision made to extubate pt per pt wishes per daughter (health care proxy). Pt DNR/DNI, this evening after MD conversation with pt and pt daughters.\n\nCV: HR 80's to 104 NSR/ST with rare to occ PVC's, nipride gtt weaned for goal MAPS 50-65 MD's, please see careview. Nipride gtt dc'd at 1745 as pt refused gtt and made .\n\nResp/Neuro: Please see careview for vent settings/ ABGS. Pt extubated at approx 1545, pt placed on face tent 100% for comfort, RR 20's, O2 sats 94-99%. Pt started on morphine gtt for pt comfort with effect. Pt appropriate, able to verbalize wishes, MAE.\n\nGI/GU: ABd soft, +BS x 4, no stool. Foley cath draining amber u/o see flowsheet.\n\nID: T max 99.8, tylenol given for pt comfort. Abx dc'd as pt .\n\nA/P: 79 y/o female with wide open MR, refused surgery/medical management, pt . Continue to provide comfort to pt, pain control. Continue to provide emotional support to pt and family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-11-12 00:00:00.000", "description": "Report", "row_id": 1434217, "text": "Nursing Progress Note 1900-0700\nS: \"Forget it!\" (in response to turning/mouth care)\n\nO: Please see flowsheet for complete objective data.\n\nPt conts to be . Morphine gtt @ 1mg/hr. Arousable to painful stimuli. Early in shift-pt did not want to be turned or have mouth care done. As pt became less alert, able to perform care without objection, closes mouth and suck on swabs.\n\nBP 67-99/44-55, NSR, HR-90's. RR 10-20's, Sats 92-100. Left CT draining serosang drainage, R no drainage. UO decreasing <20cc/hr. No stool.\n\nP: cont present management, titrate MSO4 gtt for comfort. ?poss call out to floor. Emotionally support family members.\n" }, { "category": "Nursing/other", "chartdate": "2133-11-12 00:00:00.000", "description": "Report", "row_id": 1434218, "text": "CCU NPN\nPt , pt expired at 1540. Family present at bedside and spoke with RN, pallative care , MD's. Family instructed to contact director for further arrangements. No valuables were on/left at pt bedside-no valuables present confirmed with family. Post mortem care done.\n" }, { "category": "Nursing/other", "chartdate": "2133-11-12 00:00:00.000", "description": "Report", "row_id": 1434219, "text": "CCU NPN\nspelling correction: to contact funeral director\n" }, { "category": "Nursing/other", "chartdate": "2133-11-10 00:00:00.000", "description": "Report", "row_id": 1434209, "text": "Respiratory Care:\n\nPatient intubated on mechanical support. ETT pulled back to 19cm @ lip. Bs equal/clear and decreased bilaterally. CXR repeated with ETT 4cm above the carina. CXR suggestive of CHF/PNA. PaO2 decreasing to 70. Peep increased to 7cm. BP initially low but better after sedation lightened. Sx'd for sm amounts of thick/thin bloody secretions. Combivent MDI started and given via vent checks. No auto peep. Repeat ABG's improving with PaCO2 WNL. No further changes made. See Carevue for further details.\nPlan: Continue with mechanical support and increase Peep as needed.\n" }, { "category": "Nursing/other", "chartdate": "2133-11-10 00:00:00.000", "description": "Report", "row_id": 1434210, "text": "ccu nsg progress note.\no:sedated-versed gtt @ 3mg/hr. responds to noxious stim, but does note follow commands. soft restraints to upper extrem. intubated/vented w present settings-ac/450x16/65%/+7 w abg-7.37/59/92/35/6. breath sounds=deminished/course throughout. sx-initially thick bl tinged secretions-subsequently deminished in vol. needs adeq sedation or significantly over breathes vent. initially hypotensive-narcan x2 w improvement in bp (extrem sensitive to fentanyl). nipride added to improve forward flow-presently @ 1.22mcg/kg/min. npo. adeq uo to intake. low grade t-cultured & abx started. am hct 27.9 down from 30.0.\n\na:sever mr mitral valve leaflets.\n\np:maint adeq sedation. titrate nipride to map of 60. cardiac cath-?x. echo. abx as ordered. reck hct. support pt/family as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2133-11-10 00:00:00.000", "description": "Report", "row_id": 1434211, "text": "Resp Care\n\nPt remains intubated and currently vented on full support with changes made accordingly. BS slightly course sxing for small amts of thick blood tinged secretions. Pt placed on heated wire circuit for adequate humidification. Transported to and from Cath Lab without any incident. Bilateral chest tubes in place due to effusions. Will cont with vent support and wean Fio2 as tol.\n" }, { "category": "Nursing/other", "chartdate": "2133-11-10 00:00:00.000", "description": "Report", "row_id": 1434212, "text": "CCU Nursing Progress NOTE 7am-7pm\nS: Orally intubated and sedated.\n\nO: CV - HR 80-90's nsr with rare single pvc's. BP cont labile 80-130/50-60's. Nipride titrated from 3mcgs/kg/ to 0.3mcgs/kg/min per bp.\nTo cath lab to CA prior to surgery. CA are clean. pt with r fem venous and art sheaths in place. RA in cath lab 14, PA 50/26, PCWP 31. co/ci 5.39/3.06 in cath lab. RA 15>>8. PAD 30>>25.\n\nResp - ls are coarse throughout. Sx via ett for small amt thick bloody, brown secretions. Spec sent for c/s. Vent 65%/500/16br/7peep with abg 7.43/48/178. Oral secretions are copious and clear.\n4pm-5pm Bilat chest tubes placed by CT connected to 20cm sx. L chest tube draining 150cc bloody drainage. R ct drained 900cc straw colored drainage. DSGS are clean, dry and intact post. CXR done post placement.\n\nGI - OGT in place with no aspirates. Abd is soft with +bs, no stool\n\nGU - Foley cath intact clear yellow urine, draining 35-50cc/hr. Rec'd lasix x1 this am for 300cc urine out.\n\nNeuro - Pt moves upper extremities to noxious stimuli. Cont on Versed 3.5mg/hr with good sedative effect.\n\nSocial - 2 daughters and have spoken with and understand the ramifications of surgery. After much thought, the daughters are leaning toward DNR. They have spoken with this nurse at length. Their mother's wishes are to not have any kind of surgery. They are currently discussing this with their husbands and will call back later tonight with their decision. I have relayed this information to Dr. as well as Dr. .\n\nA: 79yof with MV leaflet, awaiting possible surgery.\n\nP: Cont maintain sedation for comfort, cont titrate Nipride for BP control, check co/ci, dc r groin art sheaths when able, CT of chest when able, maintain chest tubes as ordered, cont keep family informed and supported through this hospitalization.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-11-11 00:00:00.000", "description": "Report", "row_id": 1434213, "text": "S:Pt sedated.\n\nO:please see careview.\n\nCV:HR 80-90's. NSR with occa pvc's. BP 82/48-111/62.Nipride currently .2mcgs/kg/min.Right art sheath removed with minimal oozing at the cath insertion site. Pa line out of place in RA will be removed in M.D. Last #'s at 1900 co 7.1/ci 4.01/svr 674/ pap s/d 37/25 at 2300. current cvp 8.\n\nRESP: vent settings 50%/500/16/7peep. abg on those settings 7.46/48/116/35.Bilat chest tubes in place right chest tube restitched with good results no more bleeding from that chest tube. Left chest tube with a small amount of blood at the insertion site. LS coarse.\n\nNeuro:sedated on midaz with good effect. pt will respond to noxious stimuli.cont on versed 3.5mg/hr.\n\nGI:OGT in place. BS + BM -.\n\nGU: draining 30-40cc/hr. foley in place.\n\nSocial: surgeons call daughter and spoke with her aboutwhether or not the pt will have the . in the a.m family declined. pt will not be going to .\n\nA: MV LEAFLET FAILURE.\n\nP:NIPRIDE FOR BP CONTROL. CONTINUE TO WATCH CHEST TUBES AND RIGHT GROIN FOR BLEEEDING. CONTINUE TO FOLLOW HCT. KEEP FAMILY INVOLVED.\n" }, { "category": "Nursing/other", "chartdate": "2133-11-09 00:00:00.000", "description": "Report", "row_id": 1434207, "text": "Respiratory Care\nPt recieved from hospital intubated with 7.0 taped at 20 at lip. Tube retaped cxr indicates tube needs to be withdrawn 1 cm. Pt placed on a/c settings from outside hospital, needs sedation md for vent changes. Suctioning mod amts of thick frank blood.\n" }, { "category": "Nursing/other", "chartdate": "2133-11-09 00:00:00.000", "description": "Report", "row_id": 1434208, "text": "CCU Nursing Admit Note 1700-1900\nS: Orally intubated and sedated\n\nO: 79yof admitted from osh at 1700. PMH COPD, anxiety, smoker, glaucoma, cataract, HTN.\nPt admitted from home to osh on with chief c/o sudden onset of sob. Pt dx with bilat infiltrates and COPD exacerbation, and was rx with steriods, slntg, Morphine, Levaquin. CT of chest was (-) for PE. Course at osh was complicated by elevated troponin, labile bp 70-130/s requiring levophed. Pt was managed on 100%nrb x2days as well as BIPAP, but on she required intubation. On and echo was done and showed \"MV flap/significant MR\" (by nursing report). PT was tx to for further management.\n\nT max 100 po. Pt had been on Ceftriaxone at osh, but was dc/d d/t (-) cultures. WBC at osh \n\nCV - HR 80-120 snr with occ pvc's. BP via aline 87-110/60's. dp/pt pulses d/d.\n\nResp - ls are coarse throughout and pt was sx via ett for thick bloody secretions (also reported bloody secretions from osh). Vent settings AC 50%/450/16br/5peep with sats 93-98%. Pt overbreathing vent by 12.\n\nSedation - Pt tx on Propofol gtt 10mcgs/kg/min. Started on Fentanyl 100mcgs/ and Versed 2mg gtt with good effect.\n\nGU - foley cath to clear amber urine.\n\nGI - ogt patent and is in good placement. Abd is soft with +bs.\n\nSkin - Intact. Bilat heels reddened and elevated on pillow.\n\nSocial - pt is widowed and lives alone. Has 2 daughters per report.\n\nA: 79yof tx to for management of flail mv.\n\nP: monitor hemodynamics and resp status, check pnd labs, cont sedation until poc is finalized, keep family informed of poc per multidisiciplinary rounds.\n" }, { "category": "Radiology", "chartdate": "2133-11-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935883, "text": " 5:10 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: proper placement of chest tubes\n Admitting Diagnosis: PULMONARY EDEMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman intubated with PNA, COPD, CHF s/p bilateral chest tube\n placement\n REASON FOR THIS EXAMINATION:\n proper placement of chest tubes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient intubated with pneumonia, COPD and CHF with bilateral\n chest tube placement. Evaluate chest tube.\n\n COMPARISON: at 15:07.\n\n SUPINE AP CHEST: An endotracheal tube is in place with the tip approximately\n 4.3 cm from the carina. A nasogastric tube is in place, with the tip\n terminating beyond the radiograph. There is an inferior approach Swan-Ganz\n catheter in place, with the tip overlying the distal portion of the right\n pulmonary artery. Bilateral chest tubes are noted, with the tip oriented\n inferiorly. The cardiac and mediastinal contours are unchanged, with a\n calcified aorta. A right pleural effusion layering posteriorly may be\n decreased in the interim.\n\n IMPRESSION: No definite pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-11-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 936015, "text": " 1:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess placement of chest tubes\n Admitting Diagnosis: PULMONARY EDEMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman intubated with PNA, COPD, CHF s/p bilateral chest tube\n placement\n REASON FOR THIS EXAMINATION:\n Please assess placement of chest tubes\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 1:41 P.M. ON \n\n INDICATION: Multiple medical problems as above. Assess placement of\n bilateral chest tubes.\n\n FINDINGS: Compared with 11/14 at 5:24 p.m., the positions of both chest tubes\n at the bases bilaterally are unchanged. The Swan-Ganz catheter has been\n withdrawn to the level of the right atrium. No pneumothorax.\n\n No significant interval changes in the patchy right lung densities.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-11-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935714, "text": " 5:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for appropriate placement of ET tube\n Admitting Diagnosis: PULMONARY EDEMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with CHF s/p intubation, transferred from OSH\n REASON FOR THIS EXAMINATION:\n Eval for appropriate placement of ET tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old woman with CHF, status post intubation.\n\n No comparison.\n\n FINDINGS: The study is somewhat limited due to positioning, and right\n costophrenic angle is not fully included. The patient is status post\n intubation, with endotracheal tube terminating approximately 1.5 cm above the\n carina. Thoracic aorta is tortuous. The heart is top normal in size. Note\n is made of increased interstitial markings and perihilar opacity especially on\n the right, with bilateral effusion. There are bilateral lower lobe opacities,\n more prominent on the right.\n\n IMPRESSION: Somewhat limited study. Endotracheal tube terminating 1.5 cm\n above the carina. Congestive heart failure with interstitial edema and\n effusion. Bilateral lower lobe opacities, more prominent on the right,\n worrisome for multifpcal pneumonia in this patient with fever.\n\n Dr. was informed by telephone immediately after the completion of the\n study.\n\n" }, { "category": "Radiology", "chartdate": "2133-11-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935833, "text": " 2:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT placement, infiltrates\n Admitting Diagnosis: PULMONARY EDEMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman intubated with PNA, COPD, CHF\n REASON FOR THIS EXAMINATION:\n eval ETT placement, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, AP portable, single view.\n\n INDICATION: Intubated, pneumonia, COPD and CHF. Evaluate ETT placement.\n\n FINDINGS: AP single view of the chest has been obtained with the patient in\n supine position and comparison is made with the next previous similar\n examination obtained during the evening of the preceding day (). The patient remains intubated, the ETT and NG tube remaining in\n unchanged position. A Swan-Ganz catheter has been approached from below and\n reaches the central portion of the right PA. The previously described diffuse\n pulmonary densities most marked in the central portions remain and indicate\n persistent pulmonary edema. Pleural effusion may have increased as judged\n from the degree of blunting of the left lateral pleural sinus. The heart is\n only moderately enlarged. Noteworthy is the presence of rather advanced\n calcifications in the mitral ring. Water-soluble contrast media collection in\n the left kidney is noted and indicates moments of contrast CT during the\n latest interval.\n\n IMPRESSION: Persistent pulmonary edema, successful advancement of Swan-Ganz\n from below.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-11-11 00:00:00.000", "description": "P CAROTID SERIES COMPLETE PORT", "row_id": 935949, "text": " 7:35 AM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: pre-op for possible MVR, please do both L & R\n Admitting Diagnosis: PULMONARY EDEMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with MVP and severe MR\n REASON FOR THIS EXAMINATION:\n pre-op for possible MVR, please do both L & R\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Carotid series complete.\n\n REASON: Preop mitral valve repair.\n\n FINDINGS: Duplex evaluation was performed of bilateral carotid arteries.\n There is no significant plaque seen bilaterally.\n\n On the right, peak velocities are 62, 51, and 55 cm/sec in the ICA, CCA, and\n ECA respectively. This is consistent with no stenosis.\n\n On the left, peak velocities are 57, 57, and 60 cm/sec in the ICA, CCA, and\n ECA respectively. This is consistent with no stenosis.\n\n There is antegrade vertebral flow bilaterally.\n\n IMPRESSION: Normal carotid study.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-11-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935726, "text": " 7:30 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: check ET tube placement\n Admitting Diagnosis: PULMONARY EDEMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with CHF s/p intubation, transferred from OSH\n\n REASON FOR THIS EXAMINATION:\n check ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old woman with CHF, status post intubation.\n\n PORTABLE AP CHEST RADIOGRAPH: Comparison was made to a prior chest radiograph\n dated approximately 2 hours earlier on the same day. Endotracheal tube is\n pulled back, terminating approximately 4 cm above the carina. No\n pneumothorax. Nasogastric tube is coursing down below the left hemidiaphragm,\n and the sidehole is seen probably in the fundus. Again note is made of\n tortuous aorta. Cardiac silhouette is unchanged compared to the prior study.\n Note is made of diffuse and extensive interstitial edema, worsened especially\n on the left compared to the prior study. Bilateral pleural effusion and\n bilateral lower lobe opacity is again seen.\n\n IMPRESSION: Tubes and lines as described above. Increased bilateral edema,\n persistent pleural effusion and consolidations in the lower lobes, suggestive\n of CHF and pneumonia in this patient with fever.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2143-09-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 802351, "text": " 10:46 AM\n CHEST (PA & LAT) Clip # \n Reason: s/p AVR w/resolving CHF r/o effusion/infiltrate\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with critical AS and crackles at L base.\n\n REASON FOR THIS EXAMINATION:\n s/p AVR w/resolving CHF r/o effusion/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Aortic stenosis, crackles at left base, s/p AVR. Evaluate for\n chf, infiltrate.\n\n PA AND LEFT LATERAL VIEW is compared with supine view from .\n\n FINDINGS: There has been interval removal of the ET tube, left IJ SG catheter\n and left-sided chest tubes. There is persistent left lower lobe\n collapse/consolidation with interval increase in the size of the left pleural\n effusion. The heart remains stably enlarged, but there is no evidence of\n vascular engorgement. The previously described nodular opacity in the right\n mid-lung zone is not apparent on the current study. There is a severe\n thoracic scoliosis and diffuse demineralization.\n\n IMPRESSION;\n 1) Persistent left lower lobe collapse/consolidation with moderate size left\n pleural effusions, worse in the interval.\n\n 2) Stable cardiomegaly with no evidence of overt heart failure.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2143-09-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 801566, "text": " 4:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ro ptx\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with sob\n REASON FOR THIS EXAMINATION:\n ro ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INDICATION: Shortness of breath.\n\n Comparison to study of the prior day.\n\n FINDINGS: The endotracheal tube is located beneath the thoracic inlet. A PA\n catheter inserted via the left IJ terminates within the right main pulmonary\n artery. A dual lead cardiac pacer is unchanged with lead tips in the expected\n location of the right atrium and right ventricular apex. The patient has a\n severe scoliosis. Accounting for this, there is still cardiomegaly. There is\n persistent retrocardiac opacification. There is vascular engorgement with\n indistinctness of both upper and lower lobe vessels. A nodular opacity is\n seen in the right mid lung zones.\n\n IMPRESSION:\n 1) No pneumothorax post appropriate placement of PA catheter.\n 2) Worsening CHF.\n 3) Left lower lobe atelectasis/pneumonia.\n 4) Nodular opacity in right mid lung likely represents overlying engorged\n vessels. Continued radiographs are recommended do document resolution with\n clinical improvement.\n\n" }, { "category": "Radiology", "chartdate": "2143-09-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 801620, "text": " 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with sob\n\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Short of breath rule out effusion.\n\n VIEWS: Single AP portable view, comparison dated .\n\n FINDINGS: Stable cardiomegaly with improved pulmonary vascular congestion.\n Increase in left retrocardiac opacity consistent with atelectasis or\n consolidation. The previously mentioned nodular opacity in the right middle\n lung field is not seen, consistent with resolving vascular engorgement. Small\n left pleural effusion. The endotracheal tube has been removed. Left-sided\n chest tube, mediastinal drain, and Swan-Ganz catheter remain in unchanged and\n satisfactory position. No change in position of left-sided pacemaker with dual\n electrodes. Thoracic scoliosis, right concave. Status post CABG with sternal\n wires, mediastinal clips, and aortic valve prosthesis.\n\n IMPRESSION: Improving congestive heart failure with stable cardiomegaly. Left\n pleural effusion with left lower lobe collapse and consolidation. Lines and\n tubes in satisfactory position.\n\n" }, { "category": "Radiology", "chartdate": "2143-09-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 801751, "text": " 10:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with sob\n\n REASON FOR THIS EXAMINATION:\n eval effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath, evaluate effusion.\n\n VIEWS: Single portable upright view, comparison dated .\n\n FINDINGS: There is stable cardiomegaly without cardiac failure. Unchanged\n size of large left pleural effusion, with trace right pleural effusion. Left\n lower lobe collapse/consolidation. Severe right convex thoracic scoliosis is\n again noted. Unchanged position of left sided pacemaker with dual electrodes.\n Sternal wires, mediastinal clips, and aortic valve prosthesis are noted.\n\n IMPRESSION: Stable left pleural effusion and trace right pleural effusion,\n unchanged cardiomegaly without acute cardiac failure. Left lower lobe\n collapse/consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2143-09-10 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 801441, "text": " 3:34 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: better assess whether pt has retrocardiac density\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with critical AS and crackles at L base.\n REASON FOR THIS EXAMINATION:\n better assess whether pt has retrocardiac density\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Crackles at the left lung base.\n\n PA AND LATERAL CHEST: Comparison is made to prior study of . Again\n noted is mild scoliosis of the thoracic spine. There is a pacemaker with\n leads in the right atrium and right ventricle respectively. The heart is\n moderately enlarged. There is calcification of the aortic knob. Again noted\n is retrocardiac opacity, obscuring the left hemidiaphragm. The left\n costophrenic angle is blunted.\n\n IMPRESSION:\n\n 1) Left lower lobe collaps/consolidatione with left sided pleural effusion,\n and cannot exclude left lower lobe pneumonia. Overall there is no significant\n change from the prior study.\n 2) Scoliosis of thoracic spine.\n\n" }, { "category": "Radiology", "chartdate": "2143-09-14 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 801855, "text": " 3:16 PM\n CHEST (PA & LAT) Clip # \n Reason: ?Effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with critical AS and crackles at L base.\n\n REASON FOR THIS EXAMINATION:\n ?Effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Critical AS and crackles at left base.\n\n CHEST, TWO VIEWS:\n\n The patient is status-post sternotomy, with prosthetic valve. A dual lead\n pacemaker is present, with lead tips in right atrium and right ventricle.\n There is moderately severe cardiomegaly. There is obscuration of the left\n hemidiaphragm along with increased retrocardiac density and blunting of the\n left costophrenic angle. There is also blunting of the right costophrenic\n angle. There is hyperinflation, consistent with COPD. No CHF is identified.\n The lungs are otherwise grossly clear. Incidental note is made of chronic\n rotator cuff tear at left shoulder and healed right clavicular fracture. There\n is scoliosis and degenerative change.\n\n IMPRESSION:\n 1) Increased retrocardiac density consistent with left lower lobe collapse\n and/or consolidation and small bilateral pleural effusions.\n 2) No CHF.\n\n" }, { "category": "ECG", "chartdate": "2143-09-11 00:00:00.000", "description": "Report", "row_id": 194701, "text": "Atrial sensed ventricular paced rhythm. Ventricular premature beats. Since the\nprevious tracing of underlying atrial fibrillation is no longer seen.\n\n" }, { "category": "ECG", "chartdate": "2143-09-10 00:00:00.000", "description": "Report", "row_id": 194702, "text": "Atrial fibrillation\nVentricular premature complexes\nPaced beats\nRight bundle branch block with left anterior fascicular block\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2143-09-10 00:00:00.000", "description": "Report", "row_id": 194703, "text": "Atrial fibrillation with primarily ventricular paced beats, ventricular\npremature beats and an intrinsicly conducted beat with right bundle-branch\nblock/ left axis deviation morphology. ST-T wave abnormalities. Clinical\ncorrelation is suggested. Compared to the previous tracing of no\nsignificant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2143-09-09 00:00:00.000", "description": "Report", "row_id": 194704, "text": "Atrial fibrillation with intermittent ventricular paced beats, ventricular\npremature beats and intermittent intrinsicly conducted beats with right\nbundle-branch block/ left axis deviation morphology. Non-specific ST-T wave\nabnormalities. Clinical correlation is suggested. No previous tracing available\nfor comparison.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2143-09-11 00:00:00.000", "description": "Report", "row_id": 1371142, "text": "ARRIVED IN CSRU @ 1430. ON NEO TITRATING TO MAINTAIN A SBP>100. ON DOBUTAMINE @ 2.5 UCG/KG/MIN. PROPRFOL @ 10 UCG/KG/MIN. SEE FLOW SHEET FOR SPECIFIC DETAILS. ELECTROLYTES REPLENISHED. BEGAN VENT WEAN. PROGRESSING WELL. GIVEN 2L LR FOR EPISODES OF HYPOTENSION. REVERSED. AWOKE. MOVING ALL EXTREMITIES. FC. C/O INCISONAL DISCOMFORT. MED W MSO4. RESTING COMFORTABLY.\n" }, { "category": "Nursing/other", "chartdate": "2143-09-11 00:00:00.000", "description": "Report", "row_id": 1371143, "text": "PATIENT RECEIVED TOATL OF 1000CC HESPAN D/T LOW CI, LOW SBP.. IMPROVED PRESSURE WEANING NEO.. FICK CI GREAT AFTYER VOLUME WITH SVO2 67%. VPACING AT 78 PRESENTLY. PATIENT AWAKENED MAE TO COMMAND. HAD BEEN MEDICATED WITH 4MG MSO4 IV AT ..\n" }, { "category": "Nursing/other", "chartdate": "2143-09-12 00:00:00.000", "description": "Report", "row_id": 1371144, "text": "ATTEMPTING TO WEAN ON AT 40% WITH RR18-20, . PLAN TO WEAN NEO THRU THE NIGHT.. CONTINUES TO VPACED WITH OCCASIONAL PVC..\n" }, { "category": "Nursing/other", "chartdate": "2143-09-13 00:00:00.000", "description": "Report", "row_id": 1371148, "text": "NEURO: ALERT, ORIENTED TO TIME, PLACE AND EVENTS. MAE, FOLLOWS COMMANDS, COOPERATIVE. NO NEURO DEFICITS. EXTREMELY DEAF, HAVE TO YELL INTO L EAR WHICH HAS HEARING AIDE IN IT.\n\nPULM; POOR COUGH EFFORT, CLEARS THROAT. TOLERATES CHEST PT. LUNGS DIMINISHED TO BRONCIAL LLL. 02 SATS ON 2L>95%. UNABLE TO COMPREHEND USE OF IS, ? PARTLY D/T HEARING IMPAIRMENT.\n\nCV: INTERNALLY PACED RHYTHM, VERY IRREGULAR D/T FUSION BEATS/ECTOPY. HEMODYNAMICALLY STABLE. EPICARIDAL WIRES NOT TESTED D/T INTERNAL PACEMAKER. LOW H&H ONE UNIT PRBC GIVEN. SLIDING SCALE INSULIN COVERAGE QID.\n\nGI: + BOWEL SOUNDS, ABD SOFT. TOLERATING CLEAR LIQUIDS.\n\nGU: FOLEY TO CD. LOW UO, LASIX 20MG IV AT 0330 WITH FAIR RESPOSNE.\n\nSOCIAL: NO FAMILY/FRIENDS CALLED OR VISITED.\n\nPLAN: AGGRESSIVE PULM HYGIENE, ? CHEST XRAY THIS AM. TRANSFER TO FAR 2. ? WILL NEED SHORT REHAB STAY HOME HEALTH CARE SERVICES. PT AND CASE MANGEMENT TO FOLLOW FOR DC NEEDS.\n" }, { "category": "Nursing/other", "chartdate": "2143-09-12 00:00:00.000", "description": "Report", "row_id": 1371145, "text": "PATIENT EXTUBATED AT APPR0X. 1230 AM WITHOUT DIFFICULTY TO 40%FM, 4LNP WITH SA02 97% WITH RR 16-20, INTIALLY RASING FREQUENTLY THICK YELLOW SPUTUM. C/O OF LEFT SIDE THROAT SORE, ICE CHIPS GIVEN, RN EXPLAINED HOW THE TUBE HAVE IRRITATED HIS THROAT, PLAN TO KEEP MIST THRU THE NIGHT. BS ELEVATED DRIP STARTED, 2U BOLUS THEN 2U DRIP, INCREASED TO 3U/HR D/T BS 140'S WILL FOLLOW CLOSELY.. PATIENT WITH C/O DULL ACHE . INCISION A TO SHOULDER, MEDIACTED WITH 2MG MSO4 IV... WEANING NEO AS TOLERATED. SVO2 62% WITH GOOD CI BY THERMO DILUTION\n" }, { "category": "Nursing/other", "chartdate": "2143-09-12 00:00:00.000", "description": "Report", "row_id": 1371146, "text": "PATIENT DOING WELL THIS AM, CV: ST WITH OCCASIONALPVC, EXTERNAL PACER OFF PRESENTLY.. PLAN TO HAVE CARDIOLOGY UP TO EVALUATE INTERNAL PACER. CI GOOD THIS AM, ?? WEAN DOBUTAMINE, WEANING NEO PRESENTLY AT 530AM, NEO AT .5. RESP: ON 4LNP WITH SATS 96% RAISING THIN WHITE SPUTUM BILATERAL BS CLEAR DIMINISHED AT BASES. CT DRAINAGE SEROUS APPROX. 50-100C/HR DEPENDING ON ACTIVITY. PATIENT RECEIVING 2MG MSO4 IVQ2-3HRS. WITH GOOD RELIEF.BS INTIALLY ELEVATED DRIP TO 1U/HR BS 79 DRIP SHUT OFF..PLAN TO D/C DOBUTAMINE, ENCOYRAGE OOB TO CHAIR ONCE FEMORAL LINE DCD.. TO NOTE PATIENT CAN ONLY EAT SOFT FOODS, HE DROOPED HIS DENTURES ON THE HARF FLOOR THE MORNING OF THE SURGERY.. ALSO SWAN ENTAGLED IN PACER WIRES, IF MEET RESISATNCE DCING STOP NEED TO BE DONE UNDER FLURO..\n" }, { "category": "Nursing/other", "chartdate": "2143-09-12 00:00:00.000", "description": "Report", "row_id": 1371147, "text": "NPN:\n\nNEURO: ALERT AND ORIENTED X3, PT VERY HOH WITH BIL HEARING AIDS..BUT ONE HAS NO BATTERY-FAMILY TO BRING ONE IN. MAE-OOB TO CHAIR-VERY STEADY ON FEET.\nCV: 80-90'S VPACED WITH ATRIAL RATE 80-90...RARE AV PACING. INTERNAL PACER INTEROGATTED BY EPS AND WORKING APP. PALP PEDAL PULASE. WEANED OFF NEO 8AM. CI> 2.7 SWAN DC'D WITHOUT INCIDENT. R FEM ALINE DC'D. LYTES WNL. STARTED ON LOPRESSOR 12.5 PO BID-TOL WELL. BP STABLE 100-115/50-60.\nRESP: LUNGS DIM BASES WITH EXERTIONAL EXP WHEEZES IMPOROVED AFTER LASIX. COUGH WEAK-NON PROD. O2 SATS> 95% ON 4L NC O2. CT/MT TO SXN WITH NO AIRLEAK- MOD DNG EARLY.\nGU: FOLEY YO GD -GIVEN 20 IV LASIX X1 WITH SM RESPONSE.\nGI: ABD SOFT, HYPO BS- SL NAUSEA X1 TREATED WITH REGLAN WITH EFFECT. TOL SM AMT LIQ-NO APPETITE.\nENDO: GLUCOSES 147-136-COVERED WITH 3U SS REG INSULIN PER PROTOCOL.\nACTIVITY: OOB TO CHAIR X 3HRS TOL WELL-VERY STEADY ON FEET.\nCOMFORT: MED WITH MS 1MG IV X2 AND PERC 1 WITH EFFECT.\nINCISIONS: PER CAREVUE.\nA: STABLE\nP: IF REMAINS STABLE TRANSFER TO 2 IN AM.\n" }, { "category": "Nursing/other", "chartdate": "2143-09-11 00:00:00.000", "description": "Report", "row_id": 1371141, "text": "Resp Care:\nPatient admitted to CSRU S/P AVR, aortic stenosis, intubated with # 7.5 oett placed on vent See carevue resp. flow sheet. BS equal, SX scant clear thin secretions,ABG results suggested resp. acidosis, Increased RR, Last abg normal except high PaO2, in which FiO2 decreased to 40%. RRT\n" } ]

[ { "category": "Radiology", "chartdate": "2141-03-31 00:00:00.000", "description": "NON-TUNNELED", "row_id": 1229388, "text": " 8:10 AM\n MESSENERTIC Clip # \n Reason: please perform mesenteric angiography and embolization\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OMNIPAQUE Amt: 105\n ********************************* CPT Codes ********************************\n * INITAL 2ND ORDER ABD/PEL/LOWER NON-TUNNELED *\n * ADD'L 2ND/3RD ORDER ABD/PEL/LO VISERAL SEL/SUPERSEL A-GRAM *\n * EA ADD'L VESSEL AFTER BASIC A- EA ADD'L VESSEL AFTER BASIC A- *\n * -59 DISTINCT PROCEDURAL SERVICE FLUORO GUID PLCT/REPLCT/REMOVE *\n * -59 DISTINCT PROCEDURAL SERVICE US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with diverticular bleeding, with source localized to sigmoid\n colon.\n REASON FOR THIS EXAMINATION:\n please perform mesenteric angiography and embolization\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Inferior mesenteric artery angiogram and placement of a\n triple-lumen central venous catheter via the right internal jugular vein:\n .\n\n CLINICAL INDICATION: 84 year-old man with active diverticular bleeding from\n the sigmoid colon demonstrated on CTA of the abdomen and pelvis hours before\n the procedure. Mesenteric arteriogram for demonstration of active bleeding\n and transcatheter embolization as indicated by angiographic findings is\n requested.\n\n OPERATORS: , MD , MD.\n\n ANESTHESIA: Local, 1% lidocaine subcutaneously.\n\n MONITORED CONSCIOUS SEDATION: The procedure was performed under monitored\n conscious sedation. The patient received a total quantity of 1.5 mg of Versed\n and 150 mcg of fentanyl during the procedural time of 90 minutes, while his\n hemodynamic parameters and pulse oximetry were continuously monitored by\n trained radiology nurse.\n\n TECHNIQUE/FINDINGS:\n\n Informed consent for the procedure was obtained after risks, benefits, and\n potential complications had been discussed. The patient was positioned on the\n angiography table in supine position. Timeout protocol was carried out\n according to the hospital policy before the procedure.\n\n After generous infiltration of the subcutaneous tissues of the right inguinal\n region with 1% lidocaine, Dr. punctured the patent right common\n femoral artery under real-time ultrasound guidance using 21-gauge\n micropuncture needle. Over a 0.018 inch guidewire, the micropuncture needle\n was exchanged for a 4 French micropuncture sheath followed by placement of\n 0.035 inch Bentson guidewire into the abdominal aorta. A 5 French\n (Over)\n\n 8:10 AM\n MESSENERTIC Clip # \n Reason: please perform mesenteric angiography and embolization\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OMNIPAQUE Amt: 105\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n endovascular sheath was then placed into the right common femoral artery. A 5\n French Omni Flush catheter was advanced into the infrarenal abdominal aorta\n over the Bentson guidewire, and the guidewire was advanced across the aortic\n bifurcation into the left common iliac artery and further into the left common\n femoral artery. The Omni Flush catheter was then exchanged for a 5 French\n catheter which was formed over the aortic bifurcation. Selective\n catheterization of the inferior mesenteric artery was expedient using 5 French\n catheter. DSA arteriogram of the inferior mesenteric artery was\n obtained in three projections. Second order branches to the descending colon,\n splenic flexure, and sigmoid colon are demonstrated. An eccentric\n atherosclerotic plaque is identified in the inferior mesenteric artery\n approximately 1-2 cm from the inferior mesenteric artery origin associated\n with high-grade stenosis, approximately 75%. During the inferior mesenteric\n artery injections in three non-orthogonal projections, no active arterial\n bleeding was detectable in the sigmoid or the descending colon.\n Superselective catheterization followed using a Renegade STC microcatheter in\n tandem with a Transcend guidewire. Superselective DSA injections of the\n second order inferior mesenteric artery branches to the area of sigmoid colon\n identified on CTA demonstrated no active arterial extravasation. The catheter\n and sheath were removed and hemostasis achieved with an Angioseal closure\n device. A sterile dressing was applied.\n\n Attention was then diverted to the right anterior neck, which was prepped and\n draped in a sterile fashion. After generous infiltration of the subcutaneous\n tissues with 1% lidocaine, Dr. punctured the patent and fully\n compressible right internal jugular vein using a 21-gauge micropuncture needle\n under real-time ultrasound guidance. Over a 0.018 inch guidewire, the\n 21-gauge micropuncture needle was exchanged for a 4 French micropuncture\n sheath followed by advancement of 0.035 inch guidewire into the inferior\n vena cava under fluoroscopic visualization. After appropriate dilatation of\n the needle tract, a triple-lumen central venous line was advanced into the\n lower superior vena cava over a guidewire, which was subsequently removed.\n The catheter was secured to the skin using 0 silk sutures and covered with\n sterile dressing. The patient tolerated the procedure well.\n\n IMPRESSION:\n\n 1. Inferior mesenteric artery DSA angiogram in multiple non-orthogonal\n projections demonstrated no active arterial bleeding.\n 2. Multiple supraselective DSA injections of two sigmoid branches of the\n inferior mesenteric artery supplying the area of extravasation identified on\n CTA demonstrated no active extravasation.\n 3. Placement of a 7 French triple-lumen central venous line into the lower\n superior vena cava via the right internal jugular vein. The line is ready for\n use.\n (Over)\n\n 8:10 AM\n MESSENERTIC Clip # \n Reason: please perform mesenteric angiography and embolization\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OMNIPAQUE Amt: 105\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "ECG", "chartdate": "2141-03-31 00:00:00.000", "description": "Report", "row_id": 296439, "text": "Baseline artifact. Atrial fibrillation with moderate ventricular response.\nEarly precordial R wave progression of uncertain significance. Non-specific\nST-T wave abnormalities. Compared to the previous tracing of \nventricular response rate has decreased and non-specific ST-T wave\nabnormalities are slightly less marked. Suggest clinical correlation\n\n" }, { "category": "ECG", "chartdate": "2141-03-31 00:00:00.000", "description": "Report", "row_id": 296440, "text": "Atrial fibrillation. Compared to the previous tracing no change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2141-03-30 00:00:00.000", "description": "Report", "row_id": 296441, "text": "Atrial fibrillation. Compared to the previous tracing no change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2141-03-30 00:00:00.000", "description": "Report", "row_id": 296442, "text": "Atrial fibrillation. Compared to the previous tracing of no change.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2119-05-20 00:00:00.000", "description": "Report", "row_id": 1509228, "text": "Resp. Care Note\nPt seen for Atrovent neb after episode of wheezing and SOB. BS with crackles L>R, little change after Rx. cont as needed Q6\n" }, { "category": "Nursing/other", "chartdate": "2119-05-20 00:00:00.000", "description": "Report", "row_id": 1509229, "text": "CCU Nursing Progress Note\nS-\"I don't want to die, a have a 3 year old.\"\nO-Neuro alert and oriented x3, very pleasant and cooperative. At 1030 episode of sudden onset > left chest pain radiating to left shoulder, down left arm associated with numbness and tingling in left hand. SOB rr 30's HR 120 ST with freq PAC's SBP 120, received total MSO4 6mg IVB and ativan 2mg IVB with good relief of pain after 30 minutes. Team into evaluate and cardiologist had her sit forward hugging a pillow which made a marked improvment in the pain. Had another episode at 1430 with was quickly releived with MSO4 2mg IVB and ativan 1mg IVB. Pt slept comfortably for next 3-4hrs.\nCV-VSS pulsus paradox . HR 94-120ST with freq PAC's and occ PVC's. Cardiac echo repeated this am with no real change in pericardial effusion 1cm, no tampanade physiology noted, LVEF > 55%.\nResp-tachypnea rr 24-32 unable to take deep breath without pain or coughing. No sputum. One episode with audible insp wheezing while lying flat. Treated with atrovent with good effect. LS rales bilaterally. CXR LLL atelectasis with small left pleural effusion, pulmonary congestion noted. O2 sats 90% on RA, 3lnp sats 96%. Demonstrated how to use IS and pt able to inhale 500cc with goal 1000cc. Instructed to use IS q1hr 10x while awake, self motivated. O2 sats improved to 100% after IS.\nID afebrile with WBC decreasing 8.9 (13.6)\nGU-foley draining 50-70cc/hr receiving NS at 250cc/hr decreased to 125cc/hr then changed over to D5.45NS at 100cc/hr. At 1800 IVF d/c'd and will encourage po's. Urine color less concentrated.\nGI-c/o nausea this am with severe pain, relieved with ativan.\nAble to take in some breakfast and light lunch without further nausea. HCT 27.3, LFT's AST 252, alk phos 166, ALT 66 with fibrinogen 818. Hepatitis screen pnd, TSH .90, ESR 77 and pnd. Rheumatology to consult today.\nSkin-light red rash on upper back, no c/o itching. Pt at end of menses, minimal to no flow.\nSocial-sister in and very comforting, asking appropiate questions. Pt did ask that if her mother came to visit, delicately only allow her to stay alittle while. \"she means well\".\nCode status-Full\nA/P-Pleuralpericarditis d/t possible autoimmune process. Pericardial effusions stable without tampanade.\nContinue to follow pulsus q shift. Monitor signs of tampanade.\nControl pain with prn doses of MSO4 IVB for severe episodes and to start MS contin for constant low level pain. Encourage IS q1hr\nKeep pt and family imformed of POC and results of testing as dicussed in multi disciplanary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2119-05-21 00:00:00.000", "description": "Report", "row_id": 1509230, "text": "NURSING PROGRESS NOTE\nS: \" I FEEL A LITTLE BETTER\"\n\nO: NEURO: PT. AWAKE AND ALERT. MOVING ALL EXTREMITIES. CONTINUES TO HAVE PAIN IN LEFT SHOULDER. GIVEN OXYCODONE AS ORDERED AND MSO4 IR AS NEEDED FOR BREAKTHROUGH PAIN. ABLE TO MOVE SELF IN BED MUCH EASIER. PT. IN BETTER SPIRITS, SLEPT IN LONG NAPS OVERNIGHT.\n\nCV: HR 92-110 SR-ST NO VEA NOTED. BP 120/50, PULSUS 12.\n\nRESP: ON 3L NC, O2 SATS 92-96%. CRACKLES NOTED IN BASES, CLEAR IN UPPER AIRWAYS. HAS OCC EXP WHEEZE NOTED. GIVEN ATROVENT NEB AS ORDERED. DENIES C/O SOB. RR 18-22.\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE IN GOOD AMTS. ~ 100 CC/HR.\n\nGI: ABD SOFT, NO BM OVERNIGHT. + BOWEL SOUNDS.\n\nID: AFEBRILE, WBC STABLE.\n\nEND OF MENSES, LIGHT FLOW.\n\nA/P: CONT TO FOLLOW LYTES AND REPLETE AS NEEDED. ENCOURAGE C&DB, PAIN MED AS NEEDED FOR PAIN. UPDATE PT. AND FAMILY ON PLAN OF CARE PER CCU TEAM.\n" }, { "category": "Nursing/other", "chartdate": "2119-05-20 00:00:00.000", "description": "Report", "row_id": 1509227, "text": "nursing progress note\nS: \"I have pain in my shoulder\"\n\nO: Neuro: Alert and oriented x3. anxious at times about disease process. Weepy. moving all extremities.\n\nCV: hr 85-110, SR-ST with occ pac. K+ 3.5 last noc repleted with 40 meq kcl po. Mg++ 1.8, given mag oxide 400 mg po x1. bp 116/71-139/80\nc/o midsternal chest pain with deep breathing. given mso4 ivp for pain with fair relief. c/o left shoulder discomfort during noc, heat pack applied with relief from pain. Again c/o midsternal chest pain this am, given mso4 2 mg ivp. Pt. then experienced sudden onset of severe pain starting in left shoulder and radiating down left side. bp elevated to 139/90, hr 120. tachypneic with pain rate 30. given 2 mg ivp mso4 and anzimet 12.5 mg iv[ for nausea. EKG and CXR done. Pain now resolving.\n\nREsp: lungs clear, o2 sat 98% on 3l nc. o2 sat down to 92% on ra. Tachypneic with pain. rr 30's. denies c/o sob.\n\ngi: abd soft, no bm. appetite fair. npo since midnight.\n\ngu: foley draining dark yellow urine. see flowsheet for i/o totals.\n\nskin: intact, no broken areas.\n\nid: afebrile, wbc 13.5.\n\na: admitted to for workup of ? pericarditis, chest pain x 3 weeks. rheumatology consult for workup of auto immune disease.\n\nP: follow blood workup for hep b,c, coxackie virus. rheumatology consult. obtain results of cardiac echo, ? poss ct scan. mso4 prn for pain. offer reassurance and gentle explanations of all proceedures. update pt. and family on plan of care per ccu team.\n" }, { "category": "Echo", "chartdate": "2119-05-19 00:00:00.000", "description": "Report", "row_id": 80939, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. /Evaluate for effusion.\nHeight: (in) 65\nWeight (lb): 186\nBSA (m2): 1.92 m2\nBP (mm Hg): 95/63\nHR (bpm): 113\nStatus: Inpatient\nDate/Time: at 14:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nPERICARDIUM: Small pericardial effusion. Sgnificant, accentuated respiratory\nvariation in mitral/tricuspid valve inflows, c/w impaired ventricular filling.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is a small pericardial effusion. There is\nsignificant, accentuated respiratory variation in mitral/tricuspid valve\ninflows, consistent with impaired ventricular filling. There may be mild right\nventricular diastolic indentation but views suboptimal.\n\n\n" }, { "category": "Echo", "chartdate": "2119-05-20 00:00:00.000", "description": "Report", "row_id": 80910, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 67\nWeight (lb): 186\nBSA (m2): 1.96 m2\nBP (mm Hg): 177/72\nHR (bpm): 114\nStatus: Inpatient\nDate/Time: at 08:08\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\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF (>55%).\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).\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\n1. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%).\n2. There is a small pericardial effusion. There are probably no\nechocardiographic signs of tamponade.\n3. Compared with the prior study (images reviewed) of , there is\nprobably no significant change.\n\n\n" }, { "category": "Echo", "chartdate": "2119-05-22 00:00:00.000", "description": "Report", "row_id": 80909, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 67\nWeight (lb): 186\nBSA (m2): 1.96 m2\nBP (mm Hg): 132/84\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 11:32\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nLV WALL MOTION: remaining LV segments contract normally.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Compared with\nthe findings of the prior study, the size of the pericardial effusion has\ndecreased.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). The remaining\nleft ventricular segments contract normally. Right ventricular chamber size\nand free wall motion are normal. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen. There is a trvial/small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , no change.\n\n\n" }, { "category": "ECG", "chartdate": "2119-05-20 00:00:00.000", "description": "Report", "row_id": 199374, "text": "Sinus tachycardia with atrial premature complexes\nPoor R wave progression - probable normal variant\nAnterolateral ST-T changes are nonspecific\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2119-05-19 00:00:00.000", "description": "Report", "row_id": 199375, "text": "Sinus tachycardia. Diffuse non-specific ST-T wave abnormalities. There is\nslight ST segment elevations in leads II, III and aVF. Active inferior ischemic\nprocess cannot be excluded. Followup and clinical correlation are suggested. No\nprevious tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2119-05-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 916205, "text": " 2:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate heart size and for pleural effusions\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with likely pericardial effusion now with worsening dyspnea\n REASON FOR THIS EXAMINATION:\n evaluate heart size and for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Worsening dyspnea.\n\n The heart is enlarged with rounded configuration. No vascular congestion.\n There is a poorly defined process in the left lower lobe behind the heart\n consistent with atelectasis and/or consolidation. Remainder of lungs clear.\n Lateral CP angle sharp. No comparison exams on PACS.\n\n IMPRESSION: Enlarged cardiac silhouette and I cannot exclude a pericardial\n effusion. No CHF. Possible left lower lobe pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2119-05-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 916303, "text": " 7:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for PNA, effusions\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with pericardial effusion having worsening dyspnea\n REASON FOR THIS EXAMINATION:\n Please assess for PNA, effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pericardial effusion, dyspnea.\n\n CHEST, ONE VIEW: Comparison with shows stable cardiomegaly as\n well as left lower lobe atelectasis and a small left pleural effusion. There\n is evidence of mild left atrial as well as central venous pressure elevation\n consistent with pulmonary edema. There is no pneumothorax.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2144-02-12 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 895624, "text": " 9:59 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: facial CT, evaluate for injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with seizure, fall\n REASON FOR THIS EXAMINATION:\n facial CT, evaluate for injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SINUS, MAXILLOFACIAL.\n\n INDICATION: Seizure, fall, HIV, evaluate for injury.\n\n TECHNIQUE: Axial and coronal non-contrast images of the paranasal sinuses\n were reviewed.\n\n COMPARISON: No direct comparison available.\n\n SINUS CT: There is no evidence for acute fracture. There is minimal soft\n tissue swelling of the right frontal scalp. The orbital floor is intact. The\n paranasal sinuses are normally aerated, with no mucosal thickening or air\n fluid levels identified. Cribriform plates are equal in height. There is a\n small polyp within the left frontal sinus. The patient is status post right\n mandible fracture with a reconstruction plate present. There is also evidence\n of a healed previous left zygomatic arch fracture.\n\n IMPRESSION: No acute fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-02-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 895622, "text": " 9:57 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for injury/bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with seizure, fall\n REASON FOR THIS EXAMINATION:\n eval for injury/bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: HIV with alcohol abuse; status post seizure and fall.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no evidence of intra- or extra-axial hemorrhage. The\n ventricles, cisterns, and sulci are unremarkable; without effacement. There\n is no mass effect, hydrocephalus, or shift of the normally midline structures.\n The marked parenchymal atrophy and prominent ventricles may relate to the\n history of alcoholism provided. The osseous structures and paranasal sinuses\n are within normal limits. The mastoid air cells are clear.\n\n IMPRESSION: No evidence of intracranial hemorrhage or mass.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2144-02-12 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 895623, "text": " 9:59 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: evaluate for injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with seizure, fall\n REASON FOR THIS EXAMINATION:\n evaluate for injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Seizure, fall, HIV. Eval for injury.\n\n TECHNIQUE: Non-contrast axial images of the cervical spine with coronal and\n sagittal reformats were reviewed.\n\n COMPARISON: CT C-spine from .\n\n FINDINGS: There is no evidence for acute injury, including no sign for\n fractures or dislocations. There is no spondylolisthesis. There is no\n prevertebral soft tissue swelling. There is loss of the disc height at C5-C6\n with associated anterior osteophyte formation consistent with degenerative\n disease. Limited evaluation of the lung apices demonstrates two calcified\n nodules in the left apex, may be secondary to previous granulomatous\n infection. Irregular linear densities in the right apex are suggestive of\n scarring. These findings were also evident on a chest CT from , though appear more prominent on today's exam. A more complete chest\n CT scan should be performed, if clinically relevant, to exclude any new\n significant pulmonary pathology.\n\n IMPRESSION: No acute injury of the cervical spine. See above report for\n additional findings.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-02-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 895602, "text": " 8:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with seizure, altered mental status\n REASON FOR THIS EXAMINATION:\n eval for pneumonia\n ______________________________________________________________________________\n WET READ: KCLd WED 11:28 AM\n No evidence of pneumonia. Some bronchiectasis seen.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old man with seizure, altered mental status. Please\n evaluate for pneumonia.\n\n FINDINGS: AP chest radiograph dated is compared to previous\n AP chest film performed .\n\n The heart size is normal. The mediastinal and hilar contours are normal. Mild\n bronchiectasis can be seen especially in the lower lobes. The subtle\n opacities described on the previous chest x-ray are again seen and appear\n unchanged when compared to studies dating back to . There is no evidence\n of pneumonia.\n\n IMPRESSION: No evidence of pneumonia. Mild bronchiectasis.\n\n" }, { "category": "Radiology", "chartdate": "2144-02-19 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 896557, "text": " 9:49 AM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: HIV + man c dykinesia/dementia; please assess for infectious\n Admitting Diagnosis: SEIZURE\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with HIV+, p/w seziure following crack/cocaine use c persistent\n dyskinesia.\n REASON FOR THIS EXAMINATION:\n HIV + man c dykinesia/dementia; please assess for infectious etiologies (PML,\n toxo) or neoplastic processes (CNS lymphoma)\n ______________________________________________________________________________\n FINAL REPORT\n GADOLINIUM-ENHANCED BRAIN IMAGING\n\n HISTORY: HIV positive patient with seizure following crack cocaine use.\n Assess for infectious etiologies.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted gadolinium-enhanced brain imaging\n was obtained.\n\n COMPARISON STUDY: Gadolinium-enhanced MR imaging of the brain from .\n\n FINDINGS: In the five and a half year period between MR scans, no new area of\n abnormal FLAIR signal has developed within the brain. In addition to the\n slight periventricular T2 hyperintensity noted on the original study, there is\n a probable 3- to 4-mm T2 hyperintense zone seen within the left corona\n radiata. As mentioned previously, the findings could be secondary to HIV\n infection, as well as small vessel infarction potentially associated with the\n patient's known substance abuse. There are no areas of abnormal enhancement\n seen within the brain parenchyma. There is moderate brain atrophy, again\n noted, and also likely correlating with either the history of HIV infection,\n as well as substance abuse. There are no overt extracranial abnormalities\n seen.\n\n CONCLUSION: Moderate brain atrophy, with additional, essentially stable\n abnormalities as noted above.\n\n" }, { "category": "Nursing/other", "chartdate": "2144-02-12 00:00:00.000", "description": "Report", "row_id": 1449826, "text": "MICU NURSING ADMIT NOTE\n46 yo male found down by partner, thrashing with blood on his face. EMS called arrived found pt unresponsive, seizing gave ativan 6mg. Arrived to Ed lethargic no seizure activity, oral airway in place, pupils pin point, given 4mg narcan, woke, agitated, combative, +mae, became lethragic, head Ct done, LP done. Transfer to MICU for further care.\n\nPMH: HIV, AIDS, CD4 count 68, PCP, , HSV encephalitis, perianal condylomata, seizure disorder, hepatitis, avascular necrosis Left hip s/p mult hip surgeries, aseptic necrosis right hip, mania, low testosterone, polysubstance abuse, jaw fx, femur fx\n\nALLERGIES: NKA\n\nREVIEW OF SYSTEMS:\nNEURO: arrived lethargic, arouse to stim/voice, perrla 3mm, +MAE, after 1hr, arouse to voice, eyes open spontaneously, follow commands, many questions about what happened, how he got to hospital, no seizures.\nCV: hr 70-80 SR, no VEA, BP 110-120's/50-70, extrem warm palpable pulses, no edema\nRESP: lungs clear, O2 wean to room air withO2 sat >96%\nGI: abd soft flat +bs aspiration precautions, advance diet when more alert\nGU: foley intact with clear yellow urine\nSKIN: intact, left inner thigh with red area, he states is a birth mark\nSOCIAL: lives with partner, no contact from family\nACCESS: 2 PIV's #20 and #18\n\nPLAN: monitor for signs of seizures, maintain safety, aspiration precautions, follow CT results, follow LP results\n\n" }, { "category": "Nursing/other", "chartdate": "2144-02-13 00:00:00.000", "description": "Report", "row_id": 1449827, "text": "Events: Pt had uneventful shift. slept much of night.\n\nNeuro: CIWA scale initiated at start of shift. Max rating was 11 at midnight. Given 5mg Valium . Subsequent CIWA scores 6. Pt mental status is clearing as shift progresses. Initially pt had difficult time answering specific questions but now can name president, his address, phone number, and date without difficulty. Tremors have diminished to slight shake with arm extended. Pt more cooperative as well. Restraints off. Pt does continue with 'squirming' movements throughout shift. No seizure activity noted however. No hallucinations reported.\n\nResp: Lung sounds cta bilat. O2 sats high 90's on room air.\n\nCardiac: NSR on monitor. Pt slightly hypotensive when asleep. b/p 90-107/40-55. no ectopy or tachycardia noted. No episodes of hypertension.\n\nGI:Abd soft/nontender. no reports of nausea, no bm this shift. NPO except meds. D51/2 at 100cc/hr running via peripheral iv\n\nGU: Voiding large amts of urine via foley.\n\nDerm: Grossly intact. PIV x2 patent. PT has deep laceration under R eye. Plastics consulted and will return this morning to repair\n\nID: low grade temp 99.9 oral. Pt is on antiretroviral therapy.\n\nSocial: Pt' claims to be his guardian and to have power of attorney over pt. He does not want pt to have any visitors except for him as pt's friends are 'all drug addicts' and are a bad influence. We dont' have any paperwork stating has power of attorney.\n\nPlan: Call out to floor once eye laceration repaired. Monitor for s/sx of withdrawl and seizure activity. Obtain power of attorney paperwork from when he visits today. Addictions service consulted.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2155-05-10 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1012749, "text": " 3:23 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please evaluate position of new central line and interval ch\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with CAD, a/w sepsis now s/p R-IJ placement\n REASON FOR THIS EXAMINATION:\n please evaluate position of new central line and interval change in lungs\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:41 P.M., .\n\n HISTORY: Sepsis. New right IJ line placement.\n\n IMPRESSION: AP chest compared to , 5:08 a.m.:\n\n Tip of the new right IJ line ends in the lower SVC, right subclavian line tip\n projects over the superior cavoatrial junction as before, large right pleural\n effusion is stable, and small left pleural effusion unchanged. Heart size top\n normal, partially obscured by large right pleural effusion. Mediastinal\n vascular engorgement improved slightly. No pneumothorax. Gaseous distention\n of the stomach has improved.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-05-11 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1012838, "text": " 10:20 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Interval Change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with CAD, MRSA bacteremia, now in respiratory distress.\n REASON FOR THIS EXAMINATION:\n Interval Change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: at 5:48 a.m.\n\n INDICATION: Respiratory distress.\n\n Large right pleural effusion has increased in size, and right middle and right\n lower lobe atelectasis has slightly worsened in the interval.\n Small-to-moderate left pleural effusion has also slightly increased. There\n are otherwise no substantial changes within the chest. In the abdomen,\n moderate gastric distention is present as well as probable ascites.\n\n\n" }, { "category": "Echo", "chartdate": "2155-05-12 00:00:00.000", "description": "Report", "row_id": 93256, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 69\nWeight (lb): 235\nBSA (m2): 2.21 m2\nBP (mm Hg): 98/70\nHR (bpm): 96\nStatus: Outpatient\nDate/Time: at 12:08\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with 35-50%\ndecrease during respiration (estimated RAP (0-10mmHg).\n\nLEFT VENTRICLE: Depressed LVEF.\n\nRIGHT VENTRICLE: Cannot assess RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: No AS.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Resting\ntachycardia (HR>100bpm).\n\nConclusions:\nSuboptimal image quality. The left atrium is mildly dilated. The estimated\nright atrial pressure is 0-10mmHg. LV systolic function appears depressed.\nThere is no aortic valve stenosis. There is a trivial/physiologic pericardial\neffusion. Cannot determine valvular function or exclude valvular vegetations\non the basis of this study.\n\nIf clinically indicated, a TEE may be better to exclude endocarditis.\n\n\n" }, { "category": "ECG", "chartdate": "2155-05-10 00:00:00.000", "description": "Report", "row_id": 246002, "text": "Atrial fibrillation with rapid ventricular response. The previously mentioned\nmultiple abnormalities persist without diagnostic interim change. Followup and\nclinical correlation are suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2155-05-09 00:00:00.000", "description": "Report", "row_id": 246003, "text": "Atrial fibrillation with rapid ventricular response. Low limb lead voltage.\nCompared to the previous tracing of the limb lead voltage is markedly\ndiminished. Atrial fibrillation has appeared. Followup and clinical\ncorrelation are suggested.\nTRACING #1\n\n" }, { "category": "Respiratory ", "chartdate": "2155-05-12 00:00:00.000", "description": "Generic Note", "row_id": 325266, "text": "TITLE:\n Following pt for bronchodilator therapy and nasotracheal sx. Albuterol\n and Atrovent nebs increased to Q4 for worsening resp status overnight.\n Nasotracheally sxing prn for tenacious yellow secretions. Pt improves\n after rx. Oxygenation marginal, though not to be intubated. See\n flowsheet for further pt data. Will follow.\n 06:31\n" }, { "category": "Physician ", "chartdate": "2155-05-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325271, "text": "Chief Complaint: MRSA Bacteremia\n 24 Hour Events:\n CHEST PAIN - At 09:45 AM\n BLOOD CULTURED - At 10:16 AM\n EKG - At 10:16 AM\n -Family meeting held with daughters where the decision was made to\n make him DNR/DNI, with NO escalation of care (ie, no new invasive\n procedures/ or work-ups). Basically he was given a very poor prognosis\n with months to live from his gastroenterologist as he has pancreatic\n cancer. He does not know this diagnosis yet, only his daughters do, so\n they were very reasonable about goals of care. They will get back to\n us on possibly making him CMO, and would like input from his GI doctor\n Dr. , whom I emailed\n -Blood cultures came back 4/4 bottles with MRSA\n -We were unable to wean pressors due to low MAPs\n -We got a CT to better characterize his pleural effusion on CXR, and it\n showed a white out of the right lung with effusion, and a complete lung\n collapse with mucous plugging.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Piperacillin - 12:28 AM\n Piperacillin/Tazobactam (Zosyn) - 05:54 AM\n Vancomycin - 06:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Phenylephrine - 4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.6\nC (96\n HR: 114 (107 - 135) bpm\n BP: 93/66(77) {77/53(64) - 182/122(148)} mmHg\n RR: 16 (12 - 39) insp/min\n SpO2: 77%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n CVP: 7 (-3 - 17)mmHg\n Total In:\n 2,872 mL\n 895 mL\n PO:\n TF:\n IVF:\n 2,872 mL\n 895 mL\n Blood products:\n Total out:\n 353 mL\n 28 mL\n Urine:\n 353 mL\n 28 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,519 mL\n 867 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 77%\n ABG: 7.28/34/86/14/-9\n PaO2 / FiO2: 86\n Physical Examination\n General Appearance: Well nourished, Diaphoretic\n Eyes / Conjunctiva: PERRL\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:\n Diminished: right, and left base)\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, No(t) Tender:\n Extremities: Right: 2+, Left: 2+, 2+ pre-sacral edema\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x2, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 309 K/uL\n 12.9 g/dL\n 167 mg/dL\n 2.4 mg/dL\n 14 mEq/L\n 5.7 mEq/L\n 62 mg/dL\n 104 mEq/L\n 134 mEq/L\n 41.1 %\n 23.1 K/uL\n [image002.jpg]\n 04:42 AM\n 10:04 AM\n 10:14 AM\n 12:12 PM\n 03:25 PM\n 03:30 PM\n 04:28 PM\n 09:16 PM\n 03:15 AM\n 04:36 AM\n WBC\n 23.1\n Hct\n 41.1\n Plt\n 309\n Cr\n 2.0\n 2.4\n TropT\n 0.01\n TCO2\n 26\n 24\n 23\n 22\n 23\n 18\n 17\n Glucose\n 167\n Other labs: PT / PTT / INR:32.6/38.0/3.4, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:63/168, Alk Phos / T Bili:342/2.1,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:3.3 mmol/L, Albumin:2.1 g/dL, LDH:406 IU/L, Ca++:7.9\n mg/dL, Mg++:2.2 mg/dL, PO4:7.2 mg/dL\n Imaging: CT Chest\n IMPRESSION:\n 1. No evidence of pneumonia. Large right pleural effusion causing\n complete\n collapse of the right lung, which was previously partially aerated.\n Component\n of mucus plugging may be superimposed and continued radiographic\n follow-up\n needed. Moderate left pleural effusion causing complete atelectasis of\n the\n basilar left lower lobe segments. Right chest wall edema.\n 2. Atherosclerotic calcifications within the aorta and coronary\n circulation.\n 3. Interval increase in intra-abdominal ascites, with resolution of\n previously identified intrahepatic biliary dilatation and stable\n appearance to\n simple and hyperdense renal lesions better described on previously\n performed\n dedicated CT abdomen. Pancreatic ductal dilatation persists.\n Microbiology: VRE Swab: Positive\n Blood: MRSA from \n Assessment and Plan\n A/P: 82 M w/ recent admission for painless jaundice s/p ERCP with\n sphincterotomy and biliary stent c/b hypoxia requiring intubation,\n admitted with septic shock\n .\n Septic Shock: On admission was febrile, WBC > 30 with bandemia,\n tachycardic, increased RR. Now with GPC in blood. Unclear source, but\n must consider endocarditis, pulmonary, decubiti or GI source given\n recent diarrhea. Patient without abdominal pain or jaundice to suggest\n acute cholangitis.\n f/u Sputum, Blood, Urine Cx, Cdiff x 3 - MRSA+ Bacteremia - unclear\n source, ? parapneumonic effusion, endocarditis, complication of biliary\n stent placement.\n 1. Will treat broadly with Vanc/Zosyn/PO Vanco for C. Diff -\n consider d/c zosyn today.\n 2. Titrate CVP to 10, bolus as needed\n 3. Switched to phenylephrine to avoid beta adrtenergic effect of\n levophed and resulting tachycardia. Added vasopressin this AM. Check\n Mixed Venous O2 sat. Adjust PRN. Might need dobutamine for inotrpoic\n support.\n 4. Transfuse as needed for Hct>30 if MvO2 is < 70%\n 5. Basal cortisol level wnl, no stim\n 6. Line re-positioned, f/u culture of tip although unlikely\n source as placed less than 36 hours ago at OSH.\n 7. TTE for endocarditis. If negative would get CT Scan\n chest/abdomen looking for abdomen. ?osteo underlying wounds.\n 8. Wound care consult.\n 9. CT Chest today for ? effusion/pneumonia.\n .\n Hypoxia: Patient comfortable on 6L. He is willing to be intubated.\n Hypoxia likely a result of pleural effusions, sepsis, volume\n recuscitation.\n 1. ABG this AM 7.35/45/132\n 2. Continue nasal cannula at this point.\n 3. Daily CXR\n 4. Add nebulizer prn\n .\n Pleural effusions: may be malignant pleural effusions vs. chf vs. pna\n 1. ECHO, cycle enzymes, daily EKG\n 2. Empirically treat for HAP with Vanc/Zosyn\n .\n Acute Renal Failure: likely pre-renal from sepsis/hypotension. UOP has\n dropped off this morning, and now with rising Cr/lactate. Added\n vasopressin for second pressor and goal of improved renal perfusion.\n Goal MAP of 70 for today.\n 1. Follow Cr.\n .\n Biliary stricture: Patient with recent admission for painless jaudince\n requiring biliary stent and sphincterotomy. Patient due to stent\n change in . Patient does not appear to have clinical signs of\n cholangitis at this point.\n 1. NPO for now\n 2. Trend LFTs\n 3. empirically treat with Zosyn for biliary organisms\n .\n CAD: MI in 's. Give high dose ASA. Enzymes negative x1 - and with\n negative set at OSH more than 12 hours apart. No need to cycle\n further.\n .\n PUMP: Hold antihypertensives, pressors as needed. Will repeat ECHO.\n Patient grossly volume overloaded, and may require aggressive diuresis\n once he's off pressors.\n .\n RHYTHM: known afib on coumadin. Hold coumadin. Rate much improved\n after switch to neosynephrine.\n .\n ARF: Cr up to 1.9 from basline.\n 1. urine lytes show FENA 0.2%, pre-renal vs ATN in setting\n hypotension\n .\n Nutrition: Consult this AM for low albumin.\n 1. Would restart regular diet if possible although with\n respiratory status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 08:29 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": "2155-05-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325372, "text": "Chief Complaint: shock\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 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent admit with ERCP\n w/sphincterotomy and biliary stent for high grade CBD stricture c/b\n shock, requiring pressors and intubation x 48hrs peri-procedure\n (brushings were \"atypical\" and CA -9 very elevated, suspcious for\n pancreatic ca) transferred from OSH w/ shock, leukocytosis and\n hypoxemia.\n 24 Hour Events:\n more lethargic overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 12:28 AM\n Vancomycin - 06:19 PM\n Piperacillin/Tazobactam (Zosyn) - 05:49 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 05:48 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:10 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 36\nC (96.8\n HR: 123 (104 - 123) bpm\n BP: 99/70(83) {93/69(80) - 124/87(284)} mmHg\n RR: 15 (10 - 25) insp/min\n SpO2: 75%--> 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n Height: 67 Inch\n CVP: 14 (8 - 20)mmHg\n Total In:\n 1,661 mL\n 309 mL\n PO:\n TF:\n IVF:\n 1,661 mL\n 309 mL\n Blood products:\n Total out:\n 208 mL\n 162 mL\n Urine:\n 208 mL\n 162 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,453 mL\n 147 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 75%\n ABG: 7.32/36/99./22/-6\n PaO2 / FiO2: 99\n Physical Examination\n General Appearance: Well nourished, No acute distress, lethargic\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: (Expansion: Symmetric), (Breath Sounds: Bronchial:\n L apex, Diminished: entire R lung, L lung decreased)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, No(t)\n Sedated, Tone: Not assessed\n Labs / Radiology\n 12.0 g/dL\n 240 K/uL\n 160 mg/dL\n 2.8 mg/dL (1.7->2.4)\n 22 mEq/L\n 5.3 mEq/L\n 72 mg/dL\n 105 mEq/L\n 135 mEq/L\n 38.2 %\n 20.4 K/uL\n [image002.jpg]\n 03:25 PM\n 03:30 PM\n 04:28 PM\n 09:16 PM\n 03:15 AM\n 04:36 AM\n 01:04 PM\n 02:56 PM\n 04:11 AM\n 05:19 AM\n WBC\n 23.1\n 20.4\n Hct\n 41.1\n 38.2\n Plt\n 309\n 240\n Cr\n 2.0\n 2.4\n 2.6\n 2.8\n TCO2\n 22\n 23\n 18\n 17\n 19\n 19\n Glucose\n 167\n 168\n 160\n Other labs: PT / PTT / INR:32.2/40.5/3.3, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:81/141, Alk Phos / T Bili:323/2.0,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:2.1 mmol/L, Albumin:1.9 g/dL, LDH:221 IU/L, Ca++:7.5\n mg/dL, Mg++:2.1 mg/dL, PO4:5.9 mg/dL\n Imaging: no new studies\n Microbiology: --mrsa in blood\n -blood mrsa\n Assessment and Plan\n 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent admit with ERCP\n w/sphincterotomy and biliary stent for high grade CBD stricture c/b\n shock, requiring pressors and intubation x 48hrs peri-procedure\n (brushings were \"atypical\" and CA -9 very elevated, suspcious for\n pancreatic ca) transferred from OSH w/ septic shock from mrsa infection\n with progressive ARF, continued pressor requirements, large effusions\n with compressive atelectasis\n Main issues remain:\n # Shock--from mrsa bacteremia\n possible sources -> lungs/pna effusions, bowel, skin (decubs).\n With leukocytosis, diarrhea, and recent antibx also concerned for c\n diff\n -Continue pressores--Neo and vaso--weaning as tolerated, neo nearly off\n -Bolus IVF for CVP goal at least 10\n -continue broad spectum abx\n zosyn/IV vanco/po vanco--refusing so\n change to IV flagyl pending 3rd c diff cx.\n tapping effuison and consideration to reimaging of abd discussed 9lfts\n improving but with sig pain on palpation), will continue to address\n fgoals of care with family, who seem to moving toward comfort and do\n not wish for escalation opf care or agressive interventison.\n # Hypoxemia/respiratory distress\n pleural effusions + pulm edema (BNP 10K at OSH) + probable\n pna,\n Not diuresing as requiring pressors.\n Abx as above\n Cont BDs as tolerated\n Tenous and sats very positional, would have difficutly tolerating\n thoracentesis (would also need to reverse anticoag) or bronch\n at this time,\n Extensive discussions with family who understand poor prognoisis and\n risks associated with potentially therapeutic interventions\n such as /bronch given tenuous status\n Pt is DNR/DNI without excalation of care,\n # ARF\n likely ATN /intravascualr depletion from sepsis. Urine lytes appear\n pre-renal\n Renally dose meds.\n Trend u/o, cr\n # Leukocytosis\n trending down slowly but remains elevated with ,utliple potentila\n sources including infected pleural fluid, ? c diff\n continue broad coverage\n goal of care discussion with family\n # Afib: tolerating neo in terms of rates. Holding BB given pressor\n requiremetns\n Holding coumadin given supratherapeutic INR.\n # Sacral and b/l heel decubs: wound care\n # CAD\n EKG unchanged b/l and cardiac enzymes negative.\n Holding BB, ACEI while req pressors\n cont asa.\n # FEN: npo given hypoxemia and tenous resp status\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 08:29 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2155-05-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325375, "text": "Chief Complaint: shock\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 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent admit with ERCP\n w/sphincterotomy and biliary stent for high grade CBD stricture c/b\n shock, requiring pressors and intubation x 48hrs peri-procedure\n (brushings were \"atypical\" and CA -9 very elevated, suspcious for\n pancreatic ca) transferred from OSH w/ shock, leukocytosis and\n hypoxemia.\n 24 Hour Events:\n Increasingly lethargic overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 12:28 AM\n Vancomycin - 06:19 PM\n Piperacillin/Tazobactam (Zosyn) - 05:49 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 05:48 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:10 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 36\nC (96.8\n HR: 123 (104 - 123) bpm\n BP: 99/70(83) {93/69(80) - 124/87(284)} mmHg\n RR: 15 (10 - 25) insp/min\n SpO2: 75%--> 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n Height: 67 Inch\n CVP: 14 (8 - 20)mmHg\n Total In:\n 1,661 mL\n 309 mL\n PO:\n TF:\n IVF:\n 1,661 mL\n 309 mL\n Blood products:\n Total out:\n 208 mL\n 162 mL\n Urine:\n 208 mL\n 162 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,453 mL\n 147 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 75%\n ABG: 7.32/36/99./22/-6\n PaO2 / FiO2: 99\n Physical Examination\n General Appearance: Well nourished, No acute distress, lethargic\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: (Expansion: Symmetric), (Breath Sounds: Bronchial:\n L apex, Diminished: entire R lung, L lung decreased)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, No(t)\n Sedated, Tone: Not assessed\n Labs / Radiology\n 12.0 g/dL\n 240 K/uL\n 160 mg/dL\n 2.8 mg/dL (1.7->2.4)\n 22 mEq/L\n 5.3 mEq/L\n 72 mg/dL\n 105 mEq/L\n 135 mEq/L\n 38.2 %\n 20.4 K/uL\n [image002.jpg]\n 03:25 PM\n 03:30 PM\n 04:28 PM\n 09:16 PM\n 03:15 AM\n 04:36 AM\n 01:04 PM\n 02:56 PM\n 04:11 AM\n 05:19 AM\n WBC\n 23.1\n 20.4\n Hct\n 41.1\n 38.2\n Plt\n 309\n 240\n Cr\n 2.0\n 2.4\n 2.6\n 2.8\n TCO2\n 22\n 23\n 18\n 17\n 19\n 19\n Glucose\n 167\n 168\n 160\n Other labs: PT / PTT / INR:32.2/40.5/3.3, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:81/141, Alk Phos / T Bili:323/2.0,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:2.1 mmol/L, Albumin:1.9 g/dL, LDH:221 IU/L, Ca++:7.5\n mg/dL, Mg++:2.1 mg/dL, PO4:5.9 mg/dL\n Imaging: no new studies\n Microbiology: --mrsa in blood\n -blood mrsa\n Assessment and Plan\n 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent admit with ERCP\n w/sphincterotomy and biliary stent for high grade CBD stricture c/b\n shock, requiring pressors and intubation x 48hrs peri-procedure\n (brushings were \"atypical\" and CA -9 very elevated, suspicious for\n pancreatic ca)\n Transferred from OSH w/ septic shock from mrsa bacteremia w/ continued\n pressor requirements, large b/l pleural effusions with compressive\n atelectasis, leukocytosis, and progressive ARF\n Poor overall prognosis and now with multiorgan failing. Ongoing\n discussions regarding goals of care and possible transition from\n dnr/dni without escalation to comfort care today, given worsening\n lethargy/ms/pain.\n Main issues remain:\n # Shock--from mrsa bacteremia\n possible sources -> lungs/pna + effusions, bowel, skin (decubs)\n given leukocytosis, diarrhea, and recent antibx also concern for c\n diff\n -Continue pressors--Neo and vaso--weaning as tolerated, neo nearly off\n -Bolus IVF for CVP goal at least 10\n -continue broad spectum abx\n zosyn/IV vanco/ --refusing PO\n Vanco\nchange to IV flagyl pending 3rd c diff cx.\n - Tapping effusion and consideration to reimaging of abd discussed\n (lfts improving but with sig pain on palpation)\nongoing discussion\n with family regarding goals of care, as family seem to moving toward\n comfort and do not wish for escalation of care or aggressive\n interventions/procedures given overall poor prognosis and inoperable\n malignancy. Palliative care c/s to further assist family.\n # Hypoxemia/respiratory distress\n pleural effusions + pulm edema (BNP 10K at OSH) + probable pna\n Unable to diurese as requiring pressors.\n Continue Abx as above\n Cont BDs as tolerated\n Morphine for air-hunger\n Extensive discussions with family who understand poor prognoisis and\n risks associated with potentially therapeutic interventions\n such as /bronch given tenuous status\n # ARF\n likely ATN /intravascular depletion from sepsis.\n Renally dose meds.\n # Leukocytosis\n remains elevated with mutliple potential sources of persistent\n infection including pleural fluid, sacral decub ? c diff\n continue broad coverage\n goal of care discussion with family as noted\n # pain---morphine prn\n # Afib: Holding BB given pressor requirements\n Holding coumadin given supratherapeutic INR.\n # Sacral and b/l heel decubs: wound care\n # CAD\n Holding BB, ACEI while req pressors\n cont asa if able to tol po med\n ICU Care\n Nutrition:\n Comments: NPO given somnolence and resp status\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 08:29 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI, no escalation of care\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2155-05-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325381, "text": "Chief Complaint: MRSA Bacteremia\n 24 Hour Events:\n - Stably sick, likely CMO in AM.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 12:28 AM\n Vancomycin - 06:19 PM\n Piperacillin/Tazobactam (Zosyn) - 05:49 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Phenylephrine - 1.4 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 05:48 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 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.8\nC (96.5\n HR: 107 (104 - 123) bpm\n BP: 93/69(80) {87/65(75) - 124/87(284)} mmHg\n RR: 11 (11 - 25) insp/min\n SpO2: 75%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n Height: 67 Inch\n CVP: 19 (8 - 20)mmHg\n Total In:\n 1,661 mL\n 193 mL\n PO:\n TF:\n IVF:\n 1,661 mL\n 193 mL\n Blood products:\n Total out:\n 208 mL\n 90 mL\n Urine:\n 208 mL\n 90 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,453 mL\n 103 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 75%\n ABG: 7.32/36/99./22/-6\n PaO2 / FiO2: 99\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\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: Wheezes :\n Left lung field)\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended\n Extremities: Right: 2+, Left: 2+, +pre-sacral edema\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Tactile stimuli, Movement: Not assessed, Tone: Not assessed,\n arousable easily with sternal rub, but fades off to sleep quite quickly\n Labs / Radiology\n 240 K/uL\n 12.0 g/dL\n 160 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 5.3 mEq/L\n 72 mg/dL\n 105 mEq/L\n 135 mEq/L\n 38.2 %\n 20.4 K/uL\n [image002.jpg]\n 03:25 PM\n 03:30 PM\n 04:28 PM\n 09:16 PM\n 03:15 AM\n 04:36 AM\n 01:04 PM\n 02:56 PM\n 04:11 AM\n 05:19 AM\n WBC\n 23.1\n 20.4\n Hct\n 41.1\n 38.2\n Plt\n 309\n 240\n Cr\n 2.0\n 2.4\n 2.6\n 2.8\n TCO2\n 22\n 23\n 18\n 17\n 19\n 19\n Glucose\n 167\n 168\n 160\n Other labs: PT / PTT / INR:32.6/38.0/3.4, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:81/141, Alk Phos / T Bili:323/2.0,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:2.1 mmol/L, Albumin:1.9 g/dL, LDH:221 IU/L, Ca++:7.5\n mg/dL, Mg++:2.1 mg/dL, PO4:5.9 mg/dL\n Imaging: TTE: Suboptimal image quality. The left atrium is mildly\n dilated. The estimated right atrial pressure is 0-10mmHg. LV systolic\n function appears depressed. There is no aortic valve stenosis. There is\n a trivial/physiologic pericardial effusion. Cannot determine valvular\n function or exclude valvular vegetations on the basis of this study.\n ---------\n Radiology Report CT CHEST W/O CONTRAST Study Date of 2:20 PM\n , SCHED\n CT CHEST W/O CONTRAST Clip # \n Reason: r/o underlying PNA\n -----------------------------------------------------------------------\n ---------\n Final Report\n HISTORY: Bilateral pleural effusions. Evaluate for underlying\n pneumonia.\n TECHNIQUE: MDCT-acquired axial images were obtained through the chest\n without\n intravenous contrast. Contrast was withheld due to elevated BUN and\n creatinine levels. 5-mm, 1.25-mm, and coronal reformations were\n evaluated.\n CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST\n Comparison is made to multiple prior radiograph and prior CTA dated\n .\n FINDINGS: The entire right lung is collapsed, and there is a large\n right\n simple pleural effusion occupying the entire right hemithorax, with\n fluid\n extension into the lateral chest wall. The left upper lobe, lingula,\n and\n superior segment of the left lower lobe remain aerated, with the\n basilar\n segments displaying atelectasis due to compression from an adjacent\n moderate\n simple left pleural effusion. The aerated lung appears clear, and\n without\n evidence of pneumonia. No pathologically enlarged central or axillary\n lymph\n nodes are identified. Secretions are noted within the central airway.\n There is\n a small pericardial effusion and atherosclerotic calcification noted\n within\n the right and left coronary circulation and aortic root and valve. The\n main\n pulmonary artery and right pulmonary artery are dilated, measuring\n greater\n than 3 cm, likely related to elevated pressures from the large\n effusions and\n atelectasis. Right IJ catheter terminates in the mid SVC.\n This examination was not tailored for subdiaphragmatic evaluation. The\n imaged\n portion of the upper abdomen displays placement of a biliary stent with\n significant improvement/resolution of intrahepatic biliary ductal\n dilatation,\n but persistent pancreatic ductal dilatation and stable appearance to\n duodenal\n diverticulum, large simple exophytic left upper pole renal cyst, and\n hyperdense right interpolar 2 cm renal cyst. The degree of ascites\n within the\n abdomen is slightly increased from exam.\n BONE WINDOWS: Degenerative changes of the glenohumeral joint are noted\n bilaterally. There are multilevel degenerative changes within the\n spine. No\n malignant-appearing osseous lesions are identified.\n CT Chest Impression:\n .\n 1. No evidence of pneumonia. Large right pleural effusion causing\n complete\n collapse of the right lung, which was previously partially aerated.\n Component\n of mucus plugging may be superimposed and continued radiographic\n follow-up\n needed. Moderate left pleural effusion causing complete atelectasis of\n the\n basilar left lower lobe segments. Right chest wall edema.\n .\n 2. Atherosclerotic calcifications within the aorta and coronary\n circulation.\n .\n 3. Interval increase in intra-abdominal ascites, with resolution of\n previously identified intrahepatic biliary dilatation and stable\n appearance to\n simple and hyperdense renal lesions better described on previously\n performed\n dedicated CT abdomen. Pancreatic ductal dilatation persists.\n Microbiology: BCx: + MRSA\n BCx: GPC+\n UCx: Negative\n Assessment and Plan\n A/P: 82 M w/ recent admission for painless jaundice s/p ERCP with\n sphincterotomy and biliary stent c/b hypoxia requiring intubation,\n admitted with septic shock\n .\n Septic Shock: On admission was febrile, WBC > 30 with bandemia,\n tachycardic, increased RR. Now with GPC in blood. Unclear source, but\n must consider endocarditis, pulmonary, decubiti or GI source given\n recent instrumentation. Patient without abdominal pain or jaundice to\n suggest acute cholangitis.\n .\n Goals of Care: Will need to meet with family today to discuss goals of\n care\n currently no escalation of care.\n .\n f/u Sputum, Blood, Urine Cx, Cdiff x 3 - MRSA+ Bacteremia - unclear\n source, ? parapneumonic effusion, endocarditis, complication of biliary\n stent placement.\n 1. Will treat broadly with Vanc/Zosyn/PO Vanco for C. Diff -\n consider d/c zosyn today as empirirc.\n 2. Titrate CVP to 10, bolus as needed, repeat venous O2 sat.\n 3. Switched to phenylephrine to avoid beta adrtenergic effect of\n levophed and resulting tachycardia. Added vasopressin. Check Mixed\n Venous O2 sat. Adjust PRN. Might need dobutamine for inotrpoic\n support but would defer at this time.\n 4. Transfuse as needed for Hct>30 if MvO2 is < 70%.\n 5. Basal cortisol level wnl, no stim\n 6. Line re-positioned, f/u culture of tip.\n 7. TTE for endocarditis -> limited study.\n 8. Wound care consult.\n 9. Consider thoracentesis of effusion, imaging of abdomen.\n .\n Mental Status: With delerium on exam today. Likely to worsening\n renal failure, uremia, infection and other toxic derrangements.\n 1. Need to discuss goals of care with family.\n 2. Treat underlying infectious processes.\n 3. Hydrate, if oliguria persists may need CVVH/HD.\n .\n Hypoxia: Patient comfortable on 6L. He is willing to be intubated.\n Hypoxia likely a result of pleural effusions, sepsis, volume\n recuscitation.\n 1. ABG this AM 7.35/45/132\n 2. Continue nasal cannula at this point.\n 3. Daily CXR\n 4. Add nebulizer prn\n .\n Pleural effusions: may be malignant pleural effusions vs. chf vs. pna\n 1. ECHO, cycle enzymes, daily EKG\n 2. Empirically treat for HAP with Vanc/Zosyn\n d/c zosyn once\n more stable.\n .\n Acute Renal Failure: likely pre-renal from sepsis/hypotension. UOP has\n dropped off this morning, and now with rising Cr/lactate. Added\n vasopressin for second pressor and goal of improved renal perfusion.\n Goal MAP of 70 for today.\n 1. Follow Cr.\n 2. Urine Lytes from were Pre-Renal. Maintain\n adequate CVP goal 10.\n .\n Biliary stricture: Patient with recent admission for painless jaudince\n requiring biliary stent and sphincterotomy. Patient due to stent\n change in . Patient does not appear to have clinical signs of\n cholangitis at this point.\n 1. NPO for now\n 2. Trend LFTs\n 3. empirically treat with Zosyn for biliary organisms\n .\n CAD: MI in 's. Give high dose ASA. Enzymes negative x1 - and with\n negative set at OSH more than 12 hours apart. No need to cycle\n further.\n .\n PUMP: Hold antihypertensives, pressors as needed. Will repeat ECHO.\n Patient grossly volume overloaded, and may require aggressive diuresis\n once he's off pressors.\n .\n RHYTHM: known afib on coumadin. Hold coumadin. Rate much improved\n after switch to neosynephrine.\n .\n ARF: Cr up to 1.9 from basline.\n 1. urine lytes show FENA 0.2%, pre-renal vs ATN in setting\n hypotension\n .\n Nutrition: Consult for low albumin.\n 1. Likely TPN, discuss goals of care with family.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 08:29 PM\n Prophylaxis:\n DVT: elevated INR\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2155-05-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325294, "text": "Chief Complaint: septic shock, MRSA bacteremia\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 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent ERCP\n w/sphincterotomy and biliary stent for high grade stricture of CBD c/b\n shock, req pressors and intubation x48hrs peri-procedure (brushings\n were \"atypical\" and CA -9 very elevated, suspcious for pancreatic ca)\n transferred from OSH w/shock, leukocytosis (WBC 30K w/40% bands), and\n hypoxemia.\n 24 Hour Events:\n CHEST PAIN - At 09:45 AM\n BLOOD CULTURED - At 10:16 AM\n EKG - At 10:16 AM\n blood cx'd returned + MRSA\n excalating pressors- on neo then vasopressin added\n svo2 62%--improved to 77% after IVF\n family mtg yesterday to discuss goals of care\n ct chest--large R effusion with R collapse, partial L collapse with\n effusion\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Piperacillin - 12:28 AM\n Piperacillin/Tazobactam (Zosyn) - 05:54 AM\n Vancomycin - 06:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Tachypnea\n Flowsheet Data as of 11:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36\nC (96.8\n HR: 113 (107 - 123) bpm\n BP: 102/75(87) {77/53(64) - 110/75(88)} mmHg\n RR: 15 (13 - 39) insp/min\n SpO2: 77%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n Height: 67 Inch\n CVP: 14 (5 - 16)mmHg\n Total In:\n 2,872 mL\n 1,013 mL\n PO:\n TF:\n IVF:\n 2,872 mL\n 1,013 mL\n Blood products:\n Total out:\n 353 mL\n 73 mL\n Urine:\n 353 mL\n 73 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,519 mL\n 940 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 77% 6L NC and 100% FIO2 through shovel mask\n ABG: 7.28/34/86/14/-9\n PaO2 / FiO2: 86\n Physical Examination\n General Appearance: uncomfortable, lethargic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (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: (Breath Sounds: Diminished: throughout)\n transmitted BS at L apex, minimal air movement R upper zone\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\n Skin: cool LE\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): X 2, Movement: Not assessed, No(t) Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 12.9 g/dL\n 309 K/uL\n 167 mg/dL\n 2.4 mg/dL (1.9<--1.7)\n 14 mEq/L\n 5.7 mEq/L (hemolyzed)\n 62 mg/dL\n 104 mEq/L\n 134 mEq/L\n 41.1 %\n 23.1 K/uL\n [image002.jpg]\n 04:42 AM\n 10:04 AM\n 10:14 AM\n 12:12 PM\n 03:25 PM\n 03:30 PM\n 04:28 PM\n 09:16 PM\n 03:15 AM\n 04:36 AM\n WBC\n 23.1 (26)\n Hct\n 41.1\n Plt\n 309\n Cr\n 2.0\n 2.4\n TropT\n 0.01\n TCO2\n 26\n 24\n 23\n 22\n 23\n 18\n 17\n Glucose\n 167\n Other labs: PT / PTT / INR:32.6/38.0/3.4, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:63/168 increasing , Alk Phos / T\n Bili:342/2.1, Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %,\n Mono:2.1 %, Eos:0.2 %, Lactic Acid:3.3 mmol/L , Albumin:2.1 g/dL,\n LDH:406 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:7.2 mg/dL\n Imaging: CT chest\n no new cxr from this am\n Microbiology: bl MRSA\n stool neg c diff X 2\n urine lg neg\n OSH urine cx--GNR and GP cocci\n Assessment and Plan\n 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent ERCP\n w/sphincterotomy and biliary stent for high grade stricture of CBD c/b\n shock, req pressors and intubation x48hrs peri-procedure (brushings\n were \"atypical\" and CA -9 very elevated, suspcious for pancreatic ca)\n transferred from OSH w/shock, leukocytosis (WBC 30K w/40% bands), and\n hypoxemia.\n # Shock:\n Presumed sepsis w/ leukocytosis/bandemia and initial CvO2 75.\n MRSA bacteremia\n GP bacteremia- possible sources = bowel, skin (decubs). Also concerned\n for c diff given sig diarrhea and recent abx (though 1st cdiff neg) and\n ?pna.\n Continue pressores--Neo and vaso for MAP at least 65\n Bolus for CVP goal at least 10\n Cont broad spectum abx\n zosyn/IV vanco/po vanco.\n Chest CT\n if large effussions consider diagnistic but will need\n to be reversed from inr\n f/u cxs (incl from OSH), c diff.\n Checking TTE. Doubt tamponade given low CVP but need to consider in\n differential given effusion, malignancy, etc.\n # Hypoxemia: pleural effusions + pulm edema (BNP 10K at OSH) +\n probable pna,\n Not diuresing while requiring pressors.\n ?underlying pna; abx as above.\n Will not tolerate thoracentesis or bronch given tenous status\n Continue to address goals of care with family who are aware of p[oor\n prognosis and limited ability to mtolerate postentially ttherapuetic\n interventions\n Cont BDs\n Metabolic acidosis\nsepsis and renal failure,\n 3. Afib: rate better controlled on neo. Rx underlying issues and will\n try to add on bblocker when stable. Was on coumadin, holding given\n supratherapeutic INR.\n 4. Oliguric ARF: likely ATN /intravascualr depletion from sepsis. Urine\n lytes appear prerenal\n Renally dose meds.\n Trend u/o, cr\n Leukocytosis\ntrending down, continue broad coverage including c diff\n empiric awaiting final c diff cx\n 5. Sacral and b/l heel decubs: wound care\n 6. CAD: cont asa. EKG unchanged c/w b/l and cardiac enzymes negative.\n Holding BB, ACEI while req pressors.\n 7. FEN: npo given hypoxemia req sig suppl O2\n 8. Access: , \n ICU Care\n Nutrition:\n NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 08:29 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : 45 criticaly ill\n Total time spent: remains in ICU, family meeting to readdress goals of\n care\n" }, { "category": "Physician ", "chartdate": "2155-05-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325300, "text": "Chief Complaint: MRSA Bacteremia\n 24 Hour Events:\n CHEST PAIN - At 09:45 AM\n BLOOD CULTURED - At 10:16 AM\n EKG - At 10:16 AM\n -Family meeting held with daughters where the decision was made to\n make him DNR/DNI, with NO escalation of care (ie, no new invasive\n procedures/ or work-ups). Basically he was given a very poor prognosis\n with months to live from his gastroenterologist as he has pancreatic\n cancer. He does not know this diagnosis yet, only his daughters do, so\n they were very reasonable about goals of care. They will get back to\n us on possibly making him CMO, and would like input from his GI doctor\n Dr. , whom I emailed\n -Blood cultures came back 4/4 bottles with MRSA\n -We were unable to wean pressors due to low MAPs\n -We got a CT to better characterize his pleural effusion on CXR, and it\n showed a white out of the right lung with effusion, and a complete lung\n collapse with mucous plugging.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Piperacillin - 12:28 AM\n Piperacillin/Tazobactam (Zosyn) - 05:54 AM\n Vancomycin - 06:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Phenylephrine - 4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.6\nC (96\n HR: 114 (107 - 135) bpm\n BP: 93/66(77) {77/53(64) - 182/122(148)} mmHg\n RR: 16 (12 - 39) insp/min\n SpO2: 77%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n CVP: 7 (-3 - 17)mmHg\n Total In:\n 2,872 mL\n 895 mL\n PO:\n TF:\n IVF:\n 2,872 mL\n 895 mL\n Blood products:\n Total out:\n 353 mL\n 28 mL\n Urine:\n 353 mL\n 28 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,519 mL\n 867 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 77%\n ABG: 7.28/34/86/14/-9\n PaO2 / FiO2: 86\n Physical Examination\n General Appearance: Well nourished, Diaphoretic\n Eyes / Conjunctiva: PERRL\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:\n Diminished: right, and left base)\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, No(t) Tender:\n Extremities: Right: 2+, Left: 2+, 2+ pre-sacral edema\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x2, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 309 K/uL\n 12.9 g/dL\n 167 mg/dL\n 2.4 mg/dL\n 14 mEq/L\n 5.7 mEq/L\n 62 mg/dL\n 104 mEq/L\n 134 mEq/L\n 41.1 %\n 23.1 K/uL\n [image002.jpg]\n 04:42 AM\n 10:04 AM\n 10:14 AM\n 12:12 PM\n 03:25 PM\n 03:30 PM\n 04:28 PM\n 09:16 PM\n 03:15 AM\n 04:36 AM\n WBC\n 23.1\n Hct\n 41.1\n Plt\n 309\n Cr\n 2.0\n 2.4\n TropT\n 0.01\n TCO2\n 26\n 24\n 23\n 22\n 23\n 18\n 17\n Glucose\n 167\n Other labs: PT / PTT / INR:32.6/38.0/3.4, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:63/168, Alk Phos / T Bili:342/2.1,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:3.3 mmol/L, Albumin:2.1 g/dL, LDH:406 IU/L, Ca++:7.9\n mg/dL, Mg++:2.2 mg/dL, PO4:7.2 mg/dL\n Imaging: CT Chest\n IMPRESSION:\n 1. No evidence of pneumonia. Large right pleural effusion causing\n complete\n collapse of the right lung, which was previously partially aerated.\n Component\n of mucus plugging may be superimposed and continued radiographic\n follow-up\n needed. Moderate left pleural effusion causing complete atelectasis of\n the\n basilar left lower lobe segments. Right chest wall edema.\n 2. Atherosclerotic calcifications within the aorta and coronary\n circulation.\n 3. Interval increase in intra-abdominal ascites, with resolution of\n previously identified intrahepatic biliary dilatation and stable\n appearance to\n simple and hyperdense renal lesions better described on previously\n performed\n dedicated CT abdomen. Pancreatic ductal dilatation persists.\n Microbiology: VRE Swab: Positive\n Blood: MRSA from \n Assessment and Plan\n A/P: 82 M w/ recent admission for painless jaundice s/p ERCP with\n sphincterotomy and biliary stent c/b hypoxia requiring intubation,\n admitted with septic shock\n .\n Septic Shock: On admission was febrile, WBC > 30 with bandemia,\n tachycardic, increased RR. Now with GPC in blood. Unclear source, but\n must consider endocarditis, pulmonary, decubiti or GI source given\n recent instrumentation. Patient without abdominal pain or jaundice to\n suggest acute cholangitis.\n .\n f/u Sputum, Blood, Urine Cx, Cdiff x 3 - MRSA+ Bacteremia - unclear\n source, ? parapneumonic effusion, endocarditis, complication of biliary\n stent placement.\n 1. Will treat broadly with Vanc/Zosyn/PO Vanco for C. Diff -\n consider d/c zosyn today.\n 2. Titrate CVP to 10, bolus as needed\n 3. Switched to phenylephrine to avoid beta adrtenergic effect of\n levophed and resulting tachycardia. Added vasopressin this AM. Check\n Mixed Venous O2 sat. Adjust PRN. Might need dobutamine for inotrpoic\n support.\n 4. Transfuse as needed for Hct>30 if MvO2 is < 70%\n 5. Basal cortisol level wnl, no stim\n 6. Line re-positioned, f/u culture of tip although unlikely\n source as placed less than 36 hours ago at OSH.\n 7. TTE for endocarditis. If negative would get CT Scan\n chest/abdomen looking for abdomen. ?osteo underlying wounds.\n 8. Wound care consult.\n 9. CT Chest today for ? effusion/pneumonia.\n .\n Hypoxia: Patient comfortable on 6L. He is willing to be intubated.\n Hypoxia likely a result of pleural effusions, sepsis, volume\n recuscitation.\n 1. ABG this AM 7.35/45/132\n 2. Continue nasal cannula at this point.\n 3. Daily CXR\n 4. Add nebulizer prn\n .\n Pleural effusions: may be malignant pleural effusions vs. chf vs. pna\n 1. ECHO, cycle enzymes, daily EKG\n 2. Empirically treat for HAP with Vanc/Zosyn\n .\n Acute Renal Failure: likely pre-renal from sepsis/hypotension. UOP has\n dropped off this morning, and now with rising Cr/lactate. Added\n vasopressin for second pressor and goal of improved renal perfusion.\n Goal MAP of 70 for today.\n 1. Follow Cr.\n .\n Biliary stricture: Patient with recent admission for painless jaudince\n requiring biliary stent and sphincterotomy. Patient due to stent\n change in . Patient does not appear to have clinical signs of\n cholangitis at this point.\n 1. NPO for now\n 2. Trend LFTs\n 3. empirically treat with Zosyn for biliary organisms\n .\n CAD: MI in 's. Give high dose ASA. Enzymes negative x1 - and with\n negative set at OSH more than 12 hours apart. No need to cycle\n further.\n .\n PUMP: Hold antihypertensives, pressors as needed. Will repeat ECHO.\n Patient grossly volume overloaded, and may require aggressive diuresis\n once he's off pressors.\n .\n RHYTHM: known afib on coumadin. Hold coumadin. Rate much improved\n after switch to neosynephrine.\n .\n ARF: Cr up to 1.9 from basline.\n 1. urine lytes show FENA 0.2%, pre-renal vs ATN in setting\n hypotension\n .\n Nutrition: Consult this AM for low albumin.\n 1. Would restart regular diet if possible although with\n respiratory status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 08:29 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": "2155-05-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325277, "text": "82 yo ma adm at in for ERCP, placement of biliary stent w high\n suspicion for pancreatic CA. Treatment was c/b shock requiring\n intubation and pressors x 48 hrs. To Rehab on , developed\n increasing SOB, cough and edema. Transferred to OSH on . In EW\n Tmax 101.2, HR 140s, BP 72/60. Pt started on ceftriaxone, levoflox,\n clindamycin and levophed for hypotension. Transferred to on .\n Gm positive bacteremia, positive bld cx. Placed on contact\n precautions for ? MRSA and ? C-diff r/t mult loose stools.\n Levophed changed to Neo here due to persistent RAF to 140s.\n Vasopressin added.\n Pt made DNR/DNI on at family meeting.\n Pleural effusion, acute\n Assessment:\n LS on R almost absent. LUL clear but diminished. LLL diminished. CT\n scan on showed Rlung collapse due to large pleural effusion and\n mod pl effusion on L w atelectasis. Received on face tent at 70% but\n pO2 only 60. Unable tp get accurate O2 sat despite placing probes on\n different sites. RR usually 20s, but up to 30s-40s at times. Pt\n removes mask at times, but seems to do better on face tent and nc.\n Action:\n Added NC at 4L then up to 6L and increased fio2 of face tent to 100%.\n RT gave nebs and NTS pt x2 for copious amts thick purulent drainage.\n Pt only comfortable supine or turned on R side.\n Response:\n Pt improved following neb and NTS. RR back down to 20, pt able to\n sleep in short naps. Pt has difficulty with turning and nsg care.\n Takes awhile to recover breathing.\n Plan:\n Freq resp assessment, nebs, NTS when RR high and labored breathing.\n Shock, septic\n Assessment:\n Received on Neo and Vasopressin. ABP map maintained 65-70. CVP mostly\n , did dip down to 6-7 x1. MS continues confused. U/o continues to\n decrease ~ 5 mls/hr.\n Action:\n Pt given 500mls fld bolus x1 for cvp of 6.\n Response:\n Map maintained at 65-70 w pressors maxed and fld boluses.\n Plan:\n Monitor BP carefully, keep map >65. Fld per team.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o decreased to ~ 5mls q1hr, amber urine. Cr increased to 2.4. K\n elevated to 5.7.\n Action:\n Fld bolus of 500mls for cvp of 6.\n Response:\n CVP maintained >8. Diminished u/o.\n Plan:\n Continue to monitor renal function.\n Impaired Skin Integrity\n Assessment:\n Pressure ulcers bilat on heels and L elbow. Coccyx covered w allevyn\n dsg. See flow sheet for details. Pt denies pain when at rest,\n painful when moving.\n Action:\n Dsgs to lower extreme and L arm changed x2 due to weeping from\n anasarca. Allevyn dsg to coccyx changed due to soiling from stool.\n Response:\n Tol dsg changes w/o pain. Poor but stable skin condition.\n Plan:\n Continue current dsg changes. Skin care nurse consult today.\n" }, { "category": "Physician ", "chartdate": "2155-05-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325359, "text": "Chief Complaint: MRSA Bacteremia\n 24 Hour Events:\n - Stably sick, likely CMO in AM.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 12:28 AM\n Vancomycin - 06:19 PM\n Piperacillin/Tazobactam (Zosyn) - 05:49 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Phenylephrine - 1.4 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 05:48 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 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.8\nC (96.5\n HR: 107 (104 - 123) bpm\n BP: 93/69(80) {87/65(75) - 124/87(284)} mmHg\n RR: 11 (11 - 25) insp/min\n SpO2: 75%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n Height: 67 Inch\n CVP: 19 (8 - 20)mmHg\n Total In:\n 1,661 mL\n 193 mL\n PO:\n TF:\n IVF:\n 1,661 mL\n 193 mL\n Blood products:\n Total out:\n 208 mL\n 90 mL\n Urine:\n 208 mL\n 90 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,453 mL\n 103 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 75%\n ABG: 7.32/36/99./22/-6\n PaO2 / FiO2: 99\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\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: Wheezes :\n Left lung field)\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended\n Extremities: Right: 2+, Left: 2+, +pre-sacral edema\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Tactile stimuli, Movement: Not assessed, Tone: Not assessed,\n arousable easily with sternal rub, but fades off to sleep quite quickly\n Labs / Radiology\n 240 K/uL\n 12.0 g/dL\n 160 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 5.3 mEq/L\n 72 mg/dL\n 105 mEq/L\n 135 mEq/L\n 38.2 %\n 20.4 K/uL\n [image002.jpg]\n 03:25 PM\n 03:30 PM\n 04:28 PM\n 09:16 PM\n 03:15 AM\n 04:36 AM\n 01:04 PM\n 02:56 PM\n 04:11 AM\n 05:19 AM\n WBC\n 23.1\n 20.4\n Hct\n 41.1\n 38.2\n Plt\n 309\n 240\n Cr\n 2.0\n 2.4\n 2.6\n 2.8\n TCO2\n 22\n 23\n 18\n 17\n 19\n 19\n Glucose\n 167\n 168\n 160\n Other labs: PT / PTT / INR:32.6/38.0/3.4, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:81/141, Alk Phos / T Bili:323/2.0,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:2.1 mmol/L, Albumin:1.9 g/dL, LDH:221 IU/L, Ca++:7.5\n mg/dL, Mg++:2.1 mg/dL, PO4:5.9 mg/dL\n Imaging: TTE: Suboptimal image quality. The left atrium is mildly\n dilated. The estimated right atrial pressure is 0-10mmHg. LV systolic\n function appears depressed. There is no aortic valve stenosis. There is\n a trivial/physiologic pericardial effusion. Cannot determine valvular\n function or exclude valvular vegetations on the basis of this study.\n ---------\n Radiology Report CT CHEST W/O CONTRAST Study Date of 2:20 PM\n , SCHED\n CT CHEST W/O CONTRAST Clip # \n Reason: r/o underlying PNA\n -----------------------------------------------------------------------\n ---------\n Final Report\n HISTORY: Bilateral pleural effusions. Evaluate for underlying\n pneumonia.\n TECHNIQUE: MDCT-acquired axial images were obtained through the chest\n without\n intravenous contrast. Contrast was withheld due to elevated BUN and\n creatinine levels. 5-mm, 1.25-mm, and coronal reformations were\n evaluated.\n CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST\n Comparison is made to multiple prior radiograph and prior CTA dated\n .\n FINDINGS: The entire right lung is collapsed, and there is a large\n right\n simple pleural effusion occupying the entire right hemithorax, with\n fluid\n extension into the lateral chest wall. The left upper lobe, lingula,\n and\n superior segment of the left lower lobe remain aerated, with the\n basilar\n segments displaying atelectasis due to compression from an adjacent\n moderate\n simple left pleural effusion. The aerated lung appears clear, and\n without\n evidence of pneumonia. No pathologically enlarged central or axillary\n lymph\n nodes are identified. Secretions are noted within the central airway.\n There is\n a small pericardial effusion and atherosclerotic calcification noted\n within\n the right and left coronary circulation and aortic root and valve. The\n main\n pulmonary artery and right pulmonary artery are dilated, measuring\n greater\n than 3 cm, likely related to elevated pressures from the large\n effusions and\n atelectasis. Right IJ catheter terminates in the mid SVC.\n This examination was not tailored for subdiaphragmatic evaluation. The\n imaged\n portion of the upper abdomen displays placement of a biliary stent with\n significant improvement/resolution of intrahepatic biliary ductal\n dilatation,\n but persistent pancreatic ductal dilatation and stable appearance to\n duodenal\n diverticulum, large simple exophytic left upper pole renal cyst, and\n hyperdense right interpolar 2 cm renal cyst. The degree of ascites\n within the\n abdomen is slightly increased from exam.\n BONE WINDOWS: Degenerative changes of the glenohumeral joint are noted\n bilaterally. There are multilevel degenerative changes within the\n spine. No\n malignant-appearing osseous lesions are identified.\n CT Chest Impression:\n .\n 1. No evidence of pneumonia. Large right pleural effusion causing\n complete\n collapse of the right lung, which was previously partially aerated.\n Component\n of mucus plugging may be superimposed and continued radiographic\n follow-up\n needed. Moderate left pleural effusion causing complete atelectasis of\n the\n basilar left lower lobe segments. Right chest wall edema.\n .\n 2. Atherosclerotic calcifications within the aorta and coronary\n circulation.\n .\n 3. Interval increase in intra-abdominal ascites, with resolution of\n previously identified intrahepatic biliary dilatation and stable\n appearance to\n simple and hyperdense renal lesions better described on previously\n performed\n dedicated CT abdomen. Pancreatic ductal dilatation persists.\n Microbiology: BCx: + MRSA\n BCx: GPC+\n UCx: Negative\n Assessment and Plan\n A/P: 82 M w/ recent admission for painless jaundice s/p ERCP with\n sphincterotomy and biliary stent c/b hypoxia requiring intubation,\n admitted with septic shock\n .\n Septic Shock: On admission was febrile, WBC > 30 with bandemia,\n tachycardic, increased RR. Now with GPC in blood. Unclear source, but\n must consider endocarditis, pulmonary, decubiti or GI source given\n recent instrumentation. Patient without abdominal pain or jaundice to\n suggest acute cholangitis.\n .\n Goals of Care: Will need to meet with family today to discuss goals of\n care\n currently no escalation of care.\n .\n f/u Sputum, Blood, Urine Cx, Cdiff x 3 - MRSA+ Bacteremia - unclear\n source, ? parapneumonic effusion, endocarditis, complication of biliary\n stent placement.\n 1. Will treat broadly with Vanc/Zosyn/PO Vanco for C. Diff -\n consider d/c zosyn today as empirirc.\n 2. Titrate CVP to 10, bolus as needed, repeat venous O2 sat.\n 3. Switched to phenylephrine to avoid beta adrtenergic effect of\n levophed and resulting tachycardia. Added vasopressin. Check Mixed\n Venous O2 sat. Adjust PRN. Might need dobutamine for inotrpoic\n support but would defer at this time.\n 4. Transfuse as needed for Hct>30 if MvO2 is < 70%.\n 5. Basal cortisol level wnl, no stim\n 6. Line re-positioned, f/u culture of tip.\n 7. TTE for endocarditis -> limited study.\n 8. Wound care consult.\n 9. Consider thoracentesis of effusion, imaging of abdomen.\n .\n Mental Status: With delerium on exam today. Likely to worsening\n renal failure, uremia, infection and other toxic derrangements.\n 1. Need to discuss goals of care with family.\n 2. Treat underlying infectious processes.\n 3. Hydrate, if oliguria persists may need CVVH/HD.\n .\n Hypoxia: Patient comfortable on 6L. He is willing to be intubated.\n Hypoxia likely a result of pleural effusions, sepsis, volume\n recuscitation.\n 1. ABG this AM 7.35/45/132\n 2. Continue nasal cannula at this point.\n 3. Daily CXR\n 4. Add nebulizer prn\n .\n Pleural effusions: may be malignant pleural effusions vs. chf vs. pna\n 1. ECHO, cycle enzymes, daily EKG\n 2. Empirically treat for HAP with Vanc/Zosyn\n d/c zosyn once\n more stable.\n .\n Acute Renal Failure: likely pre-renal from sepsis/hypotension. UOP has\n dropped off this morning, and now with rising Cr/lactate. Added\n vasopressin for second pressor and goal of improved renal perfusion.\n Goal MAP of 70 for today.\n 1. Follow Cr.\n 2. Urine Lytes from were Pre-Renal. Maintain\n adequate CVP goal 10.\n .\n Biliary stricture: Patient with recent admission for painless jaudince\n requiring biliary stent and sphincterotomy. Patient due to stent\n change in . Patient does not appear to have clinical signs of\n cholangitis at this point.\n 1. NPO for now\n 2. Trend LFTs\n 3. empirically treat with Zosyn for biliary organisms\n .\n CAD: MI in 's. Give high dose ASA. Enzymes negative x1 - and with\n negative set at OSH more than 12 hours apart. No need to cycle\n further.\n .\n PUMP: Hold antihypertensives, pressors as needed. Will repeat ECHO.\n Patient grossly volume overloaded, and may require aggressive diuresis\n once he's off pressors.\n .\n RHYTHM: known afib on coumadin. Hold coumadin. Rate much improved\n after switch to neosynephrine.\n .\n ARF: Cr up to 1.9 from basline.\n 1. urine lytes show FENA 0.2%, pre-renal vs ATN in setting\n hypotension\n .\n Nutrition: Consult for low albumin.\n 1. Likely TPN, discuss goals of care with family.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 08:29 PM\n Prophylaxis:\n DVT: elevated INR\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2155-05-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325254, "text": "82 yo ma adm at in for ERCP, placement of biliary stent w high\n suspicion for pancreatic CA. Treatment was c/b shock requiring\n intubation and pressors x 48 hrs. To Rehab on , developed\n increasing SOB, cough and edema. Transferred to OSH on . In EW\n Tmax 101.2, HR 140s, BP 72/60. Pt started on ceftriaxone, levoflox,\n clindamycin and levophed for hypotension. Transferred to on .\n Gm positive bacteremia, positive bld cx. Placed on contact\n precautions for ? MRSA and ? C-diff r/t mult loose stools.\n Levophed changed to Neo here due to persistent RAF to 140s.\n Pleural effusion, acute\n Assessment:\n LS on R almost absent. LUL clear but diminished. LLL diminished. CT\n scan on showed Rlung collapse due to large pleural effusion and\n mod pl effusion on L w atelectasis. Received on face tent at 70% but\n pO2 only 60. Unable tpo get accurate O2 sat despite placing probes on\n different sites. Earlobe\n Action:\n Response:\n Plan:\n Shock, septic\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 Pressure ulcers bilat on heels and L elbow. Coccyx covered w allevyn\n dsg. See flow sheet for details. Pt denies pain when at rest,\n painful when moving.\n Action:\n Dsgs to lower extreme and L arm changed x2 due to weeping from\n anasarca.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2155-05-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325348, "text": "82 y.o. man w/afib on coumadin, CAD s/p MI, s/p recent ERCP\n w/sphincterotomy and biliary stent for high grade CBD stricture c/b\n shock and intubation x 48hrs peri-procedure (brushings were \"atypical\"\n and CA -9 very elevated, suspcious for pancreatic ca) transferred\n from OSH w/shock, leukocytosis (WBC 30K w/40% bands), and hypoxemia.\n Pt bld cx\nd found to have MRSA bacteremia. On pressors (neo and\n vasopressin). Chest ct revealed large r effusion with r collapse,\n partial l collapse with effusion. Pt remains a DNR/DNI without\n escalation of aggressive interventions.\n Renal failure, acute (Acute renal failure, ARF\n Assessment:\n Oliguric averaging 15cc/jhr. Generalized anasarca. Rising creatinine\n Action:\n No further treatment (ie: no dialysis) at this time.\n Response:\n Remains oliguric, worsening creatinine.\n Plan:\n Continue to monitor.\n Impaired Skin Integrity\n Assessment:\n Weeping continues from extremities. Cool extremities.\n Action:\n Coccyx wound intact. Barrier cream applied liberally to extremities\n with repositioning with softsorb on top. Waffles over legs. Remains on\n kinair bed. L lower arm now with open skin tear bleeding slightly. Area\n cleansed with ns and 4x4 applied wrapped in kerlex.\n Response:\n Continues to weep from all extremities now with open skin tear on ll\n arm.\n Plan:\n Continue with wound care as directed.\n Shock, septic\n Assessment:\n Bp remains stable with neo slowly titrated down to keep map >65.\n remains on vasopressin. Leukocytosis improving. Afebrile.\n Action:\n Able to titrate neo down to lower rate, remains on vasopressin. Remains\n on broad spectrum abx.\n Response:\n Bp remains stable. Afebrile.\n Plan:\n Wean neo as tolerated to keep map >65, monitor temp, abx.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt moaning with repositioning and at times at rest. Appears extremely\n uncomfortable with repositioning. Alert to self only. Refusing to take\n po vanco stating he is\nsick of all of this\n and doesn\nt wish to take\n the po meds. Unable to tell me why he\ns here. Agitated at times pulling\n off mask, almost pulled out aline.\n Action:\n Settles after given 2mg iv morphine after several minutes. Md aware pt\n more confused, refusing po vanco and pulling at lines requiring\n bilateral wrist restraints.\n Response:\n Pain relieved with iv morphine with stable vitals.\n Plan:\n Premedicate with position changes and dressing changes. Medicated prn\n comfort.\n" }, { "category": "Physician ", "chartdate": "2155-05-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325350, "text": "Chief Complaint: MRSA Bacteremia\n 24 Hour Events:\n - Stably sick, likely CMO in AM.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 12:28 AM\n Vancomycin - 06:19 PM\n Piperacillin/Tazobactam (Zosyn) - 05:49 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Phenylephrine - 1.4 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 05:48 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 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.8\nC (96.5\n HR: 107 (104 - 123) bpm\n BP: 93/69(80) {87/65(75) - 124/87(284)} mmHg\n RR: 11 (11 - 25) insp/min\n SpO2: 75%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n Height: 67 Inch\n CVP: 19 (8 - 20)mmHg\n Total In:\n 1,661 mL\n 193 mL\n PO:\n TF:\n IVF:\n 1,661 mL\n 193 mL\n Blood products:\n Total out:\n 208 mL\n 90 mL\n Urine:\n 208 mL\n 90 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,453 mL\n 103 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 75%\n ABG: 7.32/36/99./22/-6\n PaO2 / FiO2: 99\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\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: Wheezes :\n Left lung field)\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended\n Extremities: Right: 2+, Left: 2+, +pre-sacral edema\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Tactile stimuli, Movement: Not assessed, Tone: Not assessed,\n arousable easily with sternal rub, but fades off to sleep quite quickly\n Labs / Radiology\n 240 K/uL\n 12.0 g/dL\n 160 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 5.3 mEq/L\n 72 mg/dL\n 105 mEq/L\n 135 mEq/L\n 38.2 %\n 20.4 K/uL\n [image002.jpg]\n 03:25 PM\n 03:30 PM\n 04:28 PM\n 09:16 PM\n 03:15 AM\n 04:36 AM\n 01:04 PM\n 02:56 PM\n 04:11 AM\n 05:19 AM\n WBC\n 23.1\n 20.4\n Hct\n 41.1\n 38.2\n Plt\n 309\n 240\n Cr\n 2.0\n 2.4\n 2.6\n 2.8\n TCO2\n 22\n 23\n 18\n 17\n 19\n 19\n Glucose\n 167\n 168\n 160\n Other labs: PT / PTT / INR:32.6/38.0/3.4, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:81/141, Alk Phos / T Bili:323/2.0,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:2.1 mmol/L, Albumin:1.9 g/dL, LDH:221 IU/L, Ca++:7.5\n mg/dL, Mg++:2.1 mg/dL, PO4:5.9 mg/dL\n Imaging: TTE: Suboptimal image quality. The left atrium is mildly\n dilated. The estimated right atrial pressure is 0-10mmHg. LV systolic\n function appears depressed. There is no aortic valve stenosis. There is\n a trivial/physiologic pericardial effusion. Cannot determine valvular\n function or exclude valvular vegetations on the basis of this study.\n ---------\n Radiology Report CT CHEST W/O CONTRAST Study Date of 2:20 PM\n , SCHED\n CT CHEST W/O CONTRAST Clip # \n Reason: r/o underlying PNA\n -----------------------------------------------------------------------\n ---------\n Final Report\n HISTORY: Bilateral pleural effusions. Evaluate for underlying\n pneumonia.\n TECHNIQUE: MDCT-acquired axial images were obtained through the chest\n without\n intravenous contrast. Contrast was withheld due to elevated BUN and\n creatinine levels. 5-mm, 1.25-mm, and coronal reformations were\n evaluated.\n CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST\n Comparison is made to multiple prior radiograph and prior CTA dated\n .\n FINDINGS: The entire right lung is collapsed, and there is a large\n right\n simple pleural effusion occupying the entire right hemithorax, with\n fluid\n extension into the lateral chest wall. The left upper lobe, lingula,\n and\n superior segment of the left lower lobe remain aerated, with the\n basilar\n segments displaying atelectasis due to compression from an adjacent\n moderate\n simple left pleural effusion. The aerated lung appears clear, and\n without\n evidence of pneumonia. No pathologically enlarged central or axillary\n lymph\n nodes are identified. Secretions are noted within the central airway.\n There is\n a small pericardial effusion and atherosclerotic calcification noted\n within\n the right and left coronary circulation and aortic root and valve. The\n main\n pulmonary artery and right pulmonary artery are dilated, measuring\n greater\n than 3 cm, likely related to elevated pressures from the large\n effusions and\n atelectasis. Right IJ catheter terminates in the mid SVC.\n This examination was not tailored for subdiaphragmatic evaluation. The\n imaged\n portion of the upper abdomen displays placement of a biliary stent with\n significant improvement/resolution of intrahepatic biliary ductal\n dilatation,\n but persistent pancreatic ductal dilatation and stable appearance to\n duodenal\n diverticulum, large simple exophytic left upper pole renal cyst, and\n hyperdense right interpolar 2 cm renal cyst. The degree of ascites\n within the\n abdomen is slightly increased from exam.\n BONE WINDOWS: Degenerative changes of the glenohumeral joint are noted\n bilaterally. There are multilevel degenerative changes within the\n spine. No\n malignant-appearing osseous lesions are identified.\n CT Chest Impression:\n .\n 1. No evidence of pneumonia. Large right pleural effusion causing\n complete\n collapse of the right lung, which was previously partially aerated.\n Component\n of mucus plugging may be superimposed and continued radiographic\n follow-up\n needed. Moderate left pleural effusion causing complete atelectasis of\n the\n basilar left lower lobe segments. Right chest wall edema.\n .\n 2. Atherosclerotic calcifications within the aorta and coronary\n circulation.\n .\n 3. Interval increase in intra-abdominal ascites, with resolution of\n previously identified intrahepatic biliary dilatation and stable\n appearance to\n simple and hyperdense renal lesions better described on previously\n performed\n dedicated CT abdomen. Pancreatic ductal dilatation persists.\n Microbiology: BCx: + MRSA\n BCx: GPC+\n UCx: Negative\n Assessment and Plan\n A/P: 82 M w/ recent admission for painless jaundice s/p ERCP with\n sphincterotomy and biliary stent c/b hypoxia requiring intubation,\n admitted with septic shock\n .\n Septic Shock: On admission was febrile, WBC > 30 with bandemia,\n tachycardic, increased RR. Now with GPC in blood. Unclear source, but\n must consider endocarditis, pulmonary, decubiti or GI source given\n recent instrumentation. Patient without abdominal pain or jaundice to\n suggest acute cholangitis.\n .\n Goals of Care: Will need to meet with family today to discuss goals of\n care\n currently no escalation of care.\n .\n f/u Sputum, Blood, Urine Cx, Cdiff x 3 - MRSA+ Bacteremia - unclear\n source, ? parapneumonic effusion, endocarditis, complication of biliary\n stent placement.\n 1. Will treat broadly with Vanc/Zosyn/PO Vanco for C. Diff -\n consider d/c zosyn today as empirirc.\n 2. Titrate CVP to 10, bolus as needed\n 3. Switched to phenylephrine to avoid beta adrtenergic effect of\n levophed and resulting tachycardia. Added vasopressin this AM. Check\n Mixed Venous O2 sat. Adjust PRN. Might need dobutamine for inotrpoic\n support but would defer at this time.\n 4. Transfuse as needed for Hct>30 if MvO2 is < 70%.\n 5. Basal cortisol level wnl, no stim\n 6. Line re-positioned, f/u culture of tip.\n 7. TTE for endocarditis -> limited study.\n 8. Wound care consult.\n 9. Consider thoracentesis of effusion, imaging of abdomen.\n .\n Hypoxia: Patient comfortable on 6L. He is willing to be intubated.\n Hypoxia likely a result of pleural effusions, sepsis, volume\n recuscitation.\n 1. ABG this AM 7.35/45/132\n 2. Continue nasal cannula at this point.\n 3. Daily CXR\n 4. Add nebulizer prn\n .\n Pleural effusions: may be malignant pleural effusions vs. chf vs. pna\n 1. ECHO, cycle enzymes, daily EKG\n 2. Empirically treat for HAP with Vanc/Zosyn\n d/c zosyn once\n more stable.\n .\n Acute Renal Failure: likely pre-renal from sepsis/hypotension. UOP has\n dropped off this morning, and now with rising Cr/lactate. Added\n vasopressin for second pressor and goal of improved renal perfusion.\n Goal MAP of 70 for today.\n 1. Follow Cr.\n .\n Biliary stricture: Patient with recent admission for painless jaudince\n requiring biliary stent and sphincterotomy. Patient due to stent\n change in . Patient does not appear to have clinical signs of\n cholangitis at this point.\n 1. NPO for now\n 2. Trend LFTs\n 3. empirically treat with Zosyn for biliary organisms\n .\n CAD: MI in 's. Give high dose ASA. Enzymes negative x1 - and with\n negative set at OSH more than 12 hours apart. No need to cycle\n further.\n .\n PUMP: Hold antihypertensives, pressors as needed. Will repeat ECHO.\n Patient grossly volume overloaded, and may require aggressive diuresis\n once he's off pressors.\n .\n RHYTHM: known afib on coumadin. Hold coumadin. Rate much improved\n after switch to neosynephrine.\n .\n ARF: Cr up to 1.9 from basline.\n 1. urine lytes show FENA 0.2%, pre-renal vs ATN in setting\n hypotension\n .\n Nutrition: Consult for low albumin.\n 1. Would restart regular diet if possible although with\n respiratory status. Discuss goals of care with family.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 08:29 PM\n Prophylaxis:\n DVT: elevated INR\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2155-05-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325428, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt with comfort measures.daughters stayed with him in the early shift.\n Action:\n On morphine gtt 2 mg /hr\n Response:\n Pt comfortable.\n Plan:\n Continue with morphine gtt. Titrate as needed.\n" }, { "category": "Physician ", "chartdate": "2155-05-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325127, "text": "Chief Complaint: shock, respiratory distress\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 82 yo M w/afib on coumadin, hypothyroidism, and CAD s/p MI s/p recent\n ERCP w/sphincterotomy and biliary stent for high grade stricture of CBD\n c/b shock, req pressors and intubation x48hrs peri-procedure (brushings\n were \"atypical\" and CA -9 very elevated, suspcious for pancreatic\n ca), now transferred from OSH w/shock, hypoxemia, and leukocytosis (WBC\n 30K w/40% bands). Likely septic shock, though may be cardiogenic\n component w/BNP 10K.\n 24 Hour Events:\n EKG - At 05:58 PM\n MULTI LUMEN - START 06:25 PM\n right subclavian line inserted \n BLOOD CULTURED - At 07:24 PM\n URINE CULTURE - At 07:24 PM\n RECTAL SWAB - At 07:24 PM\n BLOOD CULTURED - At 07:41 PM\n Tachycardic on levophed so changed to neo w/improvement in HR and BP.\n A-line attempted x3 w/o success.\n CvO2 75\n OSH blood cxs-\n bottles w/GPC, spec pending\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:40 PM\n Metronidazole - 04:00 AM\n Piperacillin - 05:00 AM\n Infusions:\n Phenylephrine - 3.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Asa 325\n Atrovent q6hrs\n Changes to medical and family history: unchanged c/w prior\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 111 (101 - 134) bpm\n BP: 93/67(74) {78/26(40) - 119/72(78)} mmHg\n RR: 19 (13 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (7 - 20)mmHg\n Total In:\n 1,653 mL\n 1,676 mL\n PO:\n TF:\n IVF:\n 1,653 mL\n 1,676 mL\n Blood products:\n Total out:\n 280 mL\n 350 mL\n Urine:\n 280 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,373 mL\n 1,326 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: 7.36/46/92\n PaO2 / FiO2: 184\n Physical Examination\n General: NAD\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: irregularly irregular\n Peripheral Vascular: DP pulses via doppler\n Respiratory / Chest: clear anteriorly b/l, diminsed laterally b/l\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: 2+ b/l, weeping skin, no clubbing/cyanosis\n Skin: No rash/jaundice, +sacral decub and decubs on b/l heels\n Neurologic: Attentive, Follows simple commands, answering questions\n appropriately\n Labs / Radiology\n 12.6 g/dL\n 286 K/uL\n 119 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 5.1 mEq/L\n 49 mg/dL\n 103 mEq/L\n 137 mEq/L\n 39.3 %\n 30.6 K/uL\n [image002.jpg]\n 06:37 PM\n 09:47 PM\n 12:25 AM\n 04:00 AM\n 04:59 AM\n WBC\n 34.8\n Hct\n 40.9\n 39.3\n Plt\n 295\n 286\n Cr\n 1.7\n 1.7\n TCO2\n 26\n 27\n 27\n Glucose\n 83\n 119\n Other labs: PT / PTT / INR:26.5/33.8/2.6, ALT / AST:36/61, Alk Phos / T\n Bili:313/1.7, Differential-Neuts:86.0 %, Band:10.0 %, Lymph:0.0 %,\n Mono:4.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L, Albumin:2.0 g/dL,\n LDH:216 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Random cortisol 35.8\n Portable CXR\n b/l effusions (R>>L), R subclavian CVL deep\n Assessment and Plan\n 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent ERCP\n w/sphincterotomy and biliary stent for high grade stricture of CBD c/b\n shock, req pressors and intubation x48hrs peri-procedure (brushings\n were \"atypical\" and CA -9 very elevated, suspcious for pancreatic ca)\n transferred from OSH w/shock, leukocytosis (WBC 30K w/40% bands), and\n hypoxemia.\n 1. Shock: Presumed sepsis w/leukocytosis/bandemia and CvO2 75.\n Infectious sources- positive blood cxs from OSH, also concerned for c\n diff given sig diarrhea and recent abx. Other possibilities incl pna\n and billiary source (though LFTs improved c/w prior and abd exam not\n concerning).\n CVP goal ~10, neo for MAP at least 65.\n Broad spectum abx\n zosyn/IV vanco (change IV flagyl to po vanco for c\n diff given high risk).\n f/u cxs (incl from OSH), c diff. Consider steroids empirically if\n increasing pressor requirements. At risk of adrenal dysfunction.\n Checking TTE. Doubt tamponade given low CVP but need to consider in\n differential given effusion, malignancy, etc.\n 2. Hypoxemia: likely pleural effusions + pulm edema. BNP 10K at\n OSH, though some of this may be related to pt\ns afib and .\n Not diuresing while requiring pressors. ?underlying pna; abx as above.\n 3. Afib: rate better controlled on neo. Rx underlying issues and will\n try to add on bblocker when stable. Restart heparin when no upcoming\n procedures.\n 4. ARF: FENa 0.2 c/w pre-renal etiology (though may be an ATN\n component). Checking urine sediment. Trend Cr and uop. Renally dose\n meds.\n 5. Sacral and b/l heel decubs: wound care consult\n 6. CAD: cont asa. EKG unchanged c/w b/l and cardiac enzymes negative.\n Holding BB, ACEI while req pressors.\n 7. FEN: npo for now given hypoxemia req sig suppl O2\n 8. Access: resite CVL (placed at OSH and also too deep), re-attempt\n a-line\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 06:25 PM\n Prophylaxis:\n DVT: SQ UF Heparin once INR drifts below 2\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 min, critically ill\n" }, { "category": "Nursing", "chartdate": "2155-05-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325129, "text": "This is an 82 yr male recently admitted for new onset jaundice w/\n pancreatic dilation. At that time, pt underwent biliary stent placement\n and sphincterotemy and there was a high suspicion for pancreatic CA\n though no bx was done at that time. Treatment was c/b shock requiring\n intubation and pressors X 48hr MD notes. Pt was D/C from to\n Rehab on . At rehab pt developed increasing SOB, cough and edema.\n Pt was transferred to OSH. In EW T max 101.2, HR 140\ns, BP 72/60. Pt\n was started on ceftriaxone, levofloxacin, and clindamycin.\n Additionally, pt was started on levophed for hypotension. Pt was\n transferred to on for further management.\n Shock, septic\n Assessment:\n Pt presented to OSH w/ tmax 101.2, hypotensive as above. 3 / 4 blood\n cultures at OSH positive for gram positive cocci. Mixed venous O2 75\n MD. Pt remains pressor dependent. CVP 9-12 t/o most of shift,\n though dropped to 4 ~ 1330. Pt being r/o\nd for c-diff. ABG 7.36/46/92\n w/ am labs. Pt continuous w/ nearly continuous loose, non-productive\n cough. Received pt w/ L subclavian triple lumen line.\n Action:\n Monitoring hemodynamic status closely. Team unable to obtain a-line\n access overnoc. Cycling NBP q5min. Titrating phenylepherine to maintain\n MAP >65 MD. Flagyl has been changed to PO vanc. Pt also continues\n on IV vanc and zyosyn. Stool sample sent for C-diff cx previous shift\n per report. Urine specimen sent for legionella culture as ordered. Pt\n given NS bolus 500ml ~1330 w/ drop in CVP. Contact precautions\n initiated. Pt continues on 50% FiO2 via cool neb. RT to obtain sputum\n cx via induction as ordered. Orders obtained for mucinex.\n Response:\n Unable to make significant progress weaning phenylepherine. Pt\n hypotensive w/ SBP to 70\ns w/ doses below 3.2mcg/kg/min. BP remains\n stable on current dose\n see flow sheet.. CVP increased to 8 s/p NS\n bolus as above. Pt remains afebrile t/o shift. Pt continuous w/\n frequent loose brown stools. SpO2 remains >95% t/o shift. Pt denies any\n significant changes in SOB this shift, remains free of diaphoresis and\n remains free of s/s distress.\n Plan:\n Continue to monitor hemodynamics closely. Continue abx as ordered.\n Titrate phenylepherine to maintain MAP > 65 as ordered and wean as\n able. Monitor respiratory status and wean FiO2 as able. Continue\n mucinex as ordered.\n Tachycardia, Other\n Assessment:\n Hr to 140\ns at OSH\n AF w/ RVR. Previous shift norepinepherine was\n changed to phenylepherine and pt was given lopressor IV as ordered per\n report.\n Action:\n Continuous ECG monitoring per ICU protocol. Pt continuous on\n phenylepherine as above. Monitoring for s/s cardiac ischemia.\n Response:\n Pt c/o substernal, non-radiating chest\npressure\n at start of\n shift. Pt reported discomfort somewhat worse w/ deep inspiration. No\n acute changes in VS noted, pt remained free of diaphoresis, remained\n calm and cooperative and denied any acute increasing SOB. 12 Lead EKG\n obtained and reviewed by team who report no significant changes. HR has\n remained <130 t/o shift, and has overall remained 90\ns to low 100\n see flowsheet. Rhythm remains afib w/ rare PVC. Pt has denied any\n further episodes of chest pain, pressure or discomfort and remains free\n of distress t/o shift.\n Plan:\n Continue ECG monitoring per protocol. Continue to monitor for s/s\n cardiac ischemia.\n Impaired Skin Integrity\n Assessment:\n Pt w/ sacral decube per report. Area covered w/ allevyn dsng that has\n remained CDI t/o shift. Pt w/ several small stage II-III decubitus\n ulcers to R heal and R lateral calf w/ yellow wound base and red\n surrounding tissue. L heal and L calf w/ small decubitus ulcers w/\n yellow wound base and red surrounding tissue. R elbow red w/ small area\n of superficial peeling skin. Pt continues w/ anasarca, and RUE, and BLE\n continue to weep copious amounts of serous fluid requiring frequent\n dsng changes\n see flow sheet.\n Action:\n Pt on kinair bed w/ frequent repositioning. Soft sorb dsng w/ cling\n wrap applied to RUE and BLE. Waffle boots placed to BLE at start of\n shift to decrease pressure to heals. Orders obtained to D/C compression\n boots, and team has decided against heparin given INR of 2.6. Providing\n frequent skin care and dressing changes to minimize moisture and\n facilitate wound healing.\n Response:\n Extremities continue to ooze copious amounts of serious drainage. Pt\n tolerating dsng changes, skin care and positioning well.\n Plan:\n Continue current measures to facilitate wound healing.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2155-05-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325491, "text": "Pt continued on MSO4 gtt throughout the day with HR consistently 90-105\n with occasional PVC. Unable to obtain BP and temp 93 axillary. Pt\n appeared to be comfortable except when moved or turned. in\n visiting for several hours. At 1530 pt turned to side and\n repositioned\n appeared to be comfortable. At 1545 HR decreased to 0\n and RR to 0. Declared by Dr. . Last rites given by priest.\n given information required.\n" }, { "category": "Nursing", "chartdate": "2155-05-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325492, "text": "Pt continued on MSO4 gtt throughout the day with HR consistently 90-105\n with occasional PVC. Unable to obtain BP and temp 93 axillary. Pt\n appeared to be comfortable except when moved or turned. in\n visiting for several hours. At 1530 pt turned to side and\n repositioned\n appeared to be comfortable. At 1545 HR decreased to 0\n and RR to 0. Declared by Dr. . Last rites given by priest.\n given information required.\n" }, { "category": "Nursing", "chartdate": "2155-05-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325493, "text": "Pt continued on MSO4 gtt throughout the day with HR consistently 90-105\n with occasional PVC. Unable to obtain BP and temp 93 axillary. Pt\n appeared to be comfortable except when moved or turned. in\n visiting for several hours. At 1530 pt turned to side and\n repositioned\n appeared to be comfortable. At 1545 HR decreased to 0\n and RR to 0. Declared by Dr. . Last rites given by priest.\n given information required.\n ------ Protected Section------\n ------ Protected Section Error Entered By: , RN\n on: 16:26 ------\n" }, { "category": "Nursing", "chartdate": "2155-05-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325338, "text": "82 y.o. man w/afib on coumadin, CAD s/p MI, s/p recent ERCP\n w/sphincterotomy and biliary stent for high grade CBD stricture c/b\n shock and intubation x 48hrs peri-procedure (brushings were \"atypical\"\n and CA -9 very elevated, suspcious for pancreatic ca) transferred\n from OSH w/shock, leukocytosis (WBC 30K w/40% bands), and hypoxemia.\n Pt bld cx\nd found to have MRSA bacteremia. On pressors (neo and\n vasopressin). Chest ct revealed large r effusion with r collapse,\n partial l collapse with effusion. Pt remains a DNR/DNI without\n escalation of aggressive interventions.\n Renal failure, acute (Acute renal failure, ARF\n Assessment:\n Oliguric averaging 15cc/jhr. Generalized anasarca. Rising creatinine\n Action:\n No further treatment (ie: no dialysis) at this time.\n Response:\n Remains oliguric, worsening creatinine.\n Plan:\n Continue to monitor.\n Impaired Skin Integrity\n Assessment:\n Weeping continues from extremities. Cool extremities.\n Action:\n Coccyx wound intact. Barrier cream applied liberally to extremities\n with repositioning with softsorb on top. Waffles over legs. Remains on\n kinair bed.\n Response:\n No change. Continues to weep from all extremities.\n Plan:\n Continue with wound care as directed.\n Shock, septic\n Assessment:\n Bp remains stable with neo slowly titrated down to keep map >65.\n remains on vasopressin. Leukocytosis improving. Afebrile.\n Action:\n Able to titrate neo down to lower rate, remains on vasopressin. Remains\n on broad spectrum abx.\n Response:\n Bp remains stable. Afebrile.\n Plan:\n Wean neo as tolerated to keep map >65, monitor temp, abx.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt moaning with repositioning and at times at rest. Appears\n uncomfortable with repositioning.\n Action:\n Settles after given 2mg iv morphine.\n Response:\n Pain relieved with iv morphine with stable vitals.\n Plan:\n Premedicate with position changes and dressing changes. Medicated pn\n comfort.\n" }, { "category": "Nursing", "chartdate": "2155-05-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325111, "text": "This is an 82 yr male recently admitted for new onset jaundice w/\n pancreatic dilation. At that time, pt underwent biliary stent placement\n and sphincterotemy and there was a high suspicion for pancreatic CA\n though no bx was done at that time. Treatment was c/b shock requiring\n intubation and pressors X 48hr MD notes. Pt was D/C from to\n Rehab on . At rehab pt developed increasing SOB, cough and edema.\n Pt was transferred to OSH. In EW T max 101.2, HR 140\ns, BP 72/60. Pt\n was started on ceftriaxone, levofloxacin, and clindamycin.\n" }, { "category": "Nursing", "chartdate": "2155-05-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325112, "text": "This is an 82 yr male recently admitted for new onset jaundice w/\n pancreatic dilation. At that time, pt underwent biliary stent placement\n and sphincterotemy and there was a high suspicion for pancreatic CA\n though no bx was done at that time. Treatment was c/b shock requiring\n intubation and pressors X 48hr MD notes. Pt was D/C from to\n Rehab on . At rehab pt developed increasing SOB, cough and edema.\n Pt was transferred to OSH. In EW T max 101.2, HR 140\ns, BP 72/60. Pt\n was started on ceftriaxone, levofloxacin, and clindamycin.\n Additionally, pt was started on levophed for hypotension. Pt was\n transferred to on for further management.\n Shock, septic\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2155-05-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325115, "text": "Chief Complaint: shock, respiratory distress\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 82 yo M w/afib on coumadin, hypothyroidism, and CAD s/p MI s/p recent\n ERCP w/sphincterotomy and biliary stent for high grade stricture of CBD\n c/b shock, req pressors and intubation x48hrs peri-procedure (brushings\n were \"atypical\" and CA -9 very elevated, suspcious for pancreatic\n ca), now transferred from OSH w/shock, hypoxemia, and leukocytosis (WBC\n 30K w/40% bands). Likely septic shock, though may be cardiogenic\n component w/BNP 10K.\n 24 Hour Events:\n EKG - At 05:58 PM\n MULTI LUMEN - START 06:25 PM\n right subclavian line inserted \n BLOOD CULTURED - At 07:24 PM\n URINE CULTURE - At 07:24 PM\n RECTAL SWAB - At 07:24 PM\n BLOOD CULTURED - At 07:41 PM\n Tachycardic on levophed so changed to neo w/improvement in HR and BP.\n A-line attempted x3 w/o success.\n CvO2 75\n OSH blood cxs-\n bottles w/GPC, spec pending\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:40 PM\n Metronidazole - 04:00 AM\n Piperacillin - 05:00 AM\n Infusions:\n Phenylephrine - 3.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Asa 325\n Atrovent q6hrs\n Changes to medical and family history: unchanged c/w prior\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 111 (101 - 134) bpm\n BP: 93/67(74) {78/26(40) - 119/72(78)} mmHg\n RR: 19 (13 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (7 - 20)mmHg\n Total In:\n 1,653 mL\n 1,676 mL\n PO:\n TF:\n IVF:\n 1,653 mL\n 1,676 mL\n Blood products:\n Total out:\n 280 mL\n 350 mL\n Urine:\n 280 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,373 mL\n 1,326 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: 7.36/46/92\n PaO2 / FiO2: 184\n Physical Examination\n General: NAD\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: irregularly irregular\n Peripheral Vascular: DP pulses via doppler\n Respiratory / Chest: clear anteriorly b/l, diminsed laterally b/l\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: 3+ b/l, weeping skin, no clubbing/cyanosis\n Skin: No rash/jaundice, +sacral decub and decubs on b/l heels\n Neurologic: Attentive, Follows simple commands, answering questions\n appropriately\n Labs / Radiology\n 12.6 g/dL\n 286 K/uL\n 119 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 5.1 mEq/L\n 49 mg/dL\n 103 mEq/L\n 137 mEq/L\n 39.3 %\n 30.6 K/uL\n [image002.jpg]\n 06:37 PM\n 09:47 PM\n 12:25 AM\n 04:00 AM\n 04:59 AM\n WBC\n 34.8\n Hct\n 40.9\n 39.3\n Plt\n 295\n 286\n Cr\n 1.7\n 1.7\n TCO2\n 26\n 27\n 27\n Glucose\n 83\n 119\n Other labs: PT / PTT / INR:26.5/33.8/2.6, ALT / AST:36/61, Alk Phos / T\n Bili:313/1.7, Differential-Neuts:86.0 %, Band:10.0 %, Lymph:0.0 %,\n Mono:4.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L, Albumin:2.0 g/dL,\n LDH:216 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Random cortisol 35.8\n Portable CXR\n b/l effusions (R>>L), R subclavian CVL deep\n Assessment and Plan\n 82 yr old man with recent shock from biliary sepsis, heart failure,\n been at nursing home with significant diarrhea, new cough, SOB, and\n worsening lower ext edema now transferred with shock\n 82 yo M w/afib on coumadin, hypothyroidism, and CAD s/p MI s/p recent\n ERCP w/sphincterotomy and biliary stent for high grade stricture of CBD\n c/b shock, req pressors and intubation x48hrs peri-procedure (brushings\n were \"atypical\" and CA -9 very elevated, suspcious for pancreatic ca)\n transferred from OSH w/shock, leukocytosis (WBC 30K w/40% bands), and\n BNP 10K. Likely septic shock, though may be cardiogenic component\n w/BNP 10K- checking CvO2. Potential souces of infection= c diff given\n sig diarrhea and recent abx (most likely) vs. pna vs. biliary source\n (but LFTs better and no RUQ TTP); pan cx'd. Bolus for CVP goal ~10,\n MAP >65 w/levophed. On 6L suppl O2- hypoxemia likely pleural\n effusions + mild pulm edema; monitor O2 sats closely w/IVF\n resuscitation. Afib currently not rate controlled- but in shock and on\n levophed, rx'ing underlyzing causes. ARF- pre-renal +/- ATN, following\n uop.\n 1. Shock: septic picture. Infectious sources- positive blood cxs from\n OSH, also concerned for c diff given sig diarrhea and recent abx.\n Other possibilities incl pna and billiary source (though LFTs improved\n c/w prior).\n CVP goal 10, neo for MAP at least 65. Broad spectum abx (change IV\n flagyl to po vanco for c diff given high risk). f/u cxs, c diff.\n ++ Diarhhea and was on broad spectrum ABX recently- check\n C diff. very reassuring ABd exam,\n ++ Cough, Pleural effussions: possible PNA, check sputum\n cx, doubt\n ++ recent biliary sepsis but lfts much improved and no\n right upper\n Also concern for a cardiogenic component - high BNP\n check CvO2\n 2. Hypoxemia: likely vol overload/effusions. ?underlying pna.\n 3. Afib: rate better controlled on neo. Rx underlying issues and will\n try to add on bblocker when stable. Restart heparin when no immenent\n procedures.\n 4. ARF: pre renal and may be an ATN component, assess with volume\n resuscitation, trend Cr, UOP. Renally dose all meds. FENa 0.2, c/w\n pre-renal. Check urine sediment.\n 5. Sacral decub: wound care consult\n 6. CAD: cont asa, EKG unchanged. Cardiac enzymes negative. Holding\n BB, ACEI while req pressors.\n 7. FEN: npo for now given hypoxemia abd need for sig suppl O2\n 8. Access: resite CVL, re-attempt a-line\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 06:25 PM\n Prophylaxis:\n DVT: SQ UF Heparin once INR drifts below 2\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: critically ill\n" }, { "category": "Physician ", "chartdate": "2155-05-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325120, "text": "Chief Complaint: shock, respiratory distress\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 82 yo M w/afib on coumadin, hypothyroidism, and CAD s/p MI s/p recent\n ERCP w/sphincterotomy and biliary stent for high grade stricture of CBD\n c/b shock, req pressors and intubation x48hrs peri-procedure (brushings\n were \"atypical\" and CA -9 very elevated, suspcious for pancreatic\n ca), now transferred from OSH w/shock, hypoxemia, and leukocytosis (WBC\n 30K w/40% bands). Likely septic shock, though may be cardiogenic\n component w/BNP 10K.\n 24 Hour Events:\n EKG - At 05:58 PM\n MULTI LUMEN - START 06:25 PM\n right subclavian line inserted \n BLOOD CULTURED - At 07:24 PM\n URINE CULTURE - At 07:24 PM\n RECTAL SWAB - At 07:24 PM\n BLOOD CULTURED - At 07:41 PM\n Tachycardic on levophed so changed to neo w/improvement in HR and BP.\n A-line attempted x3 w/o success.\n CvO2 75\n OSH blood cxs-\n bottles w/GPC, spec pending\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:40 PM\n Metronidazole - 04:00 AM\n Piperacillin - 05:00 AM\n Infusions:\n Phenylephrine - 3.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Asa 325\n Atrovent q6hrs\n Changes to medical and family history: unchanged c/w prior\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 111 (101 - 134) bpm\n BP: 93/67(74) {78/26(40) - 119/72(78)} mmHg\n RR: 19 (13 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (7 - 20)mmHg\n Total In:\n 1,653 mL\n 1,676 mL\n PO:\n TF:\n IVF:\n 1,653 mL\n 1,676 mL\n Blood products:\n Total out:\n 280 mL\n 350 mL\n Urine:\n 280 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,373 mL\n 1,326 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: 7.36/46/92\n PaO2 / FiO2: 184\n Physical Examination\n General: NAD\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: irregularly irregular\n Peripheral Vascular: DP pulses via doppler\n Respiratory / Chest: clear anteriorly b/l, diminsed laterally b/l\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: 3+ b/l, weeping skin, no clubbing/cyanosis\n Skin: No rash/jaundice, +sacral decub and decubs on b/l heels\n Neurologic: Attentive, Follows simple commands, answering questions\n appropriately\n Labs / Radiology\n 12.6 g/dL\n 286 K/uL\n 119 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 5.1 mEq/L\n 49 mg/dL\n 103 mEq/L\n 137 mEq/L\n 39.3 %\n 30.6 K/uL\n [image002.jpg]\n 06:37 PM\n 09:47 PM\n 12:25 AM\n 04:00 AM\n 04:59 AM\n WBC\n 34.8\n Hct\n 40.9\n 39.3\n Plt\n 295\n 286\n Cr\n 1.7\n 1.7\n TCO2\n 26\n 27\n 27\n Glucose\n 83\n 119\n Other labs: PT / PTT / INR:26.5/33.8/2.6, ALT / AST:36/61, Alk Phos / T\n Bili:313/1.7, Differential-Neuts:86.0 %, Band:10.0 %, Lymph:0.0 %,\n Mono:4.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L, Albumin:2.0 g/dL,\n LDH:216 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Random cortisol 35.8\n Portable CXR\n b/l effusions (R>>L), R subclavian CVL deep\n Assessment and Plan\n 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent ERCP\n w/sphincterotomy and biliary stent for high grade stricture of CBD c/b\n shock, req pressors and intubation x48hrs peri-procedure (brushings\n were \"atypical\" and CA -9 very elevated, suspcious for pancreatic ca)\n transferred from OSH w/shock, leukocytosis (WBC 30K w/40% bands), and\n hypoxemia.\n 1. Shock: Presumed sepsis w/leukocytosis/bandemia and CvO2 75.\n Infectious sources- positive blood cxs from OSH, also concerned for c\n diff given sig diarrhea and recent abx. Other possibilities incl pna\n and billiary source (though LFTs improved c/w prior and abd exam not\n concerning).\n CVP goal ~10, neo for MAP at least 65.\n Broad spectum abx\n zosyn/IV vanco (change IV flagyl to po vanco for c\n diff given high risk).\n f/u cxs (incl from OSH), c diff.\n Checking TTE.\n 2. Hypoxemia: likely pleural effusions + pulm edema. BNP 10K at\n OSH, though some of this may be related to pt\ns afib and .\n Not diuresing while requiring pressors. ?underlying pna; abx as above.\n 3. Afib: rate better controlled on neo. Rx underlying issues and will\n try to add on bblocker when stable. Restart heparin when no immenent\n procedures.\n 4. ARF: FENa 0.2 c/w pre-renal etiology (though may be an ATN\n component). Checking urine sediment. Trend Cr and uop. Renally dose\n meds.\n 5. Sacral and b/l heel decubs: wound care consult\n 6. CAD: cont asa. EKG unchanged c/w b/l and cardiac enzymes negative.\n Holding BB, ACEI while req pressors.\n 7. FEN: npo for now given hypoxemia req sig suppl O2\n 8. Access: resite CVL (placed at OSH and also too deep), re-attempt\n a-line\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 06:25 PM\n Prophylaxis:\n DVT: SQ UF Heparin once INR drifts below 2\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: critically ill\n" }, { "category": "Nursing", "chartdate": "2155-05-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325178, "text": "This is an 82 yr male recently admitted for new onset jaundice w/\n pancreatic dilation. At that time, pt underwent biliary stent placement\n and sphincterotemy and there was a high suspicion for pancreatic CA.\n Treatment was c/b shock requiring intubation and pressors X 48hr MD\n notes. Pt was D/C from to Rehab on . At rehab pt developed\n increasing SOB, cough and edema. Pt was transferred to OSH on . In\n EW T max 101.2, HR 140\ns, BP 72/60. Pt was started on ceftriaxone,\n levofloxacin, and clindamycin. Additionally, pt was started on levophed\n for hypotension. Pt was transferred to on for further\n management.\n Bld cultures from OSH positive for gram positive cocci. Pt placed on\n contact precautions for ? MRSA and ? C-diff. Levophed changed to Neo\n here due to RAF to 140s. L STL cath was replaced here w L IJ. Cath\n tip sent.\n 2 blood cx from here at adm were also gm positive cocci.\n Shock, septic\n Assessment:\n Pt received on Neo at 3.2mcg/kg/min. BP dropping to map < 65. HR\n Action:\n A-line placed by team in R radial. A-line points higher than\n NBP. Increased Neo to 4.0 over time.\n Response:\n Plan:\n Pleural effusion, acute\n Assessment:\n Per cxr, large R and sm L pleural effusions. LS diminished\n throughout. Pt has congested sounding cough, keeping him awake most of\n noc. Sats diff to obtain consistently, with poor pleth despite\n changing sites, however sats freq in high 90s when obtained. Pt\n confused this noc, taking O2 mask off many times. Using yankauer to\n try to sx sputum, but minimal expectorated.\n Action:\n Guaifenesin cough med given, pt cont freq coughing. RT NTS x1 ,\n minimal secretions obtained.\n Response:\n Plan:\n Repeat cxr this am.\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2155-05-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325179, "text": "This is an 82 yr male recently admitted for new onset jaundice w/\n pancreatic dilation. At that time, pt underwent biliary stent placement\n and sphincterotemy and there was a high suspicion for pancreatic CA.\n Treatment was c/b shock requiring intubation and pressors X 48hr MD\n notes. Pt was D/C from to Rehab on . At rehab pt developed\n increasing SOB, cough and edema. Pt was transferred to OSH on . In\n EW T max 101.2, HR 140\ns, BP 72/60. Pt was started on ceftriaxone,\n levofloxacin, and clindamycin. Additionally, pt was started on levophed\n for hypotension. Pt was transferred to on for further\n management.\n Bld cultures from OSH positive for gram positive cocci. Pt placed on\n contact precautions for ? MRSA and ? C-diff. Levophed changed to Neo\n here due to RAF to 140s. L STL cath was replaced here w L IJ. Cath\n tip sent.\n 2 blood cx from here at adm were also gm positive cocci.\n Shock, septic\n Assessment:\n Pt received on Neo at 3.2mcg/kg/min. BP dropping to map < 65.\n HR U/o 20-40mls/hr.\n Action:\n A-line placed by team in R radial. A-line points higher than\n NBP. Increased Neo to 4.0 over time.\n Response:\n ABP map > 65 on Neo at 4.0, w syst freq in 80s. Unable to wean neo.\n Plan:\n Cont to monitor VS carefully. Titrate Neo to keep map > 65. ? add\n Vasopressin if map not sustained. Cont vanc and zosyn.\n Pleural effusion, acute\n Assessment:\n Per cxr, large R and sm L pleural effusions w RLL collapse. LS\n diminished throughout. Pt has congested sounding cough, keeping him\n awake most of noc. Sats diff to obtain consistently, with poor pleth\n despite changing sites, however sats freq in high 90s when obtained.\n Pt confused this noc, taking O2 mask off many times. Using yankauer\n to try to sx sputum, but minimal expectorated.\n Action:\n Guaifenesin cough med given, pt cont freq coughing. RT NTS x1 ,\n minimal secretions obtained.\n Response:\n Plan:\n Repeat cxr this am.\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2155-05-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325468, "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 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent admit with ERCP\n w/sphincterotomy and biliary stent for high grade CBD stricture c/b\n shock, requiring pressors and intubation x 48hrs peri-procedure\n (brushings were \"atypical\" and CA -9 very elevated, suspicious for\n pancreatic ca)\n 24 Hour Events:\n ARTERIAL LINE - STOP 07:00 PM\n transitioned to CMO,\n morphine and prn ativan\n meds, antibx dc/'d\n History obtained from Medical records, HO\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:19 PM\n Piperacillin/Tazobactam (Zosyn) - 05:49 AM\n Infusions:\n Morphine Sulfate - 5 mg/hour\n Other ICU medications:\n Morphine Sulfate - 06:30 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:14 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 95 (95 - 126) bpm\n BP: 96/70(81) {93/64(77) - 96/70(81)} mmHg\n RR: 10 (6 - 10) insp/min\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n Height: 67 Inch\n Total In:\n 339 mL\n 47 mL\n PO:\n TF:\n IVF:\n 339 mL\n 47 mL\n Blood products:\n Total out:\n 291 mL\n 140 mL\n Urine:\n 291 mL\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 48 mL\n -93 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, agonal breathing\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: No(t) Symmetric), (Breath Sounds:\n Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 12.0 g/dL\n 240 K/uL\n 160 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 5.3 mEq/L\n 72 mg/dL\n 105 mEq/L\n 135 mEq/L\n 38.2 %\n 20.4 K/uL\n [image002.jpg]\n 03:25 PM\n 03:30 PM\n 04:28 PM\n 09:16 PM\n 03:15 AM\n 04:36 AM\n 01:04 PM\n 02:56 PM\n 04:11 AM\n 05:19 AM\n WBC\n 23.1\n 20.4\n Hct\n 41.1\n 38.2\n Plt\n 309\n 240\n Cr\n 2.0\n 2.4\n 2.6\n 2.8\n TCO2\n 22\n 23\n 18\n 17\n 19\n 19\n Glucose\n 167\n 168\n 160\n Other labs: PT / PTT / INR:32.2/40.5/3.3, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:81/141, Alk Phos / T Bili:323/2.0,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:2.1 mmol/L, Albumin:1.9 g/dL, LDH:221 IU/L, Ca++:7.5\n mg/dL, Mg++:2.1 mg/dL, PO4:5.9 mg/dL\n Imaging: no new imaging\n Microbiology: no new labs\n Assessment and Plan\n 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent admit with ERCP\n w/sphincterotomy and biliary stent for high grade CBD stricture c/b\n shock, requiring pressors and intubation x 48hrs peri-procedure\n (brushings were \"atypical\" and CA -9 very elevated, suspicious for\n pancreatic ca)\n Transferred from OSH w/ septic shock from mrsa bacteremia w/ continued\n pressor requirements, large b/l pleural effusions with compressive\n atelectasis, leukocytosis, and progressive ARF\n Poor overall prognosis and now with multiorgan failing. Ongoing\n discussions regarding goals of care and possible transition from\n dnr/dni without escalation to comfort care today, given worsening\n lethargy/ms/pain.\n Main issues remain:\n # Shock--from mrsa bacteremia\n possible sources -> lungs/pna + effusions, bowel, skin (decubs)\n given leukocytosis, diarrhea, and recent antibx also concern for c\n diff\n -Continue pressors--Neo and vaso--weaning as tolerated, neo nearly off\n -Bolus IVF for CVP goal at least 10\n -continue broad spectum abx\n zosyn/IV vanco/ --refusing PO\n Vanco\nchange to IV flagyl pending 3rd c diff cx.\n - Tapping effusion and consideration to reimaging of abd discussed\n (lfts improving but with sig pain on palpation)\nongoing discussion\n with family regarding goals of care, as family seem to moving toward\n comfort and do not wish for escalation of care or aggressive\n interventions/procedures given overall poor prognosis and inoperable\n malignancy. Palliative care c/s to further assist family.\n # Hypoxemia/respiratory distress\n pleural effusions + pulm edema (BNP 10K at OSH) + probable pna\n Unable to diurese as requiring pressors.\n Continue Abx as above\n Cont BDs as tolerated\n Morphine for air-hunger\n Extensive discussions with family who understand poor prognoisis and\n risks associated with potentially therapeutic interventions\n such as /bronch given tenuous status\n # ARF\n likely ATN /intravascular depletion from sepsis.\n Renally dose meds.\n # Leukocytosis\n remains elevated with mutliple potential sources of persistent\n infection including pleural fluid, sacral decub ? c diff\n continue broad coverage\n goal of care discussion with family as noted\n # pain---morphine prn\n # Afib: Holding BB given pressor requirements\n Holding coumadin given supratherapeutic INR.\n # Sacral and b/l heel decubs: wound care\n # CAD\n Holding BB, ACEI while req pressors\n cont asa if able to tol po med\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2155-05-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325455, "text": "Chief Complaint: Sepsis\n 24 Hour Events:\n ARTERIAL LINE - STOP 07:00 PM\n CMO\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:19 PM\n Piperacillin/Tazobactam (Zosyn) - 05:49 AM\n Infusions:\n Morphine Sulfate - 5 mg/hour\n Other ICU medications:\n Morphine Sulfate - 06:30 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 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.8\nC (96.4\n HR: 112 (109 - 126) bpm\n BP: 96/70(81) {93/64(77) - 99/75(85)} mmHg\n RR: 8 (6 - 15) insp/min\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n Height: 67 Inch\n CVP: 0 (0 - 14)mmHg\n Total In:\n 339 mL\n 26 mL\n PO:\n TF:\n IVF:\n 339 mL\n 26 mL\n Blood products:\n Total out:\n 291 mL\n 110 mL\n Urine:\n 291 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 48 mL\n -84 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\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 240 K/uL\n 12.0 g/dL\n 160 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 5.3 mEq/L\n 72 mg/dL\n 105 mEq/L\n 135 mEq/L\n 38.2 %\n 20.4 K/uL\n [image002.jpg]\n 03:25 PM\n 03:30 PM\n 04:28 PM\n 09:16 PM\n 03:15 AM\n 04:36 AM\n 01:04 PM\n 02:56 PM\n 04:11 AM\n 05:19 AM\n WBC\n 23.1\n 20.4\n Hct\n 41.1\n 38.2\n Plt\n 309\n 240\n Cr\n 2.0\n 2.4\n 2.6\n 2.8\n TCO2\n 22\n 23\n 18\n 17\n 19\n 19\n Glucose\n 167\n 168\n 160\n Other labs: PT / PTT / INR:32.2/40.5/3.3, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:81/141, Alk Phos / T Bili:323/2.0,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:2.1 mmol/L, Albumin:1.9 g/dL, LDH:221 IU/L, Ca++:7.5\n mg/dL, Mg++:2.1 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n # CMO\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 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": "2155-05-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325470, "text": "Chief Complaint: Sepsis\n 24 Hour Events:\n ARTERIAL LINE - STOP 07:00 PM\n CMO\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:19 PM\n Piperacillin/Tazobactam (Zosyn) - 05:49 AM\n Infusions:\n Morphine Sulfate - 5 mg/hour\n Other ICU medications:\n Morphine Sulfate - 06:30 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 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.8\nC (96.4\n HR: 112 (109 - 126) bpm\n BP: 96/70(81) {93/64(77) - 99/75(85)} mmHg\n RR: 8 (6 - 15) insp/min\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n Height: 67 Inch\n CVP: 0 (0 - 14)mmHg\n Total In:\n 339 mL\n 26 mL\n PO:\n TF:\n IVF:\n 339 mL\n 26 mL\n Blood products:\n Total out:\n 291 mL\n 110 mL\n Urine:\n 291 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 48 mL\n -84 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\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 240 K/uL\n 12.0 g/dL\n 160 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 5.3 mEq/L\n 72 mg/dL\n 105 mEq/L\n 135 mEq/L\n 38.2 %\n 20.4 K/uL\n [image002.jpg]\n 03:25 PM\n 03:30 PM\n 04:28 PM\n 09:16 PM\n 03:15 AM\n 04:36 AM\n 01:04 PM\n 02:56 PM\n 04:11 AM\n 05:19 AM\n WBC\n 23.1\n 20.4\n Hct\n 41.1\n 38.2\n Plt\n 309\n 240\n Cr\n 2.0\n 2.4\n 2.6\n 2.8\n TCO2\n 22\n 23\n 18\n 17\n 19\n 19\n Glucose\n 167\n 168\n 160\n Other labs: PT / PTT / INR:32.2/40.5/3.3, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:81/141, Alk Phos / T Bili:323/2.0,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:2.1 mmol/L, Albumin:1.9 g/dL, LDH:221 IU/L, Ca++:7.5\n mg/dL, Mg++:2.1 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n 82 y/o M with MRSA sepsis and suspicion for pancreatic cancer, made CMO\n yesterday.\n Patient is CMO, comfortable on a morphine gtt. Family to come by\n today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 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": "2155-05-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325471, "text": "Chief Complaint: shock\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 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent admit with ERCP\n w/sphincterotomy and biliary stent for high grade CBD stricture c/b\n shock, requiring pressors and intubation x 48hrs peri-procedure\n (brushings were \"atypical\" and CA -9 very elevated, suspicious for\n pancreatic ca) , transferred from OSH w/ septic shock from mrsa\n bacteremia w/ continued pressor requirements, large b/l pleural\n effusions with compressive atelectasis, leukocytosis, and progressive\n ARF\n 24 Hour Events:\n ARTERIAL LINE - STOP 07:00 PM\n transitioned to CMO after family discussions\n morphine and prn ativan for comfort\n meds, antibx dc/'d\n History obtained from Medical records, HO\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:19 PM\n Piperacillin/Tazobactam (Zosyn) - 05:49 AM\n Infusions:\n Morphine Sulfate - 5 mg/hour\n Other ICU medications:\n Morphine Sulfate - 06:30 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:14 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 95 (95 - 126) bpm\n BP: 96/70(81) {93/64(77) - 96/70(81)} mmHg\n RR: 10 (6 - 10) insp/min\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n Height: 67 Inch\n Total In:\n 339 mL\n 47 mL\n PO:\n TF:\n IVF:\n 339 mL\n 47 mL\n Blood products:\n Total out:\n 291 mL\n 140 mL\n Urine:\n 291 mL\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 48 mL\n -93 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, agonal breathing\n Eyes / Conjunctiva: PERRL, icteric sclera\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: faint, (Left radial\n pulse:faint), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: No(t) Symmetric), (Breath Sounds:\n Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds decreased\n Extremities: 3+ edema, No(t) Cyanosis, Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin, warm\n Neurologic: unresponsive to voice, agonal,\n Labs / Radiology\n 12.0 g/dL\n 240 K/uL\n 160 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 5.3 mEq/L\n 72 mg/dL\n 105 mEq/L\n 135 mEq/L\n 38.2 %\n 20.4 K/uL\n [image002.jpg]\n 03:25 PM\n 03:30 PM\n 04:28 PM\n 09:16 PM\n 03:15 AM\n 04:36 AM\n 01:04 PM\n 02:56 PM\n 04:11 AM\n 05:19 AM\n WBC\n 23.1\n 20.4\n Hct\n 41.1\n 38.2\n Plt\n 309\n 240\n Cr\n 2.0\n 2.4\n 2.6\n 2.8\n TCO2\n 22\n 23\n 18\n 17\n 19\n 19\n Glucose\n 167\n 168\n 160\n Other labs: PT / PTT / INR:32.2/40.5/3.3, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:81/141, Alk Phos / T Bili:323/2.0,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:2.1 mmol/L, Albumin:1.9 g/dL, LDH:221 IU/L, Ca++:7.5\n mg/dL, Mg++:2.1 mg/dL, PO4:5.9 mg/dL\n Imaging: no new imaging\n Microbiology: no new labs\n Assessment and Plan\n 82 yo M w/ afib on coumadin, CAD s/p MI, s/p recent admit w/ ERCP and\n sphincterotomy / biliary stent for high grade CBD stricture c/b shock,\n requiring pressors and intubation x 48hrs peri-procedure (brushings\n were \"atypical\" and CA -9 very elevated, suspicious for pancreatic\n ca) transferred from OSH w/ septic shock from mrsa bacteremia w/\n continued pressor requirements, large b/l pleural effusions with\n compressive atelectasis and hypoxemia, leukocytosis, and progressive\n ARF.\n -Given progressive decline and discomfort and poor prognosis with MOSF\n and advanced malignancy, presumed to be pancreatic ca, family meeting\n yesterday with transition to CMO.\n -Antibx, pressors, medications discontinued\n - Addressing pain/comfort and air hunger with morphine and ativan as\n needed\n -O2 for comfort\n ICU Care\n Nutrition: NPO\n Glycemic Control: comfort measures only\n Lines:\n Multi Lumen - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 25 min\n" }, { "category": "Nutrition", "chartdate": "2155-05-14 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 325461, "text": "Comments:\n Noted patient changed to CMO status. Will sign off at this time. Please\n re-consult if plan of care changes.\n 10:20\n" }, { "category": "Nursing", "chartdate": "2155-05-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325320, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Remains anuric.\n Action:\n Last creat 2.6. minimal u/o\ns. urine lytes sent this am.\n Response:\n Plan:\n Continue to monitor. / no dialysis per family.\n Impaired Skin Integrity\n Assessment:\n Continues to weep from all sources. Extremeties cold. Pt. moaning with\n movement.\n Action:\n Skin assessment done. Aquacel to buttock area. Barrier cream to\n extremeties. And softsorb. Waffles.\n Response:\n No change\n Plan:\n Continue with wound care.\n Shock, septic\n Assessment:\n No further hypotension. Leukocytosis improving. Continues to broad\n spectrum antibiotics. Pt. + for mrsa. More lethargic this afternoon.\n Action:\n Bs\ns very diminished on right. Ls\ns clear on left. Remains on his right\n side. Abg\ns done at 13pm. See flow sheet. No further nasal suctioning\n required. Bs\ns hypoactive. No further stools. K+ 5.7 and given 30gms of\n k+ exylate=pt. would only drink\n of dose. No stools and repeat k+ was\n 5.7. pt. more agitated this afternoon. Cardiac echo done. ? of results.\n Remains in af. No ect. Inr very elevated. Cont. on antibiotics. Neo\n being titrated slowly. Both daughters into visit and spoke with the ho.\n And they are having difficulties making their father .\n Response:\n Able to tolerate titration. No response to k+exylate.\n Plan:\n Possible change in code status tomorrow to .\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. appears to be in more pain this afternoon with movement of limbs\n etc.\n Action:\n Given 1mg ms ivp .\n Response:\n No response noted\n Plan:\n Need to increase pain medications, especially with drsg .\n" }, { "category": "Nursing", "chartdate": "2155-05-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325405, "text": "Shock, septic\n Assessment:\n Pt. made comfort measures by daughters.\n Action:\n pressors d/c\ned. All meds d/c\ned. consulted and spent\n an hour with the daughters. morphine 2-4mg ivp for discomfort.\n Response:\n Doesn\nt appear to be in pain at this time.\n Plan:\n Daughters to stay with their father til he\ns passed away.\n" }, { "category": "Physician ", "chartdate": "2155-05-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325312, "text": "Chief Complaint: septic shock, MRSA bacteremia\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 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent ERCP\n w/sphincterotomy and biliary stent for high grade CBD stricture c/b\n shock and intubation x 48hrs peri-procedure (brushings were \"atypical\"\n and CA -9 very elevated, suspcious for pancreatic ca) transferred\n from OSH w/shock, leukocytosis (WBC 30K w/40% bands), and hypoxemia.\n 24 Hour Events:\n CHEST PAIN - At 09:45 AM\n BLOOD CULTURED - At 10:16 AM\n EKG - At 10:16 AM\n blood cx'd returned + MRSA\n escalating pressors requirements, now on neo drip and vasopressin\n SVO2 62%--improved to 77% after IVF\n Chest CT\nlarge R effusion with R collapse, partial L collapse with\n effusion\n Family mtg yesterday to discuss goals of care, DNR/DNI without\n escalation of\n aggression interventions\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Piperacillin - 12:28 AM\n Piperacillin/Tazobactam (Zosyn) - 05:54 AM\n Vancomycin - 06:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Tachypnea\n Flowsheet Data as of 11:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36\nC (96.8\n HR: 113 (107 - 123) bpm\n BP: 102/75(87) {77/53(64) - 110/75(88)} mmHg\n RR: 15 (13 - 39) insp/min\n SpO2: 77%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n Height: 67 Inch\n CVP: 14 (5 - 16)mmHg\n Total In:\n 2,872 mL\n 1,013 mL\n PO:\n TF:\n IVF:\n 2,872 mL\n 1,013 mL\n Blood products:\n Total out:\n 353 mL\n 73 mL\n Urine:\n 353 mL\n 73 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,519 mL\n 940 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 77% 6L NC and 100% FIO2 through shovel mask\n ABG: 7.28/34/86/14/-9\n PaO2 / FiO2: 86\n Physical Examination\n General Appearance: uncomfortable, lethargic, awake\n Eyes / Conjunctiva: PERRL, MMD\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (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: (Breath Sounds: Diminished: throughout)\n transmitted BS at L apex, minimal air movement R upper zone\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\n Skin: cool LE\n Neurologic: Attentive, Follows simple commands, Responds to: verbal\n stimuli, Oriented (to): X 2, Movement: Not assessed, No(t) Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 12.9 g/dL\n 309 K/uL\n 167 mg/dL\n 2.4 mg/dL (1.9<--1.7)\n 14 mEq/L\n 5.7 mEq/L (hemolyzed)\n 62 mg/dL\n 104 mEq/L\n 134 mEq/L\n 41.1 %\n 23.1 K/uL\n [image002.jpg]\n 04:42 AM\n 10:04 AM\n 10:14 AM\n 12:12 PM\n 03:25 PM\n 03:30 PM\n 04:28 PM\n 09:16 PM\n 03:15 AM\n 04:36 AM\n WBC\n 23.1 (26)\n Hct\n 41.1\n Plt\n 309\n Cr\n 2.0\n 2.4\n TropT\n 0.01\n TCO2\n 26\n 24\n 23\n 22\n 23\n 18\n 17\n Glucose\n 167\n Other labs: PT / PTT / INR:32.6/38.0/3.4, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:63/168 increasing , Alk Phos / T\n Bili:342/2.1, Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %,\n Mono:2.1 %, Eos:0.2 %, Lactic Acid:3.3 mmol/L , Albumin:2.1 g/dL,\n LDH:406 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:7.2 mg/dL\n Imaging: CT chest :\n 1. No evidence of pneumonia. Large right pleural effusion causing\n complete\n collapse of the right lung, which was previously partially aerated.\n Component\n of mucus plugging may be superimposed and continued radiographic\n follow-up\n needed. Moderate left pleural effusion causing complete atelectasis of\n the\n basilar left lower lobe segments. Right chest wall edema.\n 2. Atherosclerotic calcifications within the aorta and coronary\n circulation.\n 3. Interval increase in intra-abdominal ascites, with resolution of\n previously identified intrahepatic biliary dilatation and stable\n appearance to\n simple and hyperdense renal lesions better described on previously\n performed\n dedicated CT abdomen. Pancreatic ductal dilatation persists.\n no new cxr from this am\n Microbiology: bl MRSA\n stool neg c diff X 2\n urine lg neg\n OSH urine cx--GNR and GP cocci\n Assessment and Plan\n 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent admit with ERCP\n w/sphincterotomy and biliary stent for high grade CBD stricture c/b\n shock, requiring pressors and intubation x 48hrs peri-procedure\n (brushings were \"atypical\" and CA -9 very elevated, suspcious for\n pancreatic ca) transferred from OSH w/ shock, leukocytosis and\n hypoxemia.\n Main issues remain:\n # Shock\n Presumed sepsis w/ leukocytosis/bandemia and initial CvO2 75.\n Blood cx now + for MRSA\n possible sources -> lungs/pna effusions, bowel, skin (decubs).\n With leukocytosis, diarrhea, and recent antibx also concerned for c\n diff\n -Continue pressores--Neo and vaso\n -Bolus IVF for CVP goal at least 10\n -Broad spectum abx\n zosyn/IV vanco/po vanco.\n -F/u cxs (incl from OSH), c diff.\n -TTE to assess cards fx, Low suspic of tamponade given low CVP but in\n ddx given effusion, malignancy, etc.\n # Hypoxemia/respiratory distress\n pleural effusions + pulm edema (BNP 10K at OSH) + probable\n pna,\n Not diuresing as requiring pressors.\n Abx as above\n Cont BDs\n Tenous and sats very positional, would have difficutly tolerating\n thoracentesis (would also need to reverse anticoag) or bronch\n at this time,\n Extensive discussions with family who understand poor prognoisis and\n risks associated with potentially therapeutic interventions\n such as /bronch given tenuous status\n Pt is DNR/DNI without excalation of care,\n # Metabolic acidosis\n Likely from sepsis,progressive renal failure, lactate acidosis\n Trend lactate, support BP, IVF as above\n # ARF\n likely ATN /intravascualr depletion from sepsis. Urine lytes appear\n pre-renal\n Renally dose meds.\n Trend u/o, cr\n # Leukocytosis\n trending down, continue broad coverage including empiric for c diff\n # Afib: tolerating neo in terms of rates. Holding BB given pressor\n requiremetns\n Holding coumadin given supratherapeutic INR.\n # Sacral and b/l heel decubs: wound care\n # CAD\n EKG unchanged b/l and cardiac enzymes negative.\n Holding BB, ACEI while req pressors\n cont asa.\n # FEN: npo given hypoxemia and tenous resp status\n ICU Care\n Nutrition:\n NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 08:29 PM\n Prophylaxis:\n DVT: supratherapeutic INR\n Stress ulcer: H2B\n VAP: not intubated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : 45 criticaly ill\n Total time spent: remains in ICU, continue family updates to clarify\n goals of care\n" }, { "category": "Physician ", "chartdate": "2155-05-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325304, "text": "Chief Complaint: MRSA Bacteremia\n 24 Hour Events:\n CHEST PAIN - At 09:45 AM\n BLOOD CULTURED - At 10:16 AM\n EKG - At 10:16 AM\n -Family meeting held with daughters where the decision was made to\n make him DNR/DNI, with NO escalation of care (ie, no new invasive\n procedures/ or work-ups). Basically he was given a very poor prognosis\n with months to live from his gastroenterologist as he has pancreatic\n cancer. He does not know this diagnosis yet, only his daughters do, so\n they were very reasonable about goals of care. They will get back to\n us on possibly making him CMO, and would like input from his GI doctor\n Dr. , whom I emailed\n -Blood cultures came back 4/4 bottles with MRSA\n -We were unable to wean pressors due to low MAPs\n -We got a CT to better characterize his pleural effusion on CXR, and it\n showed a white out of the right lung with effusion, and a complete lung\n collapse with mucous plugging.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Piperacillin - 12:28 AM\n Piperacillin/Tazobactam (Zosyn) - 05:54 AM\n Vancomycin - 06:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Phenylephrine - 4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.6\nC (96\n HR: 114 (107 - 135) bpm\n BP: 93/66(77) {77/53(64) - 182/122(148)} mmHg\n RR: 16 (12 - 39) insp/min\n SpO2: 77%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n CVP: 7 (-3 - 17)mmHg\n Total In:\n 2,872 mL\n 895 mL\n PO:\n TF:\n IVF:\n 2,872 mL\n 895 mL\n Blood products:\n Total out:\n 353 mL\n 28 mL\n Urine:\n 353 mL\n 28 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,519 mL\n 867 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 77%\n ABG: 7.28/34/86/14/-9\n PaO2 / FiO2: 86\n Physical Examination\n General Appearance: Well nourished, Diaphoretic\n Eyes / Conjunctiva: PERRL\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:\n Diminished: right, and left base)\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, No(t) Tender:\n Extremities: Right: 2+, Left: 2+, 2+ pre-sacral edema\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x2, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 309 K/uL\n 12.9 g/dL\n 167 mg/dL\n 2.4 mg/dL\n 14 mEq/L\n 5.7 mEq/L\n 62 mg/dL\n 104 mEq/L\n 134 mEq/L\n 41.1 %\n 23.1 K/uL\n [image002.jpg]\n 04:42 AM\n 10:04 AM\n 10:14 AM\n 12:12 PM\n 03:25 PM\n 03:30 PM\n 04:28 PM\n 09:16 PM\n 03:15 AM\n 04:36 AM\n WBC\n 23.1\n Hct\n 41.1\n Plt\n 309\n Cr\n 2.0\n 2.4\n TropT\n 0.01\n TCO2\n 26\n 24\n 23\n 22\n 23\n 18\n 17\n Glucose\n 167\n Other labs: PT / PTT / INR:32.6/38.0/3.4, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:63/168, Alk Phos / T Bili:342/2.1,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:3.3 mmol/L, Albumin:2.1 g/dL, LDH:406 IU/L, Ca++:7.9\n mg/dL, Mg++:2.2 mg/dL, PO4:7.2 mg/dL\n Imaging: CT Chest\n IMPRESSION:\n 1. No evidence of pneumonia. Large right pleural effusion causing\n complete\n collapse of the right lung, which was previously partially aerated.\n Component\n of mucus plugging may be superimposed and continued radiographic\n follow-up\n needed. Moderate left pleural effusion causing complete atelectasis of\n the\n basilar left lower lobe segments. Right chest wall edema.\n 2. Atherosclerotic calcifications within the aorta and coronary\n circulation.\n 3. Interval increase in intra-abdominal ascites, with resolution of\n previously identified intrahepatic biliary dilatation and stable\n appearance to\n simple and hyperdense renal lesions better described on previously\n performed\n dedicated CT abdomen. Pancreatic ductal dilatation persists.\n Microbiology: VRE Swab: Positive\n Blood: MRSA from \n Assessment and Plan\n A/P: 82 M w/ recent admission for painless jaundice s/p ERCP with\n sphincterotomy and biliary stent c/b hypoxia requiring intubation,\n admitted with septic shock\n .\n Septic Shock: On admission was febrile, WBC > 30 with bandemia,\n tachycardic, increased RR. Now with GPC in blood. Unclear source, but\n must consider endocarditis, pulmonary, decubiti or GI source given\n recent instrumentation. Patient without abdominal pain or jaundice to\n suggest acute cholangitis.\n .\n Goals of Care: Will need to meet with family today to discuss goals of\n care\n currently no escalation of care.\n .\n f/u Sputum, Blood, Urine Cx, Cdiff x 3 - MRSA+ Bacteremia - unclear\n source, ? parapneumonic effusion, endocarditis, complication of biliary\n stent placement.\n 1. Will treat broadly with Vanc/Zosyn/PO Vanco for C. Diff -\n consider d/c zosyn today.\n 2. Titrate CVP to 10, bolus as needed\n 3. Switched to phenylephrine to avoid beta adrtenergic effect of\n levophed and resulting tachycardia. Added vasopressin this AM. Check\n Mixed Venous O2 sat. Adjust PRN. Might need dobutamine for inotrpoic\n support but would defer at this time.\n 4. Transfuse as needed for Hct>30 if MvO2 is < 70%.\n 5. Basal cortisol level wnl, no stim\n 6. Line re-positioned, f/u culture of tip.\n 7. TTE for endocarditis. If negative would get CT Scan\n chest/abdomen looking for abdomen. ?osteo underlying wounds.\n 8. Wound care consult.\n 9. Consider thoracentesis of effusion\n .\n Hypoxia: Patient comfortable on 6L. He is willing to be intubated.\n Hypoxia likely a result of pleural effusions, sepsis, volume\n recuscitation.\n 1. ABG this AM 7.35/45/132\n 2. Continue nasal cannula at this point.\n 3. Daily CXR\n 4. Add nebulizer prn\n .\n Pleural effusions: may be malignant pleural effusions vs. chf vs. pna\n 1. ECHO, cycle enzymes, daily EKG\n 2. Empirically treat for HAP with Vanc/Zosyn\n d/c zosyn once\n more stable.\n .\n Acute Renal Failure: likely pre-renal from sepsis/hypotension. UOP has\n dropped off this morning, and now with rising Cr/lactate. Added\n vasopressin for second pressor and goal of improved renal perfusion.\n Goal MAP of 70 for today.\n 1. Follow Cr.\n .\n Biliary stricture: Patient with recent admission for painless jaudince\n requiring biliary stent and sphincterotomy. Patient due to stent\n change in . Patient does not appear to have clinical signs of\n cholangitis at this point.\n 1. NPO for now\n 2. Trend LFTs\n 3. empirically treat with Zosyn for biliary organisms\n .\n CAD: MI in 's. Give high dose ASA. Enzymes negative x1 - and with\n negative set at OSH more than 12 hours apart. No need to cycle\n further.\n .\n PUMP: Hold antihypertensives, pressors as needed. Will repeat ECHO.\n Patient grossly volume overloaded, and may require aggressive diuresis\n once he's off pressors.\n .\n RHYTHM: known afib on coumadin. Hold coumadin. Rate much improved\n after switch to neosynephrine.\n .\n ARF: Cr up to 1.9 from basline.\n 1. urine lytes show FENA 0.2%, pre-renal vs ATN in setting\n hypotension\n .\n Nutrition: Consult for low albumin.\n 1. Would restart regular diet if possible although with\n respiratory status. Discuss goals of care with family.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 08:29 PM\n Prophylaxis:\n DVT: INR Elevated\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2155-05-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325190, "text": "This is an 82 yr male recently admitted for new onset jaundice w/\n pancreatic dilation. At that time, pt underwent biliary stent placement\n and sphincterotemy and there was a high suspicion for pancreatic CA.\n Treatment was c/b shock requiring intubation and pressors X 48hr MD\n notes. Pt was D/C from to Rehab on . At rehab pt developed\n increasing SOB, cough and edema. Pt was transferred to OSH on . In\n EW T max 101.2, HR 140\ns, BP 72/60. Pt was started on ceftriaxone,\n levofloxacin, and clindamycin. Additionally, pt was started on levophed\n for hypotension. Pt was transferred to on for further\n management.\n Bld cultures from OSH positive for gram positive cocci. Pt placed on\n contact precautions for ? MRSA and ? C-diff. Levophed changed to Neo\n here due to RAF to 140s. L STL cath was replaced here w L IJ. Cath\n tip sent.\n 2 blood cx from here at adm were also gm positive cocci.\n 2^nd specimen sent for c-diff today.\n Shock, septic\n Assessment:\n Pt received on Neo at 3.2mcg/kg/min. BP dropping to map < 65. HR\n 100-120 U/o 20-40mls/hr. CVP 11-15.\n Action:\n A-line placed by team in R radial. A-line points higher than NBP.\n Increased Neo to 4.0 over time w increased hypotension.\n Response:\n ABP map > 65 on Neo at 4.0, but positional at times causing alarms, (pt\n raises arm.) Syst freq in 80s. Unable to wean neo. U/o slightly\n lower at 18-25mls/hr. CVP did not drop, .\n Plan:\n Cont to monitor VS carefully. Titrate Neo to keep map > 65. ? add\n Vasopressin if map not sustained. Cont vanc and zosyn.\n Pleural effusion, acute\n Assessment:\n Per cxr, large R and sm L pleural effusions w RLL collapse. LS\n diminished throughout. Pt has congested sounding cough, keeping him\n awake most of noc. Sats diff to obtain consistently, with poor pleth\n despite changing sites, however sats freq in high 90s when obtained.\n Pt confused this noc, taking O2 mask off many times. Using yankauer\n to try to sx sputum, but minimal expectorated.\n Action:\n Guaifenesin cough med given, pt cont freq coughing. RT NTS x1 to see\n if this would relieve pt, minimal secretions obtained. Attempt to\n freq reorient pt.\n Response:\n Am abg good at 7.35/45/132. Pt cont. to pull off O2 mask\n Plan:\n Repeat cxr this am. ? need for restraints if confusion worsens.\n Impaired Skin Integrity\n Assessment:\n Minimal changes in multiple pressure sores (see flow sheets). Coccyx\n allevyn dsg changed due to soiled w stool. Sm amt dng and bleeding.\n Pt only c/o discomfort when moving or toughing legs.\n Action:\n Dsg changes x2 using sorb pads under kerlix. Freq turning and skin\n care. Cont on Kinair bed.\n Response:\n Continued weeping of lower extremities and L arm. Pain in legs when\n touched or moved but none when at rest.\n Plan:\n Monitor dsg sites, change prn. Skin care consult on Monday.\n" }, { "category": "Physician ", "chartdate": "2155-05-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325198, "text": "Chief Complaint: Sepsis\n 24 Hour Events:\n URINE CULTURE - At 10:11 AM\n MULTI LUMEN - START 04:00 PM\n MULTI LUMEN - STOP 04:10 PM\n right subclavian line inserted \n ARTERIAL LINE - START 08:29 PM\n - Placed Central line, bolused with IVF's with goal CVP of 10mmHg (last\n )\n - Placed A-Line - pressures stable, but increased pressors overnight.\n - Cultures growing GPC in blood\n - OSH cultures: GPC in blood (4/4 bottles), Urine +GPC/GNR, MRSA+\n - TTE not done\n - Agitated overnight, confused, pulling off oxygen at times.\n - Started vasopressin this AM for low UOP, rising lactate and rising\n Cr.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Piperacillin - 12:28 AM\n Vancomycin - 12:28 AM\n Infusions:\n Phenylephrine - 4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 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: 36.1\nC (96.9\n HR: 110 (100 - 121) bpm\n BP: 93/62(75) {72/50(59) - 120/81(96)} mmHg\n RR: 24 (11 - 30) insp/min\n SpO2: 91%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n CVP: 1 (1 - 17)mmHg\n Total In:\n 4,185 mL\n 255 mL\n PO:\n TF:\n IVF:\n 4,185 mL\n 255 mL\n Blood products:\n Total out:\n 825 mL\n 103 mL\n Urine:\n 825 mL\n 103 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,360 mL\n 152 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 91%\n ABG: 7.35/45/132/22/0\n PaO2 / FiO2: 264\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\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 anteriorly, Diminished: at R-base)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+, + lesions on fingers\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): to hospital/, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 276 K/uL\n 12.9 g/dL\n 111 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 5.0 mEq/L\n 51 mg/dL\n 104 mEq/L\n 136 mEq/L\n 41.0 %\n 26.1 K/uL\n [image002.jpg]\n 06:37 PM\n 09:47 PM\n 12:25 AM\n 04:00 AM\n 04:59 AM\n 04:25 AM\n 04:42 AM\n WBC\n 34.8\n 30.6\n 26.1\n Hct\n 40.9\n 39.3\n 41.0\n Plt\n 295\n 286\n 276\n Cr\n 1.7\n 1.7\n 1.9\n TropT\n 0.01\n TCO2\n 26\n 27\n 27\n 26\n Glucose\n 83\n 119\n 111\n Other labs: PT / PTT / INR:28.1/36.0/2.8, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:36/58, Alk Phos / T Bili:295/1.6,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:2.7 mmol/L, Albumin:1.9 g/dL, LDH:219 IU/L, Ca++:7.0\n mg/dL, Mg++:2.0 mg/dL, PO4:4.5 mg/dL\n Imaging: CXR:\n Tip of the new right IJ line ends in the lower SVC, right subclavian\n line tip\n projects over the superior cavoatrial junction as before, large right\n pleural\n effusion is stable, and small left pleural effusion unchanged. Heart\n size top\n normal, partially obscured by large right pleural effusion. Mediastinal\n vascular engorgement improved slightly. No pneumothorax. Gaseous\n distention of the stomach has improved.\n Microbiology: Blood Cultures: GPC in cultures.\n Assessment and Plan\n A/P: 82 M w/ recent admission for painless jaundice s/p ERCP with\n sphincterotomy and biliary stent c/b hypoxia requiring intubation,\n admitted with septic shock\n .\n Septic Shock: On admission was febrile, WBC > 30 with bandemia,\n tachycardic, increased RR. Now with GPC in blood. Unclear source, but\n must consider endocarditis, pulmonary, decubiti or GI source given\n recent diarrhea. Patient without abdominal pain or jaundice to suggest\n acute cholangitis.\n f/u Sputum, Blood, Urine Cx, Cdiff x 3\n 1. Will treat broadly with Vanc/Zosyn/PO Vanco for C. Diff\n 2. Titrate CVP to 10, bolus as needed\n 3. Switched to phenylephrine to avoid beta adrtenergic effect of\n levophed and resulting tachycardia. Will add vasopressin this AM.\n 4. Transfuse as needed for Hct>30 if MvO2 is < 70%\n 5. Basal cortisol level wnl, no stim\n 6. Line re-positioned, f/u culture of tip although unlikely\n source as placed less than 36 hours ago at OSH.\n 7. TTE for endocarditis. If negative would get CT Scan\n chest/abdomen looking for abdomen. ?osteo underlying wounds.\n 8. Wound care consult.\n .\n Hypoxia: Patient comfortable on 6L. He is willing to be intubated.\n Hypoxia likely a result of pleural effusions, sepsis, volume\n recuscitation.\n 1. ABG this AM 7.35/45/132\n 2. Continue nasal cannula at this point.\n 3. Daily CXR\n 4. Add nebulizer prn\n .\n Pleural effusions: may be malignant pleural effusions vs. chf vs. pna\n 1. ECHO, cycle enzymes, daily EKG\n 2. Empirically treat for HAP with Vanc/Zosyn\n .\n Acute Renal Failure: likely pre-renal from sepsis/hypotension. UOP has\n dropped off this morning, and now with rising Cr/lactate. Added\n vasopressin for second pressor and goal of improved renal perfusion.\n Goal MAP of 70 for today.\n 1. Follow Cr.\n .\n Biliary stricture: Patient with recent admission for painless jaudince\n requiring biliary stent and sphincterotomy. Patient due to stent\n change in . Patient does not appear to have clinical signs of\n cholangitis at this point.\n 1. NPO for now\n 2. Trend LFTs\n 3. empirically treat with Zosyn/Flagyl for biliary organisms\n .\n CAD: MI in 's. Give high dose ASA. Enzymes negative x1 - and with\n negative set at OSH more than 12 hours apart. No need to cycle\n further.\n .\n PUMP: Hold antihypertensives, pressors as needed. Will repeat ECHO.\n Patient grossly volume overloaded, and may require aggressive diuresis\n once he's off pressors.\n .\n RHYTHM: known afib on coumadin. Hold coumadin. Rate much improved\n after switch to neosynephrine.\n .\n ARF: Cr up to 1.9 from basline.\n 1. urine lytes show FENA 0.2%, pre-renal vs ATN in setting\n hypotension\n .\n Nutrition: Consult this AM for low albumin.\n 1. Would restart regular diet if possible although with\n respiratory status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 08:29 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2155-05-11 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325206, "text": "Chief Complaint: septic shock, respiratory distress\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 10:11 AM\n MULTI LUMEN - START 04:00 PM\n MULTI LUMEN - STOP 04:10 PM\n right subclavian line inserted \n ARTERIAL LINE - START 08:29 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Piperacillin - 12:28 AM\n Vancomycin - 12:28 AM\n Infusions:\n Phenylephrine - 4 mcg/Kg/min\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 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: 36.1\nC (96.9\n HR: 113 (100 - 129) bpm\n BP: 118/76(94) {72/50(59) - 120/81(96)} mmHg\n RR: 21 (11 - 30) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n CVP: 8 (1 - 17)mmHg\n Total In:\n 4,185 mL\n 284 mL\n PO:\n TF:\n IVF:\n 4,185 mL\n 284 mL\n Blood products:\n Total out:\n 825 mL\n 133 mL\n Urine:\n 825 mL\n 133 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,360 mL\n 151 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: 7.35/45/132/22/0\n PaO2 / FiO2: 264\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 12.9 g/dL\n 276 K/uL\n 111 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 5.0 mEq/L\n 51 mg/dL\n 104 mEq/L\n 136 mEq/L\n 41.0 %\n 26.1 K/uL\n [image002.jpg]\n 06:37 PM\n 09:47 PM\n 12:25 AM\n 04:00 AM\n 04:59 AM\n 04:25 AM\n 04:42 AM\n WBC\n 34.8\n 30.6\n 26.1\n Hct\n 40.9\n 39.3\n 41.0\n Plt\n 295\n 286\n 276\n Cr\n 1.7\n 1.7\n 1.9\n TropT\n 0.01\n TCO2\n 26\n 27\n 27\n 26\n Glucose\n 83\n 119\n 111\n Other labs: PT / PTT / INR:28.1/36.0/2.8, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:36/58, Alk Phos / T Bili:295/1.6,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:2.7 mmol/L, Albumin:1.9 g/dL, LDH:219 IU/L, Ca++:7.0\n mg/dL, Mg++:2.0 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent ERCP\n w/sphincterotomy and biliary stent for high grade stricture of CBD c/b\n shock, req pressors and intubation x48hrs peri-procedure (brushings\n were \"atypical\" and CA -9 very elevated, suspcious for pancreatic ca)\n transferred from OSH w/shock, leukocytosis (WBC 30K w/40% bands), and\n hypoxemia.\n 1. Shock: Presumed sepsis w/leukocytosis/bandemia and CvO2 75.\n Infectious sources- positive blood cxs from OSH, also concerned for c\n diff given sig diarrhea and recent abx. Other possibilities incl pna\n and billiary source (though LFTs improved c/w prior and abd exam not\n concerning).\n CVP goal ~10, neo for MAP at least 65.\n Broad spectum abx\n zosyn/IV vanco (change IV flagyl to po vanco for c\n diff given high risk).\n f/u cxs (incl from OSH), c diff. Consider steroids empirically if\n increasing pressor requirements. At risk of adrenal dysfunction.\n Checking TTE. Doubt tamponade given low CVP but need to consider in\n differential given effusion, malignancy, etc.\n 2. Hypoxemia: likely pleural effusions + pulm edema. BNP 10K at\n OSH, though some of this may be related to pt\ns afib and .\n Not diuresing while requiring pressors. ?underlying pna; abx as above.\n 3. Afib: rate better controlled on neo. Rx underlying issues and will\n try to add on bblocker when stable. Restart heparin when no upcoming\n procedures.\n 4. ARF: FENa 0.2 c/w pre-renal etiology (though may be an ATN\n component). Checking urine sediment. Trend Cr and uop. Renally dose\n meds.\n 5. Sacral and b/l heel decubs: wound care consult\n 6. CAD: cont asa. EKG unchanged c/w b/l and cardiac enzymes negative.\n Holding BB, ACEI while req pressors.\n 7. FEN: npo for now given hypoxemia req sig suppl O2\n 8. Access: resite CVL (placed at OSH and also too deep), re-attempt\n a-line\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 08:29 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\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": "2155-05-11 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325210, "text": "Chief Complaint: septic shock, respiratory distress\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 24 Hour Events:\n placed w/initial CVP 7-8. A line placed.\n OSH micro: nasal swab MRSA+, GPC in blood, GPC/GNR in urine\n Here bld cxs w/GPC\n This am, decreased uop, rising Cr, rising lactate, SBP 70s w/neo maxed.\n Vasopressin added w/sig improvement in BP and able to decrease neo.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM - stopped\n Piperacillin - 12:28 AM\n Vancomycin IV - 12:28 AM\n Po vanco\n Infusions:\n Phenylephrine - 4 mcg/Kg/min\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Other medications:\n ASA 325\n Atrovent\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 07:53 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: 36.1\nC (96.9\n HR: 113 (100 - 129) bpm\n BP: 118/76(94) {72/50(59) - 120/81(96)} mmHg\n RR: 21 (11 - 30) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n CVP: 8 (1 - 17)mmHg\n Total In:\n 4,185 mL\n 284 mL\n PO:\n TF:\n IVF:\n 4,185 mL\n 284 mL\n Blood products:\n Total out:\n 825 mL\n 133 mL\n Urine:\n 825 mL\n 133 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,360 mL\n 151 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: 7.35/45/132/22/0\n PaO2 / FiO2: 264\n Physical Examination\n Awake, aaox3, NAD\n BS diminished on R, otherwise clear\n Irregularly irregular\n Abd obese, soft, NT, +BS\n 2+ , ulcers wrapped\n Labs / Radiology\n 12.9 g/dL\n 276 K/uL\n 111 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 5.0 mEq/L\n 51 mg/dL\n 104 mEq/L\n 136 mEq/L\n 41.0 %\n 26.1 K/uL\n [image002.jpg]\n 06:37 PM\n 09:47 PM\n 12:25 AM\n 04:00 AM\n 04:59 AM\n 04:25 AM\n 04:42 AM\n WBC\n 34.8\n 30.6\n 26.1\n Hct\n 40.9\n 39.3\n 41.0\n Plt\n 295\n 286\n 276\n Cr\n 1.7\n 1.7\n 1.9\n TropT\n 0.01\n TCO2\n 26\n 27\n 27\n 26\n Glucose\n 83\n 119\n 111\n Other labs: PT / PTT / INR:28.1/36.0/2.8, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:36/58, Alk Phos / T Bili:295/1.6,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:2.7 mmol/L, Albumin:1.9 g/dL, LDH:219 IU/L, Ca++:7.0\n mg/dL, Mg++:2.0 mg/dL, PO4:4.5 mg/dL\n Micro: as above, additionally c diff negative\n AP CXR: worsening R sided effusion\n Assessment and Plan\n 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent ERCP\n w/sphincterotomy and biliary stent for high grade stricture of CBD c/b\n shock, req pressors and intubation x48hrs peri-procedure (brushings\n were \"atypical\" and CA -9 very elevated, suspcious for pancreatic ca)\n transferred from OSH w/shock, leukocytosis (WBC 30K w/40% bands), and\n hypoxemia.\n 1. Shock: Presumed sepsis w/leukocytosis/bandemia and initial CvO2\n 75. GP bacteremia- possible sources = bowel, skin (decubs). Also\n concerned for c diff given sig diarrhea and recent abx (though 1^st\n cdiff neg) and ?pna.\n CVP goal ~10\n Neo and vaso for MAP at least 65\n Recheck CvO2\n Cont broad spectum abx\n zosyn/IV vanco (change IV flagyl to po vanco\n for c diff given high risk).\n Chest CT\n f/u cxs (incl from OSH), c diff.\n Consider steroids empirically if increasing pressor requirements. At\n risk of adrenal dysfunction.\n Checking TTE. Doubt tamponade given low CVP but need to consider in\n differential given effusion, malignancy, etc.\n 2. Hypoxemia: likely pleural effusions + pulm edema. BNP 10K at\n OSH, though some of this may be related to pt\ns afib and .\n Not diuresing while requiring pressors. ?underlying pna; abx as above.\n Cont BDs.\n 3. Afib: rate better controlled on neo. Rx underlying issues and will\n try to add on bblocker when stable. Was on coumadin, holding given\n supratherapeutic INR.\n 4. Oliguric ARF: Suspect now developing ATN. Recheck urine lytes and\n also check urine sediment. Trend Cr and uop. Renally dose meds.\n 5. Sacral and b/l heel decubs: wound care consult\n 6. CAD: cont asa. EKG unchanged c/w b/l and cardiac enzymes negative.\n Holding BB, ACEI while req pressors.\n 7. FEN: npo for now given hypoxemia req sig suppl O2\n 8. Access: , \n ICU Care\n Nutrition:\n Glycemic Control: RISS\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 08:29 PM\n Prophylaxis:\n DVT: INR supratherapeutic\n Stress ulcer:\n VAP: HOB elevation\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": "2155-05-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325213, "text": "Chief Complaint: Sepsis\n 24 Hour Events:\n URINE CULTURE - At 10:11 AM\n MULTI LUMEN - START 04:00 PM\n MULTI LUMEN - STOP 04:10 PM\n right subclavian line inserted \n ARTERIAL LINE - START 08:29 PM\n - Placed Central line, bolused with IVF's with goal CVP of 10mmHg (last\n )\n - Placed A-Line - pressures stable, but increased pressors overnight.\n - Cultures growing GPC in blood\n - OSH cultures: GPC in blood (4/4 bottles), Urine +GPC/GNR, MRSA+\n - TTE not done\n - Agitated overnight, confused, pulling off oxygen at times.\n - Started vasopressin this AM for low UOP, rising lactate and rising\n Cr.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Piperacillin - 12:28 AM\n Vancomycin - 12:28 AM\n Infusions:\n Phenylephrine - 4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 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: 36.1\nC (96.9\n HR: 110 (100 - 121) bpm\n BP: 93/62(75) {72/50(59) - 120/81(96)} mmHg\n RR: 24 (11 - 30) insp/min\n SpO2: 91%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n CVP: 1 (1 - 17)mmHg\n Total In:\n 4,185 mL\n 255 mL\n PO:\n TF:\n IVF:\n 4,185 mL\n 255 mL\n Blood products:\n Total out:\n 825 mL\n 103 mL\n Urine:\n 825 mL\n 103 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,360 mL\n 152 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 91%\n ABG: 7.35/45/132/22/0\n PaO2 / FiO2: 264\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\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 anteriorly, Diminished: at R-base)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+, + lesions on fingers\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): to hospital/, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 276 K/uL\n 12.9 g/dL\n 111 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 5.0 mEq/L\n 51 mg/dL\n 104 mEq/L\n 136 mEq/L\n 41.0 %\n 26.1 K/uL\n [image002.jpg]\n 06:37 PM\n 09:47 PM\n 12:25 AM\n 04:00 AM\n 04:59 AM\n 04:25 AM\n 04:42 AM\n WBC\n 34.8\n 30.6\n 26.1\n Hct\n 40.9\n 39.3\n 41.0\n Plt\n 295\n 286\n 276\n Cr\n 1.7\n 1.7\n 1.9\n TropT\n 0.01\n TCO2\n 26\n 27\n 27\n 26\n Glucose\n 83\n 119\n 111\n Other labs: PT / PTT / INR:28.1/36.0/2.8, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:36/58, Alk Phos / T Bili:295/1.6,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:2.7 mmol/L, Albumin:1.9 g/dL, LDH:219 IU/L, Ca++:7.0\n mg/dL, Mg++:2.0 mg/dL, PO4:4.5 mg/dL\n Imaging: CXR:\n Tip of the new right IJ line ends in the lower SVC, right subclavian\n line tip\n projects over the superior cavoatrial junction as before, large right\n pleural\n effusion is stable, and small left pleural effusion unchanged. Heart\n size top\n normal, partially obscured by large right pleural effusion. Mediastinal\n vascular engorgement improved slightly. No pneumothorax. Gaseous\n distention of the stomach has improved.\n Microbiology: Blood Cultures: GPC in cultures.\n Assessment and Plan\n A/P: 82 M w/ recent admission for painless jaundice s/p ERCP with\n sphincterotomy and biliary stent c/b hypoxia requiring intubation,\n admitted with septic shock\n .\n Septic Shock: On admission was febrile, WBC > 30 with bandemia,\n tachycardic, increased RR. Now with GPC in blood. Unclear source, but\n must consider endocarditis, pulmonary, decubiti or GI source given\n recent diarrhea. Patient without abdominal pain or jaundice to suggest\n acute cholangitis.\n f/u Sputum, Blood, Urine Cx, Cdiff x 3\n 1. Will treat broadly with Vanc/Zosyn/PO Vanco for C. Diff\n 2. Titrate CVP to 10, bolus as needed\n 3. Switched to phenylephrine to avoid beta adrtenergic effect of\n levophed and resulting tachycardia. Added vasopressin this AM. Check\n Mixed Venous O2 sat. Adjust PRN. Might need dobutamine for inotrpoic\n support.\n 4. Transfuse as needed for Hct>30 if MvO2 is < 70%\n 5. Basal cortisol level wnl, no stim\n 6. Line re-positioned, f/u culture of tip although unlikely\n source as placed less than 36 hours ago at OSH.\n 7. TTE for endocarditis. If negative would get CT Scan\n chest/abdomen looking for abdomen. ?osteo underlying wounds.\n 8. Wound care consult.\n 9. CT Chest today for ? effusion/pneumonia.\n .\n Hypoxia: Patient comfortable on 6L. He is willing to be intubated.\n Hypoxia likely a result of pleural effusions, sepsis, volume\n recuscitation.\n 1. ABG this AM 7.35/45/132\n 2. Continue nasal cannula at this point.\n 3. Daily CXR\n 4. Add nebulizer prn\n .\n Pleural effusions: may be malignant pleural effusions vs. chf vs. pna\n 1. ECHO, cycle enzymes, daily EKG\n 2. Empirically treat for HAP with Vanc/Zosyn\n .\n Acute Renal Failure: likely pre-renal from sepsis/hypotension. UOP has\n dropped off this morning, and now with rising Cr/lactate. Added\n vasopressin for second pressor and goal of improved renal perfusion.\n Goal MAP of 70 for today.\n 1. Follow Cr.\n .\n Biliary stricture: Patient with recent admission for painless jaudince\n requiring biliary stent and sphincterotomy. Patient due to stent\n change in . Patient does not appear to have clinical signs of\n cholangitis at this point.\n 1. NPO for now\n 2. Trend LFTs\n 3. empirically treat with Zosyn for biliary organisms\n .\n CAD: MI in 's. Give high dose ASA. Enzymes negative x1 - and with\n negative set at OSH more than 12 hours apart. No need to cycle\n further.\n .\n PUMP: Hold antihypertensives, pressors as needed. Will repeat ECHO.\n Patient grossly volume overloaded, and may require aggressive diuresis\n once he's off pressors.\n .\n RHYTHM: known afib on coumadin. Hold coumadin. Rate much improved\n after switch to neosynephrine.\n .\n ARF: Cr up to 1.9 from basline.\n 1. urine lytes show FENA 0.2%, pre-renal vs ATN in setting\n hypotension\n .\n Nutrition: Consult this AM for low albumin.\n 1. Would restart regular diet if possible although with\n respiratory status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 08:29 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2155-05-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325109, "text": "This is an 82 yr male recently admitted for new onset jaundice w/\n pancreatic dilation. At that time, pt underwent biliary stent placement\n and sphincterotemy and there was a high suspicion for pancreatic CA\n though no bx was done at that time. Treatment was c/b shock requiring\n intubation and pressors X 48hr MD notes. Pt was D/C from to NH.\n At pt developed increasing SOB, cough and edema. Pt was transferred\n to OSH and was later transferred to . In EW Tmax 101.2, HR 140\n BP 72/60, SpO2 90%.\n" }, { "category": "Physician ", "chartdate": "2155-05-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325088, "text": "Chief Complaint: septic shock\n 24 Hour Events:\n EKG - At 05:58 PM\n MULTI LUMEN - START 06:25 PM\n right subclavian line inserted \n BLOOD CULTURED - At 07:24 PM\n URINE CULTURE - At 07:24 PM\n RECTAL SWAB - At 07:24 PM\n BLOOD CULTURED - At 07:41 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:40 PM\n Metronidazole - 04:00 AM\n Piperacillin - 05:00 AM\n Infusions:\n Phenylephrine - 3.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Dyspnea\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 115 (101 - 134) bpm\n BP: 119/50(62) {78/26(40) - 119/72(78)} mmHg\n RR: 26 (13 - 26) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 16 (7 - 20)mmHg\n Total In:\n 1,653 mL\n 1,580 mL\n PO:\n TF:\n IVF:\n 1,653 mL\n 1,580 mL\n Blood products:\n Total out:\n 280 mL\n 210 mL\n Urine:\n 280 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,373 mL\n 1,370 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: 7.36/46/91./26/0\n PaO2 / FiO2: 184\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), irregullar, 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: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 286 K/uL\n 12.6 g/dL\n 119 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 5.1 mEq/L\n 49 mg/dL\n 103 mEq/L\n 137 mEq/L\n 39.3 %\n 34.8 K/uL\n [image002.jpg]\n 06:37 PM\n 09:47 PM\n 12:25 AM\n 04:00 AM\n 04:59 AM\n WBC\n 34.8\n Hct\n 40.9\n 39.3\n Plt\n 295\n 286\n Cr\n 1.7\n 1.7\n TCO2\n 26\n 27\n 27\n Glucose\n 83\n 119\n Other labs: PT / PTT / INR:26.5/33.8/2.6, ALT / AST:36/61, Alk Phos / T\n Bili:313/1.7, Differential-Neuts:86.0 %, Band:10.0 %, Lymph:0.0 %,\n Mono:4.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L, Albumin:2.0 g/dL,\n LDH:216 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 06:25 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2155-05-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325090, "text": "Chief Complaint: septic shock\n 24 Hour Events:\n EKG - At 05:58 PM\n MULTI LUMEN - START 06:25 PM\n right subclavian line inserted \n BLOOD CULTURED - At 07:24 PM\n URINE CULTURE - At 07:24 PM\n RECTAL SWAB - At 07:24 PM\n BLOOD CULTURED - At 07:41 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:40 PM\n Metronidazole - 04:00 AM\n Piperacillin - 05:00 AM\n Infusions:\n Phenylephrine - 3.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Dyspnea\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 115 (101 - 134) bpm\n BP: 119/50(62) {78/26(40) - 119/72(78)} mmHg\n RR: 26 (13 - 26) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 16 (7 - 20)mmHg\n Total In:\n 1,653 mL\n 1,580 mL\n PO:\n TF:\n IVF:\n 1,653 mL\n 1,580 mL\n Blood products:\n Total out:\n 280 mL\n 210 mL\n Urine:\n 280 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,373 mL\n 1,370 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: 7.36/46/91./26/0\n PaO2 / FiO2: 184\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), irregullar, 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: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 286 K/uL\n 12.6 g/dL\n 119 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 5.1 mEq/L\n 49 mg/dL\n 103 mEq/L\n 137 mEq/L\n 39.3 %\n 34.8 K/uL\n [image002.jpg]\n 06:37 PM\n 09:47 PM\n 12:25 AM\n 04:00 AM\n 04:59 AM\n WBC\n 34.8\n Hct\n 40.9\n 39.3\n Plt\n 295\n 286\n Cr\n 1.7\n 1.7\n TCO2\n 26\n 27\n 27\n Glucose\n 83\n 119\n Other labs: PT / PTT / INR:26.5/33.8/2.6, ALT / AST:36/61, Alk Phos / T\n Bili:313/1.7, Differential-Neuts:86.0 %, Band:10.0 %, Lymph:0.0 %,\n Mono:4.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L, Albumin:2.0 g/dL,\n LDH:216 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n A/P: 82 M w/ recent admission for painless jaundice s/p ERCP with\n sphincterotomy and biliary stent c/b hypoxia requiring intubation,\n admitted with septic shock\n Septic Shock: Febrile, WBC > 30 with bandemia, tachycardic, increased\n RR. Unclear source, but differential includes pulmonary or GI source\n given recent diarrhea. Patient without abdominal pain or jaundice to\n suggest acute cholangitis.\n Sputum, Blood, Urine Cx, Cdiff x 3\n 1. Will treat broadly with Vanc/Zosyn/Flagyl\n 2. Titrate CVP to , bolus as needed\n 3. Switched to phenylephrine to avoid beta adrtenergic effect of\n levophed\n 4. Transfuse as needed for Hct>30 if MvO2 is < 70%\n 5. Basal cortisol level\n 6. Re-site line given malpsitioning of line\n Hypoxia: Patient comfortable on 6L. He is willing to be intubated.\n Hypoxia likely a result of pleural effusions.\n 1. ABG\n 2. Continue nasal cannula at this point\n 3. Daily CXR\n 4. Add nebulizer prn\n Pleural effusions: may be malignant pleural effusions vs. chf vs. pna\n 1. Consider thoracentesis, diagnostic and therapetic\n 2. ECHO, cycle enzymes, daily EKG\n 3. Empirically treat for HAP with Vanc/Zosyn\n Biliary stricture: Patient with recent admission for painless jaudince\n requiring biliary stent and sphincterotomy. Patient due to stent\n change in . Patient does not appear to have clinical signs of\n cholangitis at this point.\n 1. NPO for now\n 2. Trend LFTs\n 3. empirically treat with Zosyn/Flagyl for biliary bugs\n CAD: MI in 's. Give high dose ASA. Cycle enzymes.\n PUMP: Hold antihypertensives, pressors as needed. Will repeat ECHO.\n Patient grossly volume overloaded, and may require aggressive diuresis\n once he's off pressors.\n RHYTHM: known afib on coumadin. Hold coumadin. Rate much improved\n after switch to neosynephrine\n ARF: Cr up to 1.9 from basline.\n 1. urine lytes show FENA 0.2%, pre-renal vs ATN in setting\n hypotension\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 06:25 PM, will need line re-sited today\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2155-05-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325095, "text": ":\n 82 yr old man with recent admit () with new onset juandice\n with pacreatic dilation,\n s/p sphincetrotmoty and biliary stent, complicated by shock (pressors,\n intubationx 48hrs periprocedure)\n All cx neg but brushings were \"atypical\" and CA -9 very elevated\n suspcious for panc CA - plan for follow up for US guided Bx, redo stent\n in , out oncology eval.\n Has been at NH since then, states that he has been coughing, more short\n of breath, increased lower ext edema, was sent to hospital, w\n Temp 101.2 HR 140's BP 72/60 rr20 sats 90%\n ABG 7.48/35/70 on 3L\n and CXR with large bilat pleural eff, requiring 6 L nasal cannula.\n WBC 30K and K 5.9\n pro - bnp 10, 859\n Rx ceftriaxone, Levoquin, Clinda at Hospital. Requiring Levophed\n for low BP. Right subclavian central line inserted there.\n Bilat LENI negative\n CXR persistent bilat pleural eff\n Transferred here at 1800 via ambulance. Arrived on insulin drip\n at 2u/hr which was d/c\nd w blood sugar in 80s.\n Also on levophed at .17mcg/kg/min.\n : Pt A&O x2, occ c/o lower extreme pain, particularly L leg with\n movement.\n Pt skin is in bad shape with coccyx decubitus as well as anasarca,\n weeping lower extremities with pink sores evident on lower calves and\n heels. L heel is purple red. He needs skin care consult which was\n ordered and Kinaire bed which is here with pt.\n hosp called with report of 3 bld cx gm positive w pairs and\n clusters, MDs aware.\n Pleural effusion, acute\n Assessment:\n Received on High flow neb at 50%. LS: clear RUL / diminished t/o lung\n fields. Occ wheezing. Sats good at 97-100. Freq non-productive\n cough. c/o sob at times.\n Action:\n ABGs x3, attempted a-line # of times unsuccessfully. CXR at 0300.\n Atrovent neb at 0400.\n Response:\n pO2 improved from 72-82 at 0100. CXR showed increasing failure. Pt\n felt improved breathing following neb.\n Plan:\n Nebs q6hrs. Follow abgs. A-line if possible.\n Shock, septic\n Assessment:\n Received on levophed at .2mcg/kg/min. map > 62. sbp >87. Rapid AF up\n to 140s. Lactate up to 2.9.\n Action:\n Metoprolol 5mg iv x2 w some reduction of HR for short period of time.\n 1L NS. Levophed d/c\nd and Neo started to reduce tachycardia.\n Response:\n Reduced tachycardia after neo started.\n Plan:\n Titrate neo to maintain map > 60. Monitor for tachycardia,\n hypotension.\n Pain control (acute pain, chronic pain)\n Assessment:\n Occ c/o pain bilat in legs esp when moving, but minimal pain when at\n rest.\n Action:\n Pain med not given due to minimal pain at rest.\n Response:\n Tolerated well.\n Plan:\n Pain med if pt requests for sustained pain.\n Impaired Skin Integrity\n Assessment:\n Coccyx pressure sore covered w allevyn dsg, intact. Bilat lower legs\n weeping. L heel red/purple. R heel has sores on side of heel. L arm\n weeping. Pt can only minimally move L arm, states due to torn ligament\n in shoulder. L elbow very red and swollen.\n Action:\n Bathed pt, changed pads to legs and L arm q4hrs. padding in place at L\n elbow.\n Response:\n Pt tol treatment well.\n Plan:\n Skin care nurse consult for Monday. Keep pt clean and dry as\n possible. Maintain allevyn dsg intact if possible til Monday or change\n if soiled.\n" }, { "category": "Physician ", "chartdate": "2155-05-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325096, "text": "Chief Complaint: shock, respiratory distress\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 82 yo M w/afib on coumadin, hypothyroidism, and CAD s/p MI s/p recent\n ERCP w/sphincterotomy and biliary stent for high grade stricture of CBD\n c/b shock, req pressors and intubation x48hrs peri-procedure (brushings\n were \"atypical\" and CA -9 very elevated, suspcious for pancreatic ca)\n transferred from OSH w/shock, leukocytosis (WBC 30K w/40% bands), and\n BNP 10K. Likely septic shock, though may be cardiogenic component\n w/BNP 10K- checking CvO2. Potential souces of infection= c diff given\n sig diarrhea and recent abx (most likely) vs. pna vs. biliary source\n (but LFTs better and no RUQ TTP); pan cx'd. Bolus for CVP goal ~10,\n MAP >65 w/levophed. On 6L suppl O2- hypoxemia likely pleural\n effusions + mild pulm edema; monitor O2 sats closely w/IVF\n resuscitation. Afib currently not rate controlled- but in shock and on\n levophed, rx'ing underlyzing causes. ARF- pre-renal +/- ATN, following\n uop.\n 24 Hour Events:\n EKG - At 05:58 PM\n MULTI LUMEN - START 06:25 PM\n right subclavian line inserted \n BLOOD CULTURED - At 07:24 PM\n URINE CULTURE - At 07:24 PM\n RECTAL SWAB - At 07:24 PM\n BLOOD CULTURED - At 07:41 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:40 PM\n Metronidazole - 04:00 AM\n Piperacillin - 05:00 AM\n Infusions:\n Phenylephrine - 3.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:01 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: 36.8\nC (98.3\n HR: 111 (101 - 134) bpm\n BP: 93/67(74) {78/26(40) - 119/72(78)} mmHg\n RR: 19 (13 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (7 - 20)mmHg\n Total In:\n 1,653 mL\n 1,676 mL\n PO:\n TF:\n IVF:\n 1,653 mL\n 1,676 mL\n Blood products:\n Total out:\n 280 mL\n 350 mL\n Urine:\n 280 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,373 mL\n 1,326 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: 7.36/46/91./26/0\n PaO2 / FiO2: 184\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), irregularly irregular\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Absent), (Left DP pulse:\n Absent), pulses w/doppler\n Respiratory / Chest: (Breath Sounds: Diminished: bilaterally)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\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 12.6 g/dL\n 286 K/uL\n 119 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 5.1 mEq/L\n 49 mg/dL\n 103 mEq/L\n 137 mEq/L\n 39.3 %\n 34.8 K/uL\n [image002.jpg]\n 06:37 PM\n 09:47 PM\n 12:25 AM\n 04:00 AM\n 04:59 AM\n WBC\n 34.8\n Hct\n 40.9\n 39.3\n Plt\n 295\n 286\n Cr\n 1.7\n 1.7\n TCO2\n 26\n 27\n 27\n Glucose\n 83\n 119\n Other labs: PT / PTT / INR:26.5/33.8/2.6, ALT / AST:36/61, Alk Phos / T\n Bili:313/1.7, Differential-Neuts:86.0 %, Band:10.0 %, Lymph:0.0 %,\n Mono:4.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L, Albumin:2.0 g/dL,\n LDH:216 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 82 yr old man with recent shock from biliary sepsis, heart failure,\n been at nursing home with significant diarrhea, new cough, SOB, and\n worsening lower ext edema now transferred with shock\n 1. Shock: Suspect septic picture with C diff as most concerning\n source\n CVP now, will continue volume resusitation to CVP closer to\n 10\n Meanwhile use levophed to maintain MAPs at 60, UOP,\n ++ Diarhhea and was on broad spectrum ABX recently- check\n C diff. very reassuring ABd exam,\n ++ Cough, Pleural effussions: possible PNA, check sputum\n cx, doubt\n ++ recent biliary sepsis but lfts much improved and no\n right upper\n Check blood and urine cultures as well\n Also concern for a cardiogenic component - high BNP\n check Scvo2 -\n 2. Hypoxemia: new O2 requirement, getting volume resuscitation,\n 3. Afib: poorly rate controlled but is in shock and on levophed, Rx\n underlying issues and will try to add on bblocker when stable.\n Restart heparin when no immenent procedures\n 4. ARF: pre renal and may be an ATN component, assess with volume\n resuscitation, trend Cr UOP Renally dose all meds\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 06:25 PM\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 :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2155-05-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325097, "text": "Chief Complaint: shock, respiratory distress\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 82 yo M w/afib on coumadin, hypothyroidism, and CAD s/p MI s/p recent\n ERCP w/sphincterotomy and biliary stent for high grade stricture of CBD\n c/b shock, req pressors and intubation x48hrs peri-procedure (brushings\n were \"atypical\" and CA -9 very elevated, suspcious for pancreatic\n ca), now transferred from OSH w/shock, hypoxemia, and leukocytosis (WBC\n 30K w/40% bands). Likely septic shock, though may be cardiogenic\n component w/BNP 10K.\n 24 Hour Events:\n EKG - At 05:58 PM\n MULTI LUMEN - START 06:25 PM\n right subclavian line inserted \n BLOOD CULTURED - At 07:24 PM\n URINE CULTURE - At 07:24 PM\n RECTAL SWAB - At 07:24 PM\n BLOOD CULTURED - At 07:41 PM\n Tachycardic on levophed so changed to neo w/improvement in HR and BP.\n A-line attempted x3 w/o success.\n CvO2 75\n OSH blood cxs-\n bottles w/GPC, spec pending\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:40 PM\n Metronidazole - 04:00 AM\n Piperacillin - 05:00 AM\n Infusions:\n Phenylephrine - 3.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Asa 325\n Atrovent q6hrs\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:01 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: 36.8\nC (98.3\n HR: 111 (101 - 134) bpm\n BP: 93/67(74) {78/26(40) - 119/72(78)} mmHg\n RR: 19 (13 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (7 - 20)mmHg\n Total In:\n 1,653 mL\n 1,676 mL\n PO:\n TF:\n IVF:\n 1,653 mL\n 1,676 mL\n Blood products:\n Total out:\n 280 mL\n 350 mL\n Urine:\n 280 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,373 mL\n 1,326 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: 7.36/46/91./26/0\n PaO2 / FiO2: 184\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), irregularly irregular\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Absent), (Left DP pulse:\n Absent), pulses w/doppler\n Respiratory / Chest: clear anteriorly b/l, diminsed laterally b/l\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing,\n weeping skin\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice, sacral decub, decubs\n on heels b/l\n Neurologic: Attentive, Follows simple commands, answering questions\n appropriately\n Labs / Radiology\n 12.6 g/dL\n 286 K/uL\n 119 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 5.1 mEq/L\n 49 mg/dL\n 103 mEq/L\n 137 mEq/L\n 39.3 %\n 34.8 K/uL\n [image002.jpg]\n 06:37 PM\n 09:47 PM\n 12:25 AM\n 04:00 AM\n 04:59 AM\n WBC\n 34.8\n Hct\n 40.9\n 39.3\n Plt\n 295\n 286\n Cr\n 1.7\n 1.7\n TCO2\n 26\n 27\n 27\n Glucose\n 83\n 119\n Other labs: PT / PTT / INR:26.5/33.8/2.6, ALT / AST:36/61, Alk Phos / T\n Bili:313/1.7, Differential-Neuts:86.0 %, Band:10.0 %, Lymph:0.0 %,\n Mono:4.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L, Albumin:2.0 g/dL,\n LDH:216 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Random cortisol 35\n Portable CXR\n b/l effusions (R>>L), R subclavian CVL deep\n Assessment and Plan\n 82 yr old man with recent shock from biliary sepsis, heart failure,\n been at nursing home with significant diarrhea, new cough, SOB, and\n worsening lower ext edema now transferred with shock\n 82 yo M w/afib on coumadin, hypothyroidism, and CAD s/p MI s/p recent\n ERCP w/sphincterotomy and biliary stent for high grade stricture of CBD\n c/b shock, req pressors and intubation x48hrs peri-procedure (brushings\n were \"atypical\" and CA -9 very elevated, suspcious for pancreatic ca)\n transferred from OSH w/shock, leukocytosis (WBC 30K w/40% bands), and\n BNP 10K. Likely septic shock, though may be cardiogenic component\n w/BNP 10K- checking CvO2. Potential souces of infection= c diff given\n sig diarrhea and recent abx (most likely) vs. pna vs. biliary source\n (but LFTs better and no RUQ TTP); pan cx'd. Bolus for CVP goal ~10,\n MAP >65 w/levophed. On 6L suppl O2- hypoxemia likely pleural\n effusions + mild pulm edema; monitor O2 sats closely w/IVF\n resuscitation. Afib currently not rate controlled- but in shock and on\n levophed, rx'ing underlyzing causes. ARF- pre-renal +/- ATN, following\n uop.\n 1. Shock: septic picture. Infectious sources- positive blood cxs from\n OSH, also concerned for c diff given sig diarrhea and recent abx.\n Other possibilities incl pna and billiary source (though LFTs improved\n c/w prior).\n CVP goal 10, neo for MAP at least 65. Broad spectum abx (change IV\n flagyl to po vanco for c diff given high risk). f/u cxs, c diff.\n ++ Diarhhea and was on broad spectrum ABX recently- check\n C diff. very reassuring ABd exam,\n ++ Cough, Pleural effussions: possible PNA, check sputum\n cx, doubt\n ++ recent biliary sepsis but lfts much improved and no\n right upper\n Also concern for a cardiogenic component - high BNP\n check CvO2\n 2. Hypoxemia: likely vol overload/effusions. ?underlying pna.\n 3. Afib: rate better controlled on neo. Rx underlying issues and will\n try to add on bblocker when stable. Restart heparin when no immenent\n procedures.\n 4. ARF: pre renal and may be an ATN component, assess with volume\n resuscitation, trend Cr, UOP. Renally dose all meds. FENa 0.2, c/w\n pre-renal. Check urine sediment.\n 5. Sacral decub: wound care consult\n 6. CAD: cont asa, EKG unchanged. Cardiac enzymes negative. Holding\n BB, ACEI while req pressors.\n 7. FEN: npo for now given hypoxemia abd need for sig suppl O2\n 8. Access: resite CVL, re-attempt a-line\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 06:25 PM\n Prophylaxis:\n DVT: SQ UF Heparin once INR drifts below 2\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2155-05-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325100, "text": "Chief Complaint: septic shock\n 24 Hour Events:\n EKG - At 05:58 PM\n MULTI LUMEN - START 06:25 PM\n right subclavian line inserted \n BLOOD CULTURED - At 07:24 PM\n URINE CULTURE - At 07:24 PM\n RECTAL SWAB - At 07:24 PM\n BLOOD CULTURED - At 07:41 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:40 PM\n Metronidazole - 04:00 AM\n Piperacillin - 05:00 AM\n Infusions:\n Phenylephrine - 3.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Dyspnea\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 115 (101 - 134) bpm\n BP: 119/50(62) {78/26(40) - 119/72(78)} mmHg\n RR: 26 (13 - 26) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 16 (7 - 20)mmHg\n Total In:\n 1,653 mL\n 1,580 mL\n PO:\n TF:\n IVF:\n 1,653 mL\n 1,580 mL\n Blood products:\n Total out:\n 280 mL\n 210 mL\n Urine:\n 280 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,373 mL\n 1,370 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: 7.36/46/91./26/0\n PaO2 / FiO2: 184\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), irregullar, 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: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 286 K/uL\n 12.6 g/dL\n 119 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 5.1 mEq/L\n 49 mg/dL\n 103 mEq/L\n 137 mEq/L\n 39.3 %\n 34.8 K/uL\n [image002.jpg]\n 06:37 PM\n 09:47 PM\n 12:25 AM\n 04:00 AM\n 04:59 AM\n WBC\n 34.8\n Hct\n 40.9\n 39.3\n Plt\n 295\n 286\n Cr\n 1.7\n 1.7\n TCO2\n 26\n 27\n 27\n Glucose\n 83\n 119\n Other labs: PT / PTT / INR:26.5/33.8/2.6, ALT / AST:36/61, Alk Phos / T\n Bili:313/1.7, Differential-Neuts:86.0 %, Band:10.0 %, Lymph:0.0 %,\n Mono:4.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L, Albumin:2.0 g/dL,\n LDH:216 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n A/P: 82 M w/ recent admission for painless jaundice s/p ERCP with\n sphincterotomy and biliary stent c/b hypoxia requiring intubation,\n admitted with septic shock\n Septic Shock: Febrile, WBC > 30 with bandemia, tachycardic, increased\n RR. Unclear source, but differential includes pulmonary or GI source\n given recent diarrhea. Patient without abdominal pain or jaundice to\n suggest acute cholangitis.\n Sputum, Blood, Urine Cx, Cdiff x 3\n 1. Will treat broadly with Vanc/Zosyn/Flagyl\n 2. Titrate CVP to , bolus as needed\n 3. Switched to phenylephrine to avoid beta adrtenergic effect of\n levophed\n 4. Transfuse as needed for Hct>30 if MvO2 is < 70%\n 5. Basal cortisol level wnl, no stim\n 6. Re-site line given malpsitioning of line\n Hypoxia: Patient comfortable on 6L. He is willing to be intubated.\n Hypoxia likely a result of pleural effusions.\n 1. ABG\n 2. Continue nasal cannula at this point\n 3. Daily CXR\n 4. Add nebulizer prn\n Pleural effusions: may be malignant pleural effusions vs. chf vs. pna\n 1. ECHO, cycle enzymes, daily EKG\n 2. Empirically treat for HAP with Vanc/Zosyn\n Biliary stricture: Patient with recent admission for painless jaudince\n requiring biliary stent and sphincterotomy. Patient due to stent\n change in . Patient does not appear to have clinical signs of\n cholangitis at this point.\n 1. NPO for now\n 2. Trend LFTs\n 3. empirically treat with Zosyn/Flagyl for biliary organisms\n CAD: MI in 's. Give high dose ASA. Cycle enzymes.\n PUMP: Hold antihypertensives, pressors as needed. Will repeat ECHO.\n Patient grossly volume overloaded, and may require aggressive diuresis\n once he's off pressors.\n RHYTHM: known afib on coumadin. Hold coumadin. Rate much improved\n after switch to neosynephrine\n ARF: Cr up to 1.9 from basline.\n 1. urine lytes show FENA 0.2%, pre-renal vs ATN in setting\n hypotension\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 06:25 PM, will need line re-sited today\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2155-05-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325163, "text": "This is an 82 yr male recently admitted for new onset jaundice w/\n pancreatic dilation. At that time, pt underwent biliary stent placement\n and sphincterotemy and there was a high suspicion for pancreatic CA.\n Treatment was c/b shock requiring intubation and pressors X 48hr MD\n notes. Pt was D/C from to Rehab on . At rehab pt developed\n increasing SOB, cough and edema. Pt was transferred to OSH yesterday.\n In EW T max 101.2, HR 140\ns, BP 72/60. Pt was started on ceftriaxone,\n levofloxacin, and clindamycin. Additionally, pt was started on levophed\n for hypotension. Pt was transferred to on for further\n management.\n Shock, septic\n Assessment:\n Pt presented to OSH w/ tmax 101.2, hypotensive as above. 3 / 4 blood\n cultures at OSH positive for gram positive cocci. Mixed venous O2 75\n MD. Pt remains pressor dependent. CVP 9-12 t/o most of shift,\n though dropped to 4 ~ 1330. Pt being r/o\nd for c-diff. ABG 7.36/46/92\n w/ am labs. Pt continuous w/ nearly continuous loose, non-productive\n cough. Received pt w/ L subclavian triple lumen line.\n Action:\n Monitoring hemodynamic status closely. Team unable to obtain a-line\n access overnoc despite several attempts. Cycling NBP q5min. Titrating\n phenylepherine to maintain MAP >65 MD. Flagyl has been changed to\n PO vanc. Pt also continues on IV vanc and zyosyn. Stool sample sent for\n C-diff cx previous shift per report. Urine specimen sent for legionella\n culture as ordered. Pt has received NS 500ml bolus X 4 since initial\n CVP drop at 1330\n see flowsheet and . Contact precautions\n initiated. Pt continues on 50% FiO2 via cool neb. RT to obtain sputum\n cx via induction as ordered. Team reports that they will order mucinex\n for pt tonight\n awaiting orders.\n Response:\n Unable to make significant progress weaning phenylepherine. Pt\n hypotensive w/ SBP to 70\ns w/ doses below 3.2mcg/kg/min. BP remains\n stable on current dose\n see flow sheet.. CVP increased to 8 s/p NS\n bolus as above. Pt remains afebrile t/o shift. Pt continuous w/\n frequent loose brown stools. SpO2 remains >95% t/o shift. Pt denies any\n significant changes in SOB this shift, remains free of diaphoresis and\n remains free of s/s distress.\n Plan:\n Continue to monitor hemodynamics closely. Continue abx as ordered.\n Titrate phenylepherine to maintain MAP > 65 as ordered and wean as\n able. Monitor respiratory status and wean FiO2 as able. Continue\n mucinex as ordered.\n Tachycardia, Other\n Assessment:\n Hr to 140\ns at OSH\n AF w/ RVR. Previous shift norepinepherine was\n changed to phenylepherine and pt was given lopressor IV as ordered per\n report.\n Action:\n Continuous ECG monitoring per ICU protocol. Pt continuous on\n phenylepherine as above. Monitoring for s/s cardiac ischemia.\n Response:\n Pt c/o substernal, non-radiating chest\npressure\n at start of\n shift. Pt reported discomfort somewhat worse w/ deep inspiration. No\n acute changes in VS noted, pt remained free of diaphoresis, remained\n calm and cooperative and denied any acute increasing SOB. 12 Lead EKG\n obtained and reviewed by team who report no significant changes. HR has\n remained <130 t/o shift, and has overall remained 90\ns to low 100\n see flowsheet. Rhythm remains afib w/ rare PVC. Pt has denied any\n further episodes of chest pain, pressure or discomfort and remains free\n of distress t/o shift.\n Plan:\n Continue ECG monitoring per protocol. Continue to monitor for s/s\n cardiac ischemia.\n Impaired Skin Integrity\n Assessment:\n Pt w/ sacral decube per report. Area covered w/ allevyn dsng that has\n remained CDI t/o shift. Pt w/ several small stage II-III decubitus\n ulcers to R heal and R lateral calf w/ yellow wound base and red\n surrounding tissue. L heal and L calf w/ small decubitus ulcers w/\n yellow wound base and red surrounding tissue. R elbow red w/ small area\n of superficial peeling skin. Pt continues w/ anasarca, and RUE, and BLE\n continue to weep copious amounts of serous fluid requiring frequent\n dsng changes\n see flow sheet.\n Action:\n Pt on kinair bed w/ frequent repositioning. Soft sorb dsng w/ cling\n wrap applied to RUE and BLE. Waffle boots placed to BLE at start of\n shift to decrease pressure to heals. Orders obtained to D/C compression\n boots, and team has decided against heparin given INR of 2.6. Providing\n frequent skin care and dressing changes to minimize moisture and\n facilitate wound healing.\n Response:\n Extremities continue to ooze copious amounts of serious drainage. Pt\n tolerating dsng changes, skin care and positioning well.\n Plan:\n Continue current measures to facilitate wound healing.\n ------ Protected Section ------\n Correction to above: pt received total NS bolus 500ml X 3 this shift as\n ordered. See orders and .\n ------ Protected Section Addendum Entered By: , RN\n on: 18:47 ------\n" }, { "category": "Nursing", "chartdate": "2155-05-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325156, "text": "This is an 82 yr male recently admitted for new onset jaundice w/\n pancreatic dilation. At that time, pt underwent biliary stent placement\n and sphincterotemy and there was a high suspicion for pancreatic CA.\n Treatment was c/b shock requiring intubation and pressors X 48hr MD\n notes. Pt was D/C from to Rehab on . At rehab pt developed\n increasing SOB, cough and edema. Pt was transferred to OSH yesterday.\n In EW T max 101.2, HR 140\ns, BP 72/60. Pt was started on ceftriaxone,\n levofloxacin, and clindamycin. Additionally, pt was started on levophed\n for hypotension. Pt was transferred to on for further\n management.\n Shock, septic\n Assessment:\n Pt presented to OSH w/ tmax 101.2, hypotensive as above. 3 / 4 blood\n cultures at OSH positive for gram positive cocci. Mixed venous O2 75\n MD. Pt remains pressor dependent. CVP 9-12 t/o most of shift,\n though dropped to 4 ~ 1330. Pt being r/o\nd for c-diff. ABG 7.36/46/92\n w/ am labs. Pt continuous w/ nearly continuous loose, non-productive\n cough. Received pt w/ L subclavian triple lumen line.\n Action:\n Monitoring hemodynamic status closely. Team unable to obtain a-line\n access overnoc despite several attempts. Cycling NBP q5min. Titrating\n phenylepherine to maintain MAP >65 MD. Flagyl has been changed to\n PO vanc. Pt also continues on IV vanc and zyosyn. Stool sample sent for\n C-diff cx previous shift per report. Urine specimen sent for legionella\n culture as ordered. Pt has received NS 500ml bolus X 4 since initial\n CVP drop at 1330\n see flowsheet and . Contact precautions\n initiated. Pt continues on 50% FiO2 via cool neb. RT to obtain sputum\n cx via induction as ordered. Team reports that they will order mucinex\n for pt tonight\n awaiting orders.\n Response:\n Unable to make significant progress weaning phenylepherine. Pt\n hypotensive w/ SBP to 70\ns w/ doses below 3.2mcg/kg/min. BP remains\n stable on current dose\n see flow sheet.. CVP increased to 8 s/p NS\n bolus as above. Pt remains afebrile t/o shift. Pt continuous w/\n frequent loose brown stools. SpO2 remains >95% t/o shift. Pt denies any\n significant changes in SOB this shift, remains free of diaphoresis and\n remains free of s/s distress.\n Plan:\n Continue to monitor hemodynamics closely. Continue abx as ordered.\n Titrate phenylepherine to maintain MAP > 65 as ordered and wean as\n able. Monitor respiratory status and wean FiO2 as able. Continue\n mucinex as ordered.\n Tachycardia, Other\n Assessment:\n Hr to 140\ns at OSH\n AF w/ RVR. Previous shift norepinepherine was\n changed to phenylepherine and pt was given lopressor IV as ordered per\n report.\n Action:\n Continuous ECG monitoring per ICU protocol. Pt continuous on\n phenylepherine as above. Monitoring for s/s cardiac ischemia.\n Response:\n Pt c/o substernal, non-radiating chest\npressure\n at start of\n shift. Pt reported discomfort somewhat worse w/ deep inspiration. No\n acute changes in VS noted, pt remained free of diaphoresis, remained\n calm and cooperative and denied any acute increasing SOB. 12 Lead EKG\n obtained and reviewed by team who report no significant changes. HR has\n remained <130 t/o shift, and has overall remained 90\ns to low 100\n see flowsheet. Rhythm remains afib w/ rare PVC. Pt has denied any\n further episodes of chest pain, pressure or discomfort and remains free\n of distress t/o shift.\n Plan:\n Continue ECG monitoring per protocol. Continue to monitor for s/s\n cardiac ischemia.\n Impaired Skin Integrity\n Assessment:\n Pt w/ sacral decube per report. Area covered w/ allevyn dsng that has\n remained CDI t/o shift. Pt w/ several small stage II-III decubitus\n ulcers to R heal and R lateral calf w/ yellow wound base and red\n surrounding tissue. L heal and L calf w/ small decubitus ulcers w/\n yellow wound base and red surrounding tissue. R elbow red w/ small area\n of superficial peeling skin. Pt continues w/ anasarca, and RUE, and BLE\n continue to weep copious amounts of serous fluid requiring frequent\n dsng changes\n see flow sheet.\n Action:\n Pt on kinair bed w/ frequent repositioning. Soft sorb dsng w/ cling\n wrap applied to RUE and BLE. Waffle boots placed to BLE at start of\n shift to decrease pressure to heals. Orders obtained to D/C compression\n boots, and team has decided against heparin given INR of 2.6. Providing\n frequent skin care and dressing changes to minimize moisture and\n facilitate wound healing.\n Response:\n Extremities continue to ooze copious amounts of serious drainage. Pt\n tolerating dsng changes, skin care and positioning well.\n Plan:\n Continue current measures to facilitate wound healing.\n" }, { "category": "Nursing", "chartdate": "2155-05-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325232, "text": "This is an 82 yr male recently admitted for new onset jaundice w/\n pancreatic dilation. At that time, pt underwent biliary stent placement\n and sphincterotemy and there was a high suspicion for pancreatic CA.\n Treatment was c/b shock requiring intubation and pressors X 48hr MD\n notes. Pt was D/C from to Rehab on . At rehab pt developed\n increasing SOB, cough and edema. Pt was transferred to OSH yesterday.\n In EW T max 101.2, HR 140\ns, BP 72/60. Pt was started on ceftriaxone,\n levofloxacin, and clindamycin. Additionally, pt was started on levophed\n for hypotension. Pt was transferred to on for further\n management.\n Shock, septic\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": "Physician ", "chartdate": "2155-05-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 325048, "text": "Chief Complaint: septic shock\n HPI:\n 82M w/ hypothyroidism, afib on Coumadin, HTN, CAD w/ MI in , s/p\n ERCP under general anesthesia on after he became jaundiced and\n US & CT Abdomen on revealed marked biliary dilatation. During\n ERCP, he received sphincterotomy and biliary stent due to high grade\n stricture. He did not tolerate the procedure well, was intubated, sent\n to the , & required Neosynephine for shock and completed a course\n of Levo/Flagy for biliary organisms. All cultures negative.\n Patient sent to rehab on and was sent to ,\n , MA after having respiratory distress. imaging notable for\n large pleural effusions. Outside vital signs: 101.2 140 72/60 90%\n FiO2. Labs signficant for WBC of 30 with 90% PMNs, Hct of 39.8, BNP of\n 10K, negative Ces, Cr of 1.9. Patient was initially given\n CTX/Levo/Clinda for broad spectrum abx, then changed to Imipenem.\n Patient reports that he's had a nonproductive cough for 3 weeks with an\n acute onset of SOB within the past 24 hours. he denies chest pain\n ,lightheadedness, palpitations, fevers, chills, abdominal pain. he\n does report increasing diarrhea for the past 3 weeks. He also reports\n increased LE edema and pain.\n Last CXR @ done on revelaed large bilateral pleural\n effusions.\n Labs on recent admission were notable for:\n CBC WNL\n CHEM10: WNL\n ALT: 494\n AST: 737\n ALKP: 2245\n Tbili: 10.7\n Alb: 2.7\n CA -9: 1824\n Cytology showed: Rare crowded glandular epithelial cells with goblet\n cell metaplasia.\n Initial plan was to have ERCP guided stent change in .\n Patient admitted from: Transfer from other hospital, \n ()\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 2 units/hour\n Norepinephrine - 0.18 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Heparin 5000U tid\n Atrovent\n Warfarin 5 mg daily\n Nadolol 20 daily\n Losartan 50 daily\n ASA 81\n Niaspan ER 750\n Triamterene 50 mg qod\n Past medical history:\n Family history:\n Social History:\n Biliary stricture s/p ERCP sphincterotomy and stent on Aptil 18, \n CAD, MI in Echo showed old IPMI. stress echo in showed no e/o\n ischemia.\n Afib: diagnosed 06. underwent DCCV in . now back in afib.\n HTN\n Obesity\n Gout\n Hypothyroidism\n Shrapnel in his face during WWII s/p removal\n Noncontributory\n Occupation:\n Drugs: quit several years ago\n Tobacco: quit several years ago\n Alcohol: none\n Other:\n Review of systems:\n Cardiovascular: No Chest pain, No Palpitations, Tachycardia, Orthopnea\n Respiratory: Cough, Dyspnea, Tachypnea\n Gastrointestinal: No Abdominal pain, Diarrhea\n Genitourinary: No Dysuria\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Jaundice\n Pain location: bilateral foot pain\n Flowsheet Data as of 08:01 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 113 (101 - 122) bpm\n BP: 95/47(60) {79/26(40) - 100/70(66)} mmHg\n RR: 13 (13 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SA (Sinus Arrhythmia)\n CVP: 7 (7 - 8)mmHg\n Total In:\n 1,077 mL\n PO:\n TF:\n IVF:\n 1,077 mL\n Blood products:\n Total out:\n 0 mL\n 160 mL\n Urine:\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 917 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, No(t) Overweight / Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated, Conjunctiva pale\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Dullness : ), (Breath Sounds: Bronchial: in RLL, Diminished: diffusely)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended,\n tympanitic\n Extremities: Right: 3+, Left: 3+, No(t) Clubbing\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 295 K/uL\n 13.2 g/dL\n 83 mg/dL\n 1.7 mg/dL\n 51 mg/dL\n 28 mEq/L\n 103 mEq/L\n 5.4 mEq/L\n 136 mEq/L\n 40.9 %\n 34.8 K/uL\n [image002.jpg]\n \n 2:33 A5/9/ 06:37 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 34.8\n Hct\n 40.9\n Plt\n 295\n Cr\n 1.7\n Glucose\n 83\n Other labs: PT / PTT / INR:25.9/32.2/2.6, Ca++:7.9 mg/dL, Mg++:2.2\n mg/dL, PO4:3.5 mg/dL\n Fluid analysis / Other labs: Bile Washings:\n Cytology showed: Rare crowded glandular epithelial cells with goblet\n cell metaplasia.\n Imaging: LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of \n 6:14 PM\n 1. Hypoechoic mass in the head of the pancreas, causing biliary\n obstruction. This appearance is highly concerning for pancreatic\n neoplasm, particulary ductal adenocarcinoma, and further evaluation\n with contrast-enhanced CT is recommended.\n 2. Echogenic liver, which could reflect presence of fatty infiltration.\n However, other forms of liver disease and more serious liver disease,\n including hepatic cirrhosis/fibrosis, cannot be excluded on the basis\n of this\n study.\n CTA ABD W&W/O C & RECONS Study Date of 10:58 PM\n IMPRESSION:\n 1. Marked biliary and pancreatic ductal dilation. No definite\n pancreatic head mass identified. Further evaluation with ERCP is\n suggested.\n 2. Bilateral pleural effusions and ascites.\n 3. Bilateral non-obstructing renal stones and renal cysts. 2.2-cm\n hyperdense cyst in the interpolar region of the right kidney. Continued\n attention to this region on followup imaging is recommended.\n The initial wet read for this examination read \"3.4-cm pancreatic head\n mass. Intra- and extrahepatic biliary ductal dilation. Pancreatic duct\n dilation. Free fluid. Bilateral pleural effusions, right greater than\n left. Enhancing right renal cyst. Left renal cyst.\" The finding of no\n definite pancreatic head mass was called to the resident caring for the\n patient on at approximately 9:30 a.m\n ERCP \n 1.Normal major papilla\n 2.Cannulation of the biliary duct was performed with a sphincterotome\n using a free-hand technique.\n 3.Cholangiogram showed a irregular malignant appearing high grade\n stricture in the distal CBD measuring 1.5 cm. The bile duct proximal to\n the stricture appeared dilated.\n 4.A sphincterotomy was performed in the 12 o'clock position using a\n sphincterotome over an existing guidewire.\n 5.Cytology samples were obtained for histology using a brush at the CBD\n stricture.\n 6.A 7cm by 10F Cotton biliary stent was placed successfully\n across the biliary stricture\n BILAT LOWER EXT VEINS PORT Study Date of 1:52 PM\n IMPRESSION: No evidence of DVT.\n CHEST (PORTABLE AP) Study Date of 12:11 PM\n IMPRESSION: Persistent bilateral pleural effusions and bibasilar\n atelectasis.\n Microbiology: None\n ECG: low voltage, afib, no ST or T-wave changes\n Assessment and Plan\n A/P: 82 M w/ recent admission for painless jaundice s/p ERCP with\n sphincterotomy and biliary stent c/b hypoxia requiring intubation,\n admitted with septic shock\n Septic Shock: Febrile, WBC > 30 with bandemia, tachycardic, increased\n RR. Unclear source, but differential includes pulmonary or GI source\n given recent diarrhea. Patient without abdominal pain or jaundice to\n suggest acute cholangitis.\n Sputum, Blood, Urine Cx, Cdiff x 3\n 1. CBC, CHEM 10, LFTs\n 2. CXR, KUB\n 3. Will treat broadly with Vanc/Zosyn/Flagyl\n 4. Titrate CVP to , bolus as needed\n 5. Pressors as needed for MAP>65\n 6. Transfuse as needed for Hct>30 if MvO2 is < 70%\n 7. Basal cortisol level\n 8. Imaging to assess placement of central line\n Hypoxia: Patient comfortable on 6L. He is willing to be intubated.\n Hypoxia likely a result of pleural effusions.\n 1. ABG\n 2. Continue nasal cannula at this point\n 3. Daily CXR\n Pleural effusions: may be malignant pleural effusions vs. chf vs. pna\n 1. Consider thoracentesis, diagnostic and therapetic\n 2. ECHO, cycle enzymes, daily EKG\n 3. Empirically treat for HAP with Vanc/Zosyn\n Biliary stricture: Patient with recent admission for painless jaudince\n requiring biliary stent and sphincterotomy. Patient due to stent\n change in . Patient does not appear to have clinical signs of\n cholangitis at this point.\n 1. NPO for now\n 2. Trend LFTs\n 3. empirically treat with Zosyn/Flagyl for biliary bugs\n CAD: MI in 's. Give high dose ASA. Cycle enzymes.\n PUMP: Hold antihypertensives, pressors as needed. Will repeat ECHO.\n Patient grossly volume overloaded, and may require aggressive diuresis\n once he's off pressors.\n RHYTHM: known afib on coumadin. Hold coumadin and rate control as\n needed. Daily EKG\n Hyperkalemia: Patient with K of 6 at OSH and 5.4 here.\n 1. Will continue to follow\n 2. Kayexalate as needed\n ARF: Cr up to 1.9 from basline. Likely pre-renal in setting of\n diarrhea.\n 1. Will check urine lytes\n 2. Hydrate with NS\n 3. Follow CR\n ICU Care\n Nutrition: NPO\n Glycemic Control finger sticks and HRSS:\n Lines: R subclavian\n Multi Lumen - 06:25 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2155-05-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325049, "text": "82 yr old man with recent admit () with new onset juandice\n with pacreatic dilation,\n s/p sphincetrotmoty and biliary stent, complicated by shock (pressors,\n intubationx 48hrs periprocedure)\n All cx neg but brushings were \"atypical\" and CA -9 very elevated\n suspcious for panc CA - plan for follow up for US guided Bx, redo stent\n in , out oncology eval.\n Has been at NH since then, states that he has been coughing, more short\n of breath, increased lower ext edema. Today was sent to hospital\n Temp 101.2 HR 140's BP 72/60 rr20 sats 90% 40\n ABG 7.48/35/70 on 3L\n and CXR with large bilat pleural eff, requiring 6 L nasal cannula.\n WBC 30K and K 5.9\n pro - bnp 10, 859\n Rx ceftriaxone, Levoquin, Clinda at Hospital. Requiring Levophed\n for low BP. Right subclavian central line inserted there.\n Bilat LENI negative\n CXR persistent bilat pleural eff\n Arrived here 1800 via ambulance. Alert and oriented times two. MAE.\n Complains of lowere extremities bilateral leg pain with movement.\n Requiring Levophed .175mcg/kg/min. Arrived on insulin drip at 2u?hr but\n this was stopped due to blood sugar in the 80\n Pt skin is in bad shape with coccyx decubitus as well as anasarca,\n weeping lower extremities with pink sores evident on lower calves and\n heels. He needs skin care consult which was ordered and Kinaire bed\n which is here with pt.\n Shock, septic\n Assessment:\n BP low requiring levophed at .175mcg/kg/min. CVP initially 8 so pt\n given one liter NS bolus over one hour with CVP up to 12. Pt with\n strong frequent productive cough. Lungs are very decreased throughout.\n Requires 6L N/C with good O2 sats. CXR done on admission. Pt has had\n two blood cultures and urine sent for culture and started on\n flagyl/vanco IV antibiotics. WBC 34\n Action:\n Culturesd and given antibiotics as ordered.\n Response:\n Pt afebrile.\n Plan:\n Follow vital signs closely, continue antibiotics, follow cultures.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complains of lower ext. pain with movement.\n Action:\n Pt positioned for comfort.\n Response:\n Pt restless still.\n Plan:\n need to be ordered for something for pain but his resp status may\n be of greater concern.\n" }, { "category": "Nursing", "chartdate": "2155-05-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325050, "text": "82 yr old man with recent admit () with new onset juandice\n with pacreatic dilation,\n s/p sphincetrotmoty and biliary stent, complicated by shock (pressors,\n intubationx 48hrs periprocedure)\n All cx neg but brushings were \"atypical\" and CA -9 very elevated\n suspcious for panc CA - plan for follow up for US guided Bx, redo stent\n in , out oncology eval.\n Has been at NH since then, states that he has been coughing, more short\n of breath, increased lower ext edema. Today was sent to hospital\n Temp 101.2 HR 140's BP 72/60 rr20 sats 90% 40\n ABG 7.48/35/70 on 3L\n and CXR with large bilat pleural eff, requiring 6 L nasal cannula.\n WBC 30K and K 5.9\n pro - bnp 10, 859\n Rx ceftriaxone, Levoquin, Clinda at Hospital. Requiring Levophed\n for low BP. Right subclavian central line inserted there.\n Bilat LENI negative\n CXR persistent bilat pleural eff\n Arrived here 1800 via ambulance. Alert and oriented times two. MAE.\n Complains of lowere extremities bilateral leg pain with movement.\n Requiring Levophed .175mcg/kg/min. Arrived on insulin drip at 2u?hr but\n this was stopped due to blood sugar in the 80\n Pt skin is in bad shape with coccyx decubitus as well as anasarca,\n weeping lower extremities with pink sores evident on lower calves and\n heels. He needs skin care consult which was ordered and Kinaire bed\n which is here with pt.\n Shock, septic\n Assessment:\n BP low requiring levophed at .175mcg/kg/min. CVP initially 8 so pt\n given one liter NS bolus over one hour with CVP up to 12. Pt with\n strong frequent productive cough. Lungs are very decreased throughout.\n Requires 6L N/C with good O2 sats. CXR done on admission. Pt has had\n two blood cultures and urine sent for culture and started on\n flagyl/vanco IV antibiotics. WBC 34\n Action:\n Culturesd and given antibiotics as ordered.\n Response:\n Pt afebrile.\n Plan:\n Follow vital signs closely, continue antibiotics, follow cultures.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complains of lower ext. pain with movement.\n Action:\n Pt positioned for comfort.\n Response:\n Pt restless still.\n Plan:\n need to be ordered for something for pain but his resp status may\n be of greater concern.\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Pleural effusion, acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2155-05-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325051, "text": "82 yr old man with recent admit () with new onset juandice\n with pacreatic dilation,\n s/p sphincetrotmoty and biliary stent, complicated by shock (pressors,\n intubationx 48hrs periprocedure)\n All cx neg but brushings were \"atypical\" and CA -9 very elevated\n suspcious for panc CA - plan for follow up for US guided Bx, redo stent\n in , out oncology eval.\n Has been at NH since then, states that he has been coughing, more short\n of breath, increased lower ext edema. Today was sent to hospital\n Temp 101.2 HR 140's BP 72/60 rr20 sats 90% 40\n ABG 7.48/35/70 on 3L\n and CXR with large bilat pleural eff, requiring 6 L nasal cannula.\n WBC 30K and K 5.9\n pro - bnp 10, 859\n Rx ceftriaxone, Levoquin, Clinda at Hospital. Requiring Levophed\n for low BP. Right subclavian central line inserted there.\n Bilat LENI negative\n CXR persistent bilat pleural eff\n Arrived here 1800 via ambulance. Alert and oriented times two. MAE.\n Complains of lowere extremities bilateral leg pain with movement.\n Requiring Levophed .175mcg/kg/min. Arrived on insulin drip at 2u?hr but\n this was stopped due to blood sugar in the 80\n Pt skin is in bad shape with coccyx decubitus as well as anasarca,\n weeping lower extremities with pink sores evident on lower calves and\n heels. He needs skin care consult which was ordered and Kinaire bed\n which is here with pt.\n Shock, septic\n Assessment:\n BP low requiring levophed at .175mcg/kg/min. CVP initially 8 so pt\n given one liter NS bolus over one hour with CVP up to 12. Pt with\n strong frequent productive cough. Lungs are very decreased throughout.\n Requires 6L N/C with good O2 sats. CXR done on admission. Pt has had\n two blood cultures and urine sent for culture and started on\n flagyl/vanco IV antibiotics. WBC 34\n Action:\n Culturesd and given antibiotics as ordered.\n Response:\n Pt afebrile.\n Plan:\n Follow vital signs closely, continue antibiotics, follow cultures.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complains of lower ext. pain with movement.\n Action:\n Pt positioned for comfort.\n Response:\n Pt restless still.\n Plan:\n need to be ordered for something for pain but his resp status may\n be of greater concern.\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Pleural effusion, acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2155-05-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325052, "text": "82 yr old man with recent admit () with new onset juandice\n with pacreatic dilation,\n s/p sphincetrotmoty and biliary stent, complicated by shock (pressors,\n intubationx 48hrs periprocedure)\n All cx neg but brushings were \"atypical\" and CA -9 very elevated\n suspcious for panc CA - plan for follow up for US guided Bx, redo stent\n in , out oncology eval.\n Has been at NH since then, states that he has been coughing, more short\n of breath, increased lower ext edema. Today was sent to hospital\n Temp 101.2 HR 140's BP 72/60 rr20 sats 90% 40\n ABG 7.48/35/70 on 3L\n and CXR with large bilat pleural eff, requiring 6 L nasal cannula.\n WBC 30K and K 5.9\n pro - bnp 10, 859\n Rx ceftriaxone, Levoquin, Clinda at Hospital. Requiring Levophed\n for low BP. Right subclavian central line inserted there.\n Bilat LENI negative\n CXR persistent bilat pleural eff\n Arrived here 1800 via ambulance. Alert and oriented times two. MAE.\n Complains of lowere extremities bilateral leg pain with movement.\n Requiring Levophed .175mcg/kg/min. Arrived on insulin drip at 2u?hr but\n this was stopped due to blood sugar in the 80\n Pt is in bad shape with coccyx decubitus as well as anasarca,\n weeping lower extremities with pink sores evident on lower calves and\n heels. He needs care which was ordered and Kinaire bed\n which is here with pt.\n Shock, septic\n Assessment:\n BP low requiring levophed at .175mcg/kg/min. CVP initially 8 so pt\n given one liter NS bolus over one hour with CVP up to . Pt with\n strong frequent productive cough. Lungs are very decreased throughout.\n Requires 6L N/C with good O2 sats. CXR done on admission. Pt has had\n two blood cultures and urine sent for culture and started on\n flagyl/vanco/zosyn IV antibiotics. WBC 34\n Action:\n Cultured and given antibiotics as ordered.\n Response:\n Pt afebrile. Cultures pending.\n Plan:\n Follow vital signs closely, continue antibiotics, follow cultures.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complains of lower ext. pain with movement.\n Action:\n Pt positioned for comfort.\n Response:\n Pt restless still.\n Plan:\n need to be ordered for something for pain but his resp status may\n be of greater concern.\n Impaired Integrity\n Assessment:\n Coccyx wounds open, stage three through dermis. Old dressing removed\n and aquacel and alevyn foam dressing applied.\n Action:\n Wound care nurse put in for next Monday.\n Response:\n Dressing changed, oozing serous sang dnd\n Plan:\n Try to keep wound clean over the WE and go by care wound care\n recommendations on Monday.\n Pleural effusion, acute\n Assessment:\n Lungs sounds are very decreased throughout. RR 20 with O2 sat 99% on 6L\n N/C but pt still complains of SOB. Team reports CXR shows bilateral\n pleural effusions.\n Action:\n Pt is to have blood gas taken to assesss his oxygenation on current O2\n delivery.\n Response:\n Awaiting blood gas results.\n Plan:\n Follow blood gas results and titrate O2 as needed. Pt remains full\n code.\n" }, { "category": "Nursing", "chartdate": "2155-05-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325053, "text": "82 yr old man with recent admit () with new onset juandice\n with pacreatic dilation,\n s/p sphincetrotmoty and biliary stent, complicated by shock (pressors,\n intubationx 48hrs periprocedure)\n All cx neg but brushings were \"atypical\" and CA -9 very elevated\n suspcious for panc CA - plan for follow up for US guided Bx, redo stent\n in , out oncology eval.\n Has been at NH since then, states that he has been coughing, more short\n of breath, increased lower ext edema. Today was sent to hospital\n Temp 101.2 HR 140's BP 72/60 rr20 sats 90% 40\n ABG 7.48/35/70 on 3L\n and CXR with large bilat pleural eff, requiring 6 L nasal cannula.\n WBC 30K and K 5.9\n pro - bnp 10, 859\n Rx ceftriaxone, Levoquin, Clinda at Hospital. Requiring Levophed\n for low BP. Right subclavian central line inserted there.\n Bilat LENI negative\n CXR persistent bilat pleural eff\n Arrived here 1800 via ambulance. Alert and oriented times two. MAE.\n Complains of lowere extremities bilateral leg pain with movement.\n Requiring Levophed .175mcg/kg/min. Arrived on insulin drip at 2u?hr but\n this was stopped due to blood sugar in the 80\n Pt is in bad shape with coccyx decubitus as well as anasarca,\n weeping lower extremities with pink sores evident on lower calves and\n heels. He needs care which was ordered and Kinaire bed\n which is here with pt.\n Shock, septic\n Assessment:\n BP low requiring levophed at .175mcg/kg/min. CVP initially 8 so pt\n given one liter NS bolus over one hour with CVP up to . Pt with\n strong frequent productive cough. Lungs are very decreased throughout.\n Requires 6L N/C with good O2 sats. CXR done on admission. Pt has had\n two blood cultures and urine sent for culture and started on\n flagyl/vanco/zosyn IV antibiotics. WBC 34\n Action:\n Cultured and given antibiotics as ordered.\n Response:\n Pt afebrile. Cultures pending.\n Plan:\n Follow vital signs closely, continue antibiotics, follow cultures.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complains of lower ext. pain with movement.\n Action:\n Pt positioned for comfort. Denies pain at rest\n Response:\n Pt restless stillat times but refused need for pain med.\n Plan:\n need to be ordered for something for pain but his resp status may\n be of greater concern. Watch closely.\n Impaired Integrity\n Assessment:\n Coccyx wounds open, stage three through dermis. Old dressing removed\n and aquacel and alevyn foam dressing applied.\n Action:\n Wound care nurse put in for next Monday.\n Response:\n Dressing changed, oozing serous sang dnd\n Plan:\n Try to keep wound clean over the WE and go by care wound care\n recommendations on Monday. Frequent turns and position changes.\n Pleural effusion, acute\n Assessment:\n Lungs sounds are very decreased throughout. RR 20 with O2 sat 99% on 6L\n N/C but pt still complains of SOB. Team reports CXR shows bilateral\n pleural effusions.\n Action:\n Pt is to have blood gas taken to assesss his oxygenation on current O2\n delivery.\n Response:\n Awaiting blood gas results.\n Plan:\n Follow blood gas results and titrate O2 as needed. Pt remains full\n code.\n" }, { "category": "Nursing", "chartdate": "2155-05-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325054, "text": "82 yr old man with recent admit () with new onset juandice\n with pacreatic dilation,\n s/p sphincetrotmoty and biliary stent, complicated by shock (pressors,\n intubationx 48hrs periprocedure)\n All cx neg but brushings were \"atypical\" and CA -9 very elevated\n suspcious for panc CA - plan for follow up for US guided Bx, redo stent\n in , out oncology eval.\n Has been at NH since then, states that he has been coughing, more short\n of breath, increased lower ext edema. Today was sent to hospital\n Temp 101.2 HR 140's BP 72/60 rr20 sats 90% 40\n ABG 7.48/35/70 on 3L\n and CXR with large bilat pleural eff, requiring 6 L nasal cannula.\n WBC 30K and K 5.9\n pro - bnp 10, 859\n Rx ceftriaxone, Levoquin, Clinda at Hospital. Requiring Levophed\n for low BP. Right subclavian central line inserted there.\n Bilat LENI negative\n CXR persistent bilat pleural eff\n Arrived here 1800 via ambulance. Alert and oriented times two. MAE.\n Complains of lowere extremities bilateral leg pain with movement.\n Requiring Levophed .175mcg/kg/min. Arrived on insulin drip at 2u?hr but\n this was stopped due to blood sugar in the 80\n Pt is in bad shape with coccyx decubitus as well as anasarca,\n weeping lower extremities with pink sores evident on lower calves and\n heels. He needs care which was ordered and Kinaire bed\n which is here with pt.\n Shock, septic\n Assessment:\n BP low requiring levophed at .175mcg/kg/min. CVP initially 8 so pt\n given one liter NS bolus over one hour with CVP up to . Pt with\n strong frequent productive cough. Lungs are very decreased throughout.\n Requires 6L N/C with good O2 sats. CXR done on admission. Pt has had\n two blood cultures and urine sent for culture and started on\n flagyl/vanco/zosyn IV antibiotics. WBC 34\n Action:\n Cultured and given antibiotics as ordered.\n Response:\n Pt afebrile. Cultures pending.\n Plan:\n Follow vital signs closely, continue antibiotics, follow cultures.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complains of lower ext. pain with movement.\n Action:\n Pt positioned for comfort. Denies pain at rest\n Response:\n Pt restless stillat times but refused need for pain med.\n Plan:\n need to be ordered for something for pain but his resp status may\n be of greater concern. Watch closely.\n Impaired Integrity\n Assessment:\n Coccyx wounds open, stage three through dermis. Old dressing removed\n and aquacel and alevyn foam dressing applied.\n Action:\n Wound care nurse put in for next Monday.\n Response:\n Dressing changed, oozing serous sang dnd\n Plan:\n Try to keep wound clean over the WE and go by care wound care\n recommendations on Monday. Frequent turns and position changes.\n Pleural effusion, acute\n Assessment:\n Lungs sounds are very decreased throughout. RR 20 with O2 sat 99% on 6L\n N/C but pt still complains of SOB. Team reports CXR shows bilateral\n pleural effusions.\n Action:\n Pt is to have blood gas taken to assesss his oxygenation on current O2\n delivery.\n Response:\n Blood gas results show PO2 72 so we increased O2 to 50% cool neb.\n Plan:\n Follow blood gas results and titrate O2 as needed. Pt remains full\n code.\n" }, { "category": "Nursing", "chartdate": "2155-05-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325055, "text": "82 yr old man with recent admit () with new onset juandice\n with pacreatic dilation,\n s/p sphincetrotmoty and biliary stent, complicated by shock (pressors,\n intubationx 48hrs periprocedure)\n All cx neg but brushings were \"atypical\" and CA -9 very elevated\n suspcious for panc CA - plan for follow up for US guided Bx, redo stent\n in , out oncology eval.\n Has been at NH since then, states that he has been coughing, more short\n of breath, increased lower ext edema. Today was sent to hospital\n Temp 101.2 HR 140's BP 72/60 rr20 sats 90% 40\n ABG 7.48/35/70 on 3L\n and CXR with large bilat pleural eff, requiring 6 L nasal cannula.\n WBC 30K and K 5.9\n pro - bnp 10, 859\n Rx ceftriaxone, Levoquin, Clinda at Hospital. Requiring Levophed\n for low BP. Right subclavian central line inserted there.\n Bilat LENI negative\n CXR persistent bilat pleural eff\n Arrived here 1800 via ambulance. Alert and oriented times two. MAE.\n Complains of lower extremities bilateral leg pain with movement.\n Requiring Levophed .175mcg/kg/min. Arrived on insulin drip at 2u/hr but\n this was stopped due to blood sugar in the 80\n Pt is in bad shape with coccyx decubitus as well as anasarca,\n weeping lower extremities with pink sores evident on lower calves and\n heels. He needs care which was ordered and Kinaire bed\n which is here with pt.\n Shock, septic\n Assessment:\n BP low requiring levophed at .175-.22mcg/kg/min. CVP initially 8 so pt\n given one liter NS bolus over one hour with CVP up to . Pt with\n strong frequent productive cough. Lungs are very decreased throughout.\n Requires 6L N/C with good O2 sats. CXR done on admission. Pt has had\n two blood cultures and urine sent for culture and started on\n flagyl/vanco/zosyn IV antibiotics. WBC 34\n Action:\n Cultured and given antibiotics as ordered.\n Response:\n Pt afebrile. Cultures pending.\n Plan:\n Follow vital signs closely, continue antibiotics, follow cultures.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complains of lower ext. pain with movement.\n Action:\n Pt positioned for comfort. Denies pain at rest\n Response:\n Pt restless stillat times but refused need for pain med.\n Plan:\n need to be ordered for something for pain but his resp status may\n be of greater concern. Watch closely.\n Impaired Integrity\n Assessment:\n Coccyx wounds open, stage three through dermis. Old dressing removed\n and aquacel and alevyn foam dressing applied.\n Action:\n Wound care nurse put in for next Monday.\n Response:\n Dressing changed, oozing serous sang dnd\n Plan:\n Try to keep wound clean over the WE and go by care wound care\n recommendations on Monday. Frequent turns and position changes.\n Pleural effusion, acute\n Assessment:\n Lungs sounds are very decreased throughout. RR 20 with O2 sat 99% on 6L\n N/C but pt still complains of SOB. Team reports CXR shows bilateral\n pleural effusions.\n Action:\n Pt had blood gas taken to assesss his oxygenation on current O2\n delivery.\n Response:\n Blood gas results show PO2 72 so we increased O2 to 50% cool neb.\n Plan:\n Follow blood gas results and titrate O2 as needed. Pt remains full\n code.\n" }, { "category": "Physician ", "chartdate": "2155-05-09 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 325045, "text": "Chief Complaint: shock, resp distress\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 82 yr old man with recent admit () with new onset juandice\n with pacreatic dilation,\n s/p sphincetrotmoty and biliary stent, complicated by shock (pressors,\n intubationx 48hrs periprocedure)\n All cx neg but brushings were \"atypical\" and CA -9 very elevated\n suspcious for panc CA - plan for follow up for US guided Bx, redo stent\n in , out oncology eval.\n Has been at NH since then, states that he has been coughing, more short\n of breath, increased lower ext edema. Today was sent to hospital\n Temp 101.2 HR 140's BP 72/60 rr20 sats 90% 40\n ABG 7.48/35/70 on 3L\n and CXR with large bilat pleural eff, requiring 6 L nasal cannula.\n WBC 30K and K 5.9\n pro - bnp 10, 859\n Rx ceftriaxone, Levoquin, Clinda\n Bilat LENI negative\n CXR persistent bilat pleural eff\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 2 units/hour\n Norepinephrine - 0.18 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Afib\n Htn\n CAD MI \n Obesity\n Gout\n face shrapnel (WW2)\n last Echo LVEF 50%\n Occupation: retired\n Drugs: neg\n Tobacco: quit 40 years ago\n Alcohol: rare, none recent\n Other: ww2 vet, widower, 2 daughters\n Review of systems:\n Constitutional: Fatigue, Fevers\n Cardiovascular: No(t) Chest pain, Palpitations, No(t) Edema,\n Tachycardia, Orthopnea\n Respiratory: Cough, 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: Foley\n Integumentary (skin): Jaundice\n Flowsheet Data as of 06:37 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 101 (101 - 122) bpm\n BP: 80/58(63) {80/58(63) - 80/58(63)} mmHg\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 10 mL\n PO:\n TF:\n IVF:\n 10 mL\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -90 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n ABG: ////\n Physical Examination\n General Appearance: Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular (Right DP pulse: Absent), (Left DP pulse: Absent),\n but dopplerable\n Respiratory / Chest: (Breath Sounds: Diminished bilat with bronchial\n Extremities: Right: 4+, Left: 4+\n Skin: Not assessed, weeping\n Neurologic: Attentive, Follows simple commands\n Labs / Radiology\n 231\n 38.8\n 228\n 1.9\n 47\n 26\n 100\n 5.8\n 133\n 32.1\n [image002.jpg] PMN 51%, bands 40%, momo 7, 2\n PTT 25.5, inr 1.9\n Ca 7.6/Phos 3/Mg 2\n Alb 1.9\n T bili 1.7, D bili 1, alk phos 283, Alt 30, AST 52, amylase 3,\n CK trop neg\n Above are OSH labs\n Assessment and Plan\n 82 yr old man with recent shock from biliary sepsis, heart failure,\n been at nursing home with significant diarrhea, new cough, SOB, and\n worsening lower ext edema now transferred with shock\n 1. Shock: Suspect septic picture with C diff as most concerning\n source\n CVP now, will continue volume resusitation to CVP closer to\n 10\n Meanwhile use levophed to maintain MAPs at 60, UOP,\n ++ Diarhhea and was on broad spectrum ABX recently- check\n C diff. very reassuring ABd exam,\n ++ Cough, Pleural effussions: possible PNA, check sputum\n cx, doubt\n ++ recent biliary sepsis but lfts much improved and no\n right upper\n Check blood and urine cultures as well\n Also concern for a cardiogenic component - high BNP\n check Scvo2 -\n 2. Hypoxemia: new O2 requirement, getting volume resuscitation,\n 3. Afib: poorly rate controlled but is in shock and on levophed, Rx\n underlying issues and will try to add on bblocker when stable.\n Restart heparin when no immenent procedures\n 4. ARF: pre renal and may be an ATN component, assess with volume\n resuscitation, trend Cr UOP Renally dose all meds\n ICU Care\n Nutrition: NPO tonight in case resp decompensation\n Glycemic Control:\n Lines / Intubation: CVL from OSH, resite by 24 hours, pull back\n Comments:\n Prophylaxis:\n DVT: on coumadin, hold Rx sq heparin and convert to IV heparing when\n able\n Stress ulcer: PPI\n Communication: with pt, trying to reach family\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 60\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2155-05-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325061, "text": ":\n 82 yr old man with recent admit () with new onset juandice\n with pacreatic dilation,\n s/p sphincetrotmoty and biliary stent, complicated by shock (pressors,\n intubationx 48hrs periprocedure)\n All cx neg but brushings were \"atypical\" and CA -9 very elevated\n suspcious for panc CA - plan for follow up for US guided Bx, redo stent\n in , out oncology eval.\n Has been at NH since then, states that he has been coughing, more short\n of breath, increased lower ext edema, was sent to hospital, w\n Temp 101.2 HR 140's BP 72/60 rr20 sats 90%\n ABG 7.48/35/70 on 3L\n and CXR with large bilat pleural eff, requiring 6 L nasal cannula.\n WBC 30K and K 5.9\n pro - bnp 10, 859\n Rx ceftriaxone, Levoquin, Clinda at Hospital. Requiring Levophed\n for low BP. Right subclavian central line inserted there.\n Bilat LENI negative\n CXR persistent bilat pleural eff\n Transferred here at 1800 via ambulance. Arrived on insulin drip\n at 2u/hr which was d/c\nd w blood sugar in 80s.\n Also on levophed at .17mcg/kg/min.\n : Pt A&O x2, occ c/o lower extreme pain, particularly L leg with\n movement.\n Pt skin is in bad shape with coccyx decubitus as well as anasarca,\n weeping lower extremities with pink sores evident on lower calves and\n heels. L heel is purple red. He needs skin care consult which was\n ordered and Kinaire bed which is here with pt.\n Pleural effusion, acute\n Assessment:\n Received on High flow neb at 50%. LS clear diminished t/o.\n Sats good at 97-100. Freq non-productive cough.\n Action:\n ABG at 0100.\n Response:\n pO2 improved from 72-82 at 0100.\n Plan:\n Shock, septic\n Assessment:\n Received on levophed at .2mcg/kg/min. map > 62. sbp >87. Rapid AF up\n to 140s. Lactate up to 2.9 from\n Action:\n Metoprolol 5mg iv x1 w some reduction of HR for short period of time.\n 1L NS.\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Occ c/o pain bilat in legs esp when moving.\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2155-05-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325240, "text": "This is an 82 yr male recently admitted for new onset jaundice w/\n pancreatic dilation. At that time, pt underwent biliary stent placement\n and sphincterotemy and there was a high suspicion for pancreatic CA.\n Treatment was c/b shock requiring intubation and pressors X 48hr MD\n notes. Pt was D/C from to Rehab on . At rehab pt developed\n increasing SOB, cough and edema. Pt was transferred to OSH yesterday.\n In EW T max 101.2, HR 140\ns, BP 72/60. Pt was started on ceftriaxone,\n levofloxacin, and clindamycin. Additionally, pt was started on levophed\n for hypotension. Pt was transferred to on for further\n management.\n Shock, septic\n Assessment:\n blood cx at OSH positive for MRSA as was blood culture at on\n current admission. Pt w/ worsening hemodynamic instability w/ increased\n fluid and pressor requirements\n see event note and flowsheet.\n Action:\n Pt started on vasopressin per event note. Neo titrated to current dose\n of 4mcg/kg/min. Pt has received total 2L NS in boluses today. Continues\n on abx as ordered. Following respiratory assessment closely, trending\n ABG, mixed venous O2 sats and lactate. Pt taken for chest CT this\n afternoon.\n Response:\n MAP\ns maintained >65-70 as ordered w/ increasing doses of vasopressors\n as ordered and fluid boluses as ordered. Unable to obtain good pleth on\n pulse ox probe this shift despite multiple locations of placement\n (earlobe, forehead, fingers, toes), warm packs. Following clinical\n assessment and ABG\ns. ABG on NRB w/ event per previous note\n 7.37/38/145, then 7.27/45/116. FiO2 changed to 15L via humidified face\n tent and resultant ABG 7.32/42/60. Team and Dr. report PaO2\n 60 tolerable on face tent. Pt also appears much more comfortable on\n face tent. MS continues to worsen throughout shift. Pt is now\n lethargic and disoriented. Pt was agitated and confused when daughters\n came to visit, demanding that his daughters bring him his breakfast and\n help him out of bed\n fall precautions maintained. Pt also asking to be\n taken back to his room in the hospital and is frequently pulling of O2\n mask and . SvO2 63 during event previously documented. Repeat\n SvO2 77 after receiving fluid bolus. Lactate trending up to 3.3\n presently.\n Family meeting occurred this afternoon with pt\ns 2 daughters and Dr.\n . This RN was present. Family reports understanding that pt is\n critically ill and that his prognosis is poor. Goals of care and\n options were discussed. The family later told Dr. that they\n wished to avoid escalating care including wishes for DNR/DNI\n see\n orders.\n Plan:\n Continue to monitor hemodynamic and respiratory status closely.\n Continue pressors as ordered; however, anticipate potential need for\n symptom control for worsening respiratory status. Continue abx as\n ordered. Monitor labs as ordered. Anticipate family meeting tomorrow to\n re-evaluate goals of care based on pt\ns response.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP continues to lessen, BUN and creatanine continue to increase\n see\n labs.\n Action:\n Following UOP and labs as ordered. Fluid boluses administered as\n ordered to maintain CVP >9 as ordered. Pressors titrated as ordered to\n maintain MAP >65-70,\n Response:\n CVP and MAP maintained as ordered. UOP 5-15/hr t/o most of shift. BUN\n 54, creatanine 2.0.\n Plan:\n Continue to monitor renal function and support as able. No plans for HD\n or CVVH.\n Impaired Skin Integrity\n Assessment:\n Pt continues w/ multiple decubitus ulcers and oozing of copious amounts\n of serous drainage.\n see flowsheet.\n Action:\n Dsngs changed frequently t/o shift. Pt continues on kinair bed.\n Frequent repositioning and skin care.\n Response:\n Skin assessment slightly improved today\n see flow sheet.\n Plan:\n Continue current skin measures to promote improved skin integrity.\n" }, { "category": "General", "chartdate": "2155-05-11 00:00:00.000", "description": "ICU Event Note", "row_id": 325218, "text": "At start of shift pt noted to be progressively hypotensive despite neo\n at 4mcg/kg/min w/ SBP trending down to 77. ABP accuracy confirmed via\n manual assessment per policy. UOP trending down to 5-10ml/hr, lactate\n rising, CVP within goal range. Pt A+OX3, reporting\ntoday is mother\n day.\n Pt denied worsening SOB from baseline this admission, denied any\n pain, reported comfortable and appeared free of distress. Assessment\n reviewed w/ team and orders obtained for vasopressin which was started\n as ordered. SBP increased to 130\ns w/ start of vasopressin\n facilitating weaning of neo\n see flowsheet.\n At 0930 HOB down and pt turned for incontinent care. After less than\n 5min pt became hypertensive w/ SBP to 180\ns - 190\ns, pt reported SOB\n and appeared anxious w/ increased WOB. Pt immediately returned to\n supine position w/ HOB up to 90 degrees and 100% FiO2 via NRB applied..\n Neo was stopped and ABG obtained as we have been unable to obtain good\n pleth w/ pulse ox probe. ABG was 7.37/38/145.\n Pt slowly recovered until 1045 when pt reported 8/10 chest pain that\n felt like\nsomeone sitting on (my) chest.\n Pt reported pain radiating\n down left arm and felt like the same pain he had experienced\nin \n when pt reported having had an MI. Pt again reported increased SOB;\n however, pt remained free of diaphoresis. Dr. was present at\n bedside, EKG obtained and reviewed by Dr. who reported no acute\n changes. Pt quickly recovered w/o further intervention reporting pain\n and increased SOB completely resolved. Repeat cardiac enzymes sent as\n ordered. Pt presently resting quietly in bed, denies all pain, reports\n comfortable and remains free of distress.\n" }, { "category": "Nutrition", "chartdate": "2155-05-11 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 325223, "text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n consulted for low albumin, currently 1.9 & likely multifactorial.\n Patient is currently NPO. Appetite reported to be good PTA. Will\n provide high protein supplements once diet is advanced. Will follow po\n status.\n" }, { "category": "Physician ", "chartdate": "2155-05-11 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325225, "text": "Chief Complaint: septic shock, respiratory distress\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 24 Hour Events:\n placed w/initial CVP 7-8. A line placed.\n OSH micro: GPC in blood GPC/GNR in urine\n Here bld cxs with MRSA\n This am, decreased uop, rising Cr, rising lactate, SBP 70s w/neo maxed.\n Vasopressin added w/sig improvement in BP and able to decrease neo.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM - stopped\n Piperacillin - 12:28 AM\n Vancomycin IV - 12:28 AM\n Po vanco\n Infusions:\n Phenylephrine - 4 mcg/Kg/min\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Other medications:\n ASA 325\n Atrovent\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 07:53 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: 36.1\nC (96.9\n HR: 113 (100 - 129) bpm\n BP: 118/76(94) {72/50(59) - 120/81(96)} mmHg\n RR: 21 (11 - 30) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n CVP: 8 (1 - 17)mmHg\n Total In:\n 4,185 mL\n 284 mL\n PO:\n TF:\n IVF:\n 4,185 mL\n 284 mL\n Blood products:\n Total out:\n 825 mL\n 133 mL\n Urine:\n 825 mL\n 133 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,360 mL\n 151 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: 7.35/45/132/22/0\n PaO2 / FiO2: 264\n Physical Examination\n Awake, aaox3, NAD\n BS diminished on R, otherwise clear\n Irregularly irregular\n Abd obese, soft, NT, +BS\n 2+ , ulcers wrapped\n Labs / Radiology\n 12.9 g/dL\n 276 K/uL\n 111 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 5.0 mEq/L\n 51 mg/dL\n 104 mEq/L\n 136 mEq/L\n 41.0 %\n 26.1 K/uL\n [image002.jpg]\n 06:37 PM\n 09:47 PM\n 12:25 AM\n 04:00 AM\n 04:59 AM\n 04:25 AM\n 04:42 AM\n WBC\n 34.8\n 30.6\n 26.1\n Hct\n 40.9\n 39.3\n 41.0\n Plt\n 295\n 286\n 276\n Cr\n 1.7\n 1.7\n 1.9\n TropT\n 0.01\n TCO2\n 26\n 27\n 27\n 26\n Glucose\n 83\n 119\n 111\n Other labs: PT / PTT / INR:28.1/36.0/2.8, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:36/58, Alk Phos / T Bili:295/1.6,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:2.7 mmol/L, Albumin:1.9 g/dL, LDH:219 IU/L, Ca++:7.0\n mg/dL, Mg++:2.0 mg/dL, PO4:4.5 mg/dL\n Micro: as above, additionally c diff negative\n AP CXR: worsening R sided effusion\n Assessment and Plan\n 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent ERCP\n w/sphincterotomy and biliary stent for high grade stricture of CBD c/b\n shock, req pressors and intubation x48hrs peri-procedure (brushings\n were \"atypical\" and CA -9 very elevated, suspcious for pancreatic ca)\n transferred from OSH w/shock, leukocytosis (WBC 30K w/40% bands), and\n hypoxemia.\n 1. Shock: Presumed sepsis w/leukocytosis/bandemia and initial CvO2\n 75. GP bacteremia- possible sources = bowel, skin (decubs). Also\n concerned for c diff given sig diarrhea and recent abx (though 1^st\n cdiff neg) and ?pna.\n Bolus for CVP goal at least 10\n Neo and vaso for MAP at least 65\n Recheck CvO2\n Cont broad spectum abx\n zosyn/IV vanco/po vanco.\n Chest CT\n f/u cxs (incl from OSH), c diff.\n Checking TTE. Doubt tamponade given low CVP but need to consider in\n differential given effusion, malignancy, etc.\n 2. Hypoxemia: likely pleural effusions + pulm edema. BNP 10K at\n OSH, though some of this may be related to pt\ns afib and .\n Not diuresing while requiring pressors. ?underlying pna; abx as above.\n Cont BDs.\n 3. Afib: rate better controlled on neo. Rx underlying issues and will\n try to add on bblocker when stable. Was on coumadin, holding given\n supratherapeutic INR.\n 4. Oliguric ARF: Suspect now developing ATN. Recheck urine lytes and\n also check urine sediment. Trend Cr and uop. Renally dose meds.\n 5. Sacral and b/l heel decubs: wound care consult\n 6. CAD: cont asa. EKG unchanged c/w b/l and cardiac enzymes negative.\n Holding BB, ACEI while req pressors.\n 7. FEN: npo for now given hypoxemia req sig suppl O2\n 8. Access: , \n ICU Care\n Nutrition: none yet, consider NGT\n Glycemic Control: RISS\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 08:29 PM\n Prophylaxis:\n DVT: INR supratherapeutic\n Stress ulcer:\n VAP: HOB elevation\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": "2155-05-11 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325227, "text": "Chief Complaint: septic shock, respiratory distress\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 24 Hour Events:\n placed w/initial CVP 7-8. A line placed.\n OSH micro: GPC in blood GPC/GNR in urine\n This AM bld cxs here with MRSA\n This am, decreased uop, rising Cr, rising lactate, SBP 70s w/neo maxed.\n Vasopressin added w/sig improvement in BP and able to decrease neo.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM - stopped\n Piperacillin - 12:28 AM\n Vancomycin IV - 12:28 AM\n Po vanco\n Infusions:\n Phenylephrine - 4 mcg/Kg/min\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Other medications:\n ASA 325\n Atrovent\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 07:53 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: 36.1\nC (96.9\n HR: 113 (100 - 129) bpm\n BP: 118/76(94) {72/50(59) - 120/81(96)} mmHg\n RR: 21 (11 - 30) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.5 kg (admission): 91.5 kg\n CVP: 8 (1 - 17)mmHg\n Total In:\n 4,185 mL\n 284 mL\n PO:\n TF:\n IVF:\n 4,185 mL\n 284 mL\n Blood products:\n Total out:\n 825 mL\n 133 mL\n Urine:\n 825 mL\n 133 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,360 mL\n 151 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: 7.35/45/132/22/0\n PaO2 / FiO2: 264\n Physical Examination\n Awake, aaox3, NAD\n BS diminished on R, otherwise clear\n Irregularly irregular\n Abd obese, soft, NT, +BS\n 2+ , ulcers wrapped\n Labs / Radiology\n 12.9 g/dL\n 276 K/uL\n 111 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 5.0 mEq/L\n 51 mg/dL\n 104 mEq/L\n 136 mEq/L\n 41.0 %\n 26.1 K/uL\n [image002.jpg]\n 06:37 PM\n 09:47 PM\n 12:25 AM\n 04:00 AM\n 04:59 AM\n 04:25 AM\n 04:42 AM\n WBC\n 34.8\n 30.6\n 26.1\n Hct\n 40.9\n 39.3\n 41.0\n Plt\n 295\n 286\n 276\n Cr\n 1.7\n 1.7\n 1.9\n TropT\n 0.01\n TCO2\n 26\n 27\n 27\n 26\n Glucose\n 83\n 119\n 111\n Other labs: PT / PTT / INR:28.1/36.0/2.8, CK / CKMB /\n Troponin-T:35/3/0.01, ALT / AST:36/58, Alk Phos / T Bili:295/1.6,\n Differential-Neuts:93.7 %, Band:0.0 %, Lymph:3.9 %, Mono:2.1 %, Eos:0.2\n %, Lactic Acid:2.7 mmol/L, Albumin:1.9 g/dL, LDH:219 IU/L, Ca++:7.0\n mg/dL, Mg++:2.0 mg/dL, PO4:4.5 mg/dL\n Micro: as above, additionally c diff negative\n AP CXR: worsening R sided effusion\n Assessment and Plan\n 82 yo M w/afib on coumadin, CAD s/p MI, s/p recent ERCP\n w/sphincterotomy and biliary stent for high grade stricture of CBD c/b\n shock, req pressors and intubation x48hrs peri-procedure (brushings\n were \"atypical\" and CA -9 very elevated, suspcious for pancreatic ca)\n transferred from OSH w/shock, leukocytosis (WBC 30K w/40% bands), and\n hypoxemia.\n 1. Shock: Presumed sepsis w/leukocytosis/bandemia and initial CvO2\n 75. GP bacteremia- possible sources = bowel, skin (decubs). Also\n concerned for c diff given sig diarrhea and recent abx (though 1^st\n cdiff neg) and ?pna.\n Bolus for CVP goal at least 10\n Neo and vaso for MAP at least 65\n Recheck CvO2\n Cont broad spectum abx\n zosyn/IV vanco/po vanco.\n Chest CT\n if large effussions consider diagnistic but will need\n to be reversed from inr\n f/u cxs (incl from OSH), c diff.\n Checking TTE. Doubt tamponade given low CVP but need to consider in\n differential given effusion, malignancy, etc.\n 2. Hypoxemia: likely pleural effusions + pulm edema. BNP 10K at\n OSH, though some of this may be related to pt\ns afib and .\n Not diuresing while requiring pressors. ?underlying pna; abx as above.\n Cont BDs.\n 3. Afib: rate better controlled on neo. Rx underlying issues and will\n try to add on bblocker when stable. Was on coumadin, holding given\n supratherapeutic INR.\n 4. Oliguric ARF: Suspect now developing ATN. Recheck urine lytes and\n also check urine sediment. Trend Cr and uop. Renally dose meds.\n 5. Sacral and b/l heel decubs: wound care consult\n 6. CAD: cont asa. EKG unchanged c/w b/l and cardiac enzymes negative.\n Holding BB, ACEI while req pressors.\n 7. FEN: npo for now given hypoxemia req sig suppl O2\n 8. Access: , \n ICU Care\n Nutrition: none yet, consider NGT\n Glycemic Control: RISS\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 08:29 PM\n Prophylaxis:\n DVT: INR supratherapeutic\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: we have called family and asked them to come in to\n discuss his shock and multiorgan failure and clarify goals of care-in\n light if recent ICU stay, elevate Ca -9\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "General", "chartdate": "2155-05-11 00:00:00.000", "description": "ICU Event Note", "row_id": 325236, "text": "Clinician: Attending\n Met with Mr ' daughter and reviewed his current situation,\n hypotensive on 2 pressors, anuric renal failure, worsening resp\n distress. We discussed his overall poor prognosis both from immediate\n sepsis, cardiogenic shock and in light of his probable pancreatic\n cancer.\n They underatsn his is likely to die. They are moving towards comfort\n care however they woudl like us to try for another night with fluids\n and antibiotics and see how he is in the morning.\n They agree with no escalation of care and no intubation.\n We will call them overnight if he worsens and esp if resp distress as\n we will then need to administer medications for comfort.\n Total time spent: 35 minutes\n Patient is critically ill.\n" } ]

[ { "category": "Radiology", "chartdate": "2182-05-03 00:00:00.000", "description": "OR LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. RIGHT", "row_id": 960744, "text": " 8:30 PM\n LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. RIGHT; FEMUR (AP & LAT) RIGHTClip # \n Reason: PAIN FX RODDING\n Admitting Diagnosis: MVC, FEMUR FX\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT FEMUR, SIX VIEWS.\n\n INDICATION: A series of six intraoperative radiographs of the right femur\n were obtained without a radiologist present. These demonstrate intramedullary\n rod fixation of a femoral diaphysis fracture in progress. No immediate\n hardware-related complication is seen. Please refer to operative report for\n full details.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-05-04 00:00:00.000", "description": "R FEMUR (AP & LAT) RIGHT", "row_id": 960818, "text": " 3:52 PM\n FEMUR (AP & LAT) RIGHT Clip # \n Reason: eval hardware\n Admitting Diagnosis: MVC, FEMUR FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with femur fx s/p ORIF\n REASON FOR THIS EXAMINATION:\n eval hardware\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Right femur.\n\n INDICATION: Fracture.\n\n Five views of the right femur are obtained and show fixation of a mid femoral\n fracture with an intramedullary rod and fixation screws. There is mild\n anterior angulation of the distal fragment. Hardware appears intact.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-05-03 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 960706, "text": " 2:23 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST AND AP PELVIS, \n\n HISTORY: Trauma.\n\n FINDINGS: There are no previous studies available for direct comparison.\n\n AP CHEST: Study is limited by the underlying trauma board artifact. The\n mediastinum is within normal limits for the AP technique. The cardiac\n silhouette is unremarkable. No focal contusions, pleural effusions, or overt\n pulmonary edema is seen. There are several radiopaque densities projecting\n over the interspace between the left second and third ribs. These are likely\n external to the patient. Please correlate with soft tissue injury to this\n location. Incidental note is made of a small cervical rib on the left side. No\n pneumothoraces identified. There are no displaced rib fractures.\n\n AP PELVIS: Study is limited by the underlying trauma board artifact. There\n is a urinary catheter seen. No acute fractures or dislocations are present.\n\n IMPRESSION:\n 1. No signs for acute cardiopulmonary process. There are several densities\n projecting over the left upper chest. Please correlate with physical exam for\n radiopaque foreign bodies.\n 2. No fracture identified of the pelvis.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2182-05-04 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 960815, "text": " 3:29 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for change in splenic inj, other bleed\n Admitting Diagnosis: MVC, FEMUR FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with known splenic lac, dropping hct\n REASON FOR THIS EXAMINATION:\n eval for change in splenic inj, other bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: CT abdomen and pelvis without contrast .\n\n COMPARISON: None available.\n\n INDICATION: 19-year-old female with known splenic laceration, dropping\n hematocrit. Evaluate for change in splenic injury, other bleed.\n\n TECHNIQUE: Axial imaging was obtained through the abdomen and pelvis without\n IV contrast due to patient refusal of IV contrast. Images were reformatted in\n the coronal, sagittal planes.\n\n CT ABDOMEN WITHOUT IV CONTRAST: Limited imaging of the lung bases\n demonstrates bibasilar atelectasis and tiny bilateral pleural effusions. There\n is no pericardial effusion.\n\n There is high density within the gallbladder, likely vicarious excretion of\n contrast from prior CT examinations. Imaging of the intra-abdominal organs is\n limited due to lack of IV contrast. There are low density extending from the\n splenic hilum which measures 2.6 cm in length, and may represent a splenic\n laceration. There is no significant perisplenic fluid. There is no\n perihepatic fluid. The contours of the liver, pancreas, adrenal glands, and\n kidneys are unremarkable. There is no lymphadenopathy or free intraperitoneal\n gas.\n\n CT OF THE PELVIS: There is a small amount of simple free fluid within the\n pelvis, which may be physiologic or related to splenic injury. The bladder is\n unremarkable in contour. A Foley balloon catheter is demonstrated within the\n bladder which is decompressed. The bowel within the pelvis is normal in\n caliber. There is no lymphadenopathy or free intraperitoneal gas. There is\n loss of the fat planes involving the proximal right thigh and stranding of the\n fat in this region which may be secondary to acute hemorrhage into the thigh,\n clinical correlation is recommended.\n\n BONE WINDOWS: There is no evidence of acute fracture. There are no\n suspicious lytic or blastic lesions.\n\n IMPRESSION:\n\n 1. Linear low density within the spleen as described above, which may\n represent splenic laceration, although evaluation for intraabdominal injury is\n limited due to lack of IV contrast.\n (Over)\n\n 3:29 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for change in splenic inj, other bleed\n Admitting Diagnosis: MVC, FEMUR FX\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Tiny bilateral pleural effusions and bibasilar atelectasis.\n\n 3. Loss of the fat planes involving the right proximal thigh musculature as\n well as stranding of the fat in the region which may be secondary to\n hemorrhage into the right thigh, clinical correlation is recommended. Findings\n were discussed with the surgery team by Dr. at completion\n of the examination.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2182-05-04 00:00:00.000", "description": "Report", "row_id": 1393125, "text": "2130-0700\n19 yr old female admitted s/p low speed mvc v tree from OR.\n\nNo PMH\n\nAllergy- Penicillin\n\nInjuries- R midshaft displaced femur fracture.\n Grade 1 splenic laceration.\n Multiple facial lacerations.\n Multiple L upper arm lacerations.\n\nS/P Surgical repair of femur fracture with intramedullary nailing with titanium screw and suturing of facial lacerations.\n\nNeuro: Pt arrived post general anaesthesia. Sleepy but rousable to voice and touch. Following commands consistently. R leg in knee immobiliser. Moving all other extremities purposfully. Dilaudid PCA for pain management.\n\nCV: HR SR 80'S becoming tachycardic to 120 when awake and in pain. SBP 90'S when sleeping. low 100's awake.\n\nResp: O2 weaned to 2l NC. LS clear. Cough and deep breathing encouraged.\n\nGI: Ondansetron given x2 for nausea and vomiting with effect. hypoactive bowel sounds. Can resume regular diet when able to tolerate. IVF as maintainence.\n\nGU: Foley draining large volumes clear yellow urine.\n\nID: Afebrile. Prophylactic abx.\n\nSkin: R leg OR dressing intact, slight soakage only. Knee immobiliser in place. Facial lacerations sutured by plastics and open to air. Lacerations to L upper arm open to air. Developing bruising to r upper arm. Remaining skin intact.\n\nSocial: Mother and her boyfriend (? ) visited briefly last night. Pt mentioned numerous times that is negative about pts relationship with her . Also stated that will stall her boyfriend and Mom visiting. S/W saw pt in ED. Repeat visit may be beneficial.\n\nPlan: Tx to floor.\n Monitor effectiveness of PCA.\n Pt support and encouragement needed.\n Monitor R leg dressing.\n\n" }, { "category": "Nursing/other", "chartdate": "2182-05-05 00:00:00.000", "description": "Report", "row_id": 1393126, "text": "Nursing Progress Note\nReview of Systems-see carevue for details\n\nSkin: RLE incision site good-no s/s of infection,bruising around knee,swollen.knee immobilizer in place.facial lac with stitches-baci applied.abrasions/bruises on upper extremities\n\nNeuro: alert and oriented X 3.MAE's.pt gets very anxious and weepy easily.prn ativan ordered -gave .5mg with good effect.\n\nCV: HR 90's-low 100's when sleeping and 110's-140's when awake. SBP 90's-110's/30-50's.afebrile. p boot on LLE.fluids at kvo.\n\nResp: ra. ls clear bilat and throughout.RR 11-18,psox 97-100%.\n\nGI: abd soft/nondistended.present BS. no BM-pt on colace .pt has had nausea throughout night and vomitted small amt once last night-zofran given with good effect.\n\nGU: foley cath draining clear,yellow, and adequate amt of urine an hour\n\nPain: 2 percocet given last evening with good effect. started given IV morphine after pt vomitted-seemed to work better than po pain meds.\n\nLabs: hct q 6 hours-last one 21.0 prior 21 and 20.9. K 3.3 -tried to replace K with 10meq/100cc IV-pt had to much pain at IV site. mag 1.9-2gms given. pt is a very hard stick for blood.\n\nSocial: mom will try to visit from if she can find transportation. brother visited last night-from NY,dad and step mother called last night.\n\nPt was suppose to go to floor last night-supervisor didn't want her on the floor since her HR will go up to the 150's and because hct was so low.\n\nPlan: cont with serial hct\n transfer to floor today?\n good pain control\n advance diet as tolerated\n advance activity as tolerated\n" } ]

[ { "category": "Nursing", "chartdate": "2182-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531739, "text": "88 yo woman with stage 4 breast cancer who presented with large left\n pleural effusion, hypotension and severe HAP, possibly related to\n aspiration (pt had 1 wk h/o dysphagia).\n Pleural effusion, acute\n Assessment:\n Pt with greatly diminished BS on Left, known large pleural effusion.\n RR mid 20\ns, mildly labored. Sats 93-96 on RA. PT denies respiratory\n complaints\n Action:\n HOB elevated, continues on vanco/zosyn for presumed PNA\n Response:\n Respiratory status stable through night\n Plan:\n Pt to have thoracentesis today, continue to monitor pulmonary exam\n Alteration in Nutrition\n Assessment:\n Pt , oriented x 2, pocketing ice chips and pills this evening.\n Per family this is her baseline. Tolerating ice chips with S&S of\n aspirations, lung exam unchanged sats stable on RA.\n Action:\n Aspiration precautions, pills crushed in ice cream, NPO except for\n medications\n Response:\n Plan:\n NPO Speech and Swallow consult today\n" }, { "category": "Rehab Services", "chartdate": "2182-03-11 00:00:00.000", "description": "Deferred Bedside Swallowing Evaluation", "row_id": 531831, "text": "TITLE: DEFERRED BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 88 y/o with h/o + PPD, stage IV\nright sided breast CA s/p right partial mastectomy in (no\nchemo given poor mental status and last seen by hem/onc on\n doing well) who presented to on from\n bradycardia, hypotension, and tachypenia.\nPatient reportedly was being treated for ? aspiration pna \nfamily report of difficulty swallowing at . CXR\nupon arrival revealed large left sided pleural effusion. We were\nconsulted to evaluate patient's oral and pharyngeal swallowing\nfunction and r/o aspiration while eating and drinking.\nPatient's diet order at was changed on \nfrom regular house diet to include \"avoid cold cereals, and give\npureed fruit and pureed soups\". RN reported patient noted with\n\"pocketing\" of meds crushed with ice cream this am requiring oral\ncare.\nPMHx:\ns/p basal ganglia CVA in \nL.carotid stenosis 60% MRI/MRA in \nvalvular heart disease\nHypertension\nOsteoarthritis\nperipheral vascular disease\ndepression\nLBBB at least since \nProlonged QTc\nStage IV right sided breast CA s/p right partial mastectomy\nDEFERRED EVALUATION:\nRN reported patient currently NPO for thoracentesis this\nafternoon. We will return tomorrow to re-attempt PO trials.\nContinue NPO status pending bedside swallowing evaluation.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nTotal Time: 20 minutes\n" }, { "category": "Nursing", "chartdate": "2182-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531825, "text": "88 year old female with history of Stage IV right sided breast cancer\n (no chemo d/t poor functional status) and CVA with residual Left-sided\n weakness, now with chief complaint of lethargy. Pt was sent to ED\n from , where, , the pt was found to be\n bradycardic to 40's, and unobtainable BP on the day of admission. The\n pt was picked up by a BLS ambulance and atropine was not given. Per\n pt's family since a week prior to admission the pt has been more\n listless, less interactive and more lethargic on visits. They note that\n recently she has had difficulty with swallowing at . At\n , the pt was currently being treated for aspiration\n pneumonia with levaquin and flagyl since .\n .\n In ED, CXR showed left effusion, infectious versus malignant. Pt was\n admitted to the MICU for presumed sepsis. FULL CODE.\n Pleural effusion, acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2182-03-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 532029, "text": "Patient is an 88 year old woman with a history of CVA, HTN, PVD, known\n metastatic breast CA, osteoarthritis, and depression. Admitted from\n nursing home on with hypotension, respiratory distress, found to\n have large left pleural effusion and healthcare aquired vs. aspiration\n PNA. Admitted to MICU. Had Thoracentesis yesterday with 1400mls\n off. Cultures and cytology are pending.\n Alteration in Nutrition\n Assessment:\n Patient is unable to take any PO\ns due to aspiration risk.\n Action:\n Pt kept NPO due to aspiration. HOB > 30\n. Pt has been inc to DB&C while\n awake. Pt is due for speech and swallow eval today.\n Response:\n Pt unable to facilitate her own secretions and in need of freq oral\n care. Pt continues to be NPO until speech and swallow eval done.\n Plan:\n Plan for peech and swallow eval today. Please keep pt NPO (inc meds)\n until eval done.\n Pleural effusion, acute\n Assessment:\n LS diminished. O2 sat 94-96% on 2 liters nasal cannula. Thorasynthesis\n done and 1400 ml removed. Patient is oriented times , needs\n frequent reorientation and encouragement with pulmonary toileting.\n Action:\n Aggressive chest PT done. Encouraged to cough and deep breathe. Pt\n noted to present with a very weak non-prod cough. Sometimes able to\n suction small amount of secretions with Yankaur.\n Response:\n Patient remains on 2 liters nasal cannula sating high 90\n Plan:\n Continue aggressive pulm toilet.\n" }, { "category": "Physician ", "chartdate": "2182-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 532031, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 08:30 AM\n THORACENTESIS - At 05:00 PM\n 1400ml fluid taken off\n CALLED OUT\n Patient s/p thoracentesis with 1400ml of serosanguinous fluid removed.\n Tolerated procedure well with improvement in respiratory status.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:09 AM\n Vancomycin - 08:34 PM\n Ampicillin/Sulbactam (Unasyn) - 12:44 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 77 (74 - 93) bpm\n BP: 135/72(87) {107/51(67) - 144/103(107)} mmHg\n RR: 11 (11 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (12 - 15)mmHg\n Total In:\n 670 mL\n 278 mL\n PO:\n TF:\n IVF:\n 640 mL\n 278 mL\n Blood products:\n Total out:\n 2,370 mL\n 310 mL\n Urine:\n 970 mL\n 310 mL\n NG:\n Stool:\n Drains:\n 1,400 mL\n Balance:\n -1,700 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95% on 2L NC\n ABG: ///26/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Right rhonchi, left minimal breath sounds, no wheezes\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: A+Ox2 (to , , name, not oriented to year)\n Labs / Radiology\n 387 K/uL\n 11.6 g/dL\n 83 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 32 mg/dL\n 110 mEq/L\n 146 mEq/L\n 36.6 %\n 13.1 K/uL\n [image002.jpg]\n 05:55 AM\n 03:37 AM\n 04:19 AM\n WBC\n 16.7\n 13.2\n 13.1\n Hct\n 35.9\n 37.4\n 36.6\n Plt\n 399\n 381\n 387\n Cr\n 1.4\n 1.3\n 1.0\n Glucose\n 118\n 72\n 83\n Other labs: PT / PTT / INR:15.6/28.2/1.4,\n ALT / AST:6/31, Alk Phos / T Bili:99/0.8, Lactic Acid:1.3 mmol/L,\n LDH:339 IU/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Blood CX (): NGTD\n Pleural Fluid:\n - pH 7.45\n - LDH: 398\n - protein 3.8\n - glucose 73\n - WBC: 1333, RBC: , poly: 42, lymph: 33, macro: 20\n Fluid Protein/Serum protein = 0.64 (c/w exudate)\n Fluid LDH/Serum LDH = 1.17 (c/w exudate)\n Assessment and Plan\n 88 year old woman with sepsis, likely secondary to health care\n associated/aspiration pneumonia with large left sided pleural effusion\n with exudative\n .\n # Sepsis: Pt with hypotension, tachycardia suggestive of septic shock.\n Pt's mentation is at baseline. Urine output has been approx 30 cc/hr in\n ED. Labs suggestive of lactic acidosis with an anion gap of 21. Sepsis\n likely due to pneumonia given large pleural effusion, also consider\n UTI/urosepsis. Pt now s/p 3L IVF in ED.\n - Continue norepinephrine with goal MAP>60\n - Bolus with IVF prn to try to wean norepinephrine\n - Broadly culture (blood, urine, sputum)\n - Place a-line to monitor BP's\n - CVP>12\n - Check mixed venous sat, if low consider transfusion if hct<30\n .\n # Respiratory distress: Initially pt was on NRB, was weaned down to 4L\n NC, and is now tolerating room air. be secondary to pneumonia,\n pleural effusion.\n - Check ABG\n - ATC nebs\n - Treat pneumonia with vanc, zosyn\n .\n # Anion-gap acidosis: Pt has an anion gap of 21, with a delta-delta of\n which suggests a metabolic alkalosis as well. AG acidosis likely\n due to lactic acidosis and uremia.\n - Continue IVF for elevated lactate\n - ABG as above\n - A line for ABG monitoring\n .\n # Massive left pleural effusion: Likely infectious versus malignant\n pleural effusion. Pt has recently been on a course of levaquin and\n flagyl since for aspiration pna, which was broadened to vanc and\n zosyn on admission. Given CXR from that showed a left\n consolidation with pleural effusion, it seems possible that effusion is\n secondary to indection. Pt had mediastinal LN involvement on PET scan,\n so pleural effusion could be related to known metastatic breast cancer.\n - Continue vanc and zosyn\n - US-guided thoracentesis today\n - Consider high-res CT\n .\n # Acute renal failure: Likely ATN due to hypotension, but also may be a\n component of prerenal renal failure.\n - Check urine lytes\n - Hold ACE and diuretic\n - Renally dose meds.\n .\n # Hyperphosphatemia: Perhaps related to acute renal failure.\n - Phosphate today is normal.\n .\n # Htn: Hold home lisinopril, amlodipine and hctz while pt on pressors.\n .\n # H/o CVA: Residual L deficits.\n - Continue statin.\n # FEN: IVF, replete electrolytes, S+S\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals, CVL\n # Communication: Patient\n # Code: Full (discussed with patient); HCP dtr \n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:56 AM\n 18 Gauge - 01:33 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": "2182-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 532033, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 08:30 AM\n THORACENTESIS - At 05:00 PM\n 1400ml fluid taken off\n CALLED OUT\n Patient s/p thoracentesis with 1400ml of serosanguinous fluid removed.\n Tolerated procedure well with improvement in respiratory status.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:09 AM\n Vancomycin - 08:34 PM\n Ampicillin/Sulbactam (Unasyn) - 12:44 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 77 (74 - 93) bpm\n BP: 135/72(87) {107/51(67) - 144/103(107)} mmHg\n RR: 11 (11 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (12 - 15)mmHg\n Total In:\n 670 mL\n 278 mL\n PO:\n TF:\n IVF:\n 640 mL\n 278 mL\n Blood products:\n Total out:\n 2,370 mL\n 310 mL\n Urine:\n 970 mL\n 310 mL\n NG:\n Stool:\n Drains:\n 1,400 mL\n Balance:\n -1,700 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95% on 2L NC\n ABG: ///26/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Right rhonchi, left minimal breath sounds, no wheezes\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: A+Ox2 (to , , name, not oriented to year)\n Labs / Radiology\n 387 K/uL\n 11.6 g/dL\n 83 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 32 mg/dL\n 110 mEq/L\n 146 mEq/L\n 36.6 %\n 13.1 K/uL\n [image002.jpg]\n 05:55 AM\n 03:37 AM\n 04:19 AM\n WBC\n 16.7\n 13.2\n 13.1\n Hct\n 35.9\n 37.4\n 36.6\n Plt\n 399\n 381\n 387\n Cr\n 1.4\n 1.3\n 1.0\n Glucose\n 118\n 72\n 83\n Other labs: PT / PTT / INR:15.6/28.2/1.4,\n ALT / AST:6/31, Alk Phos / T Bili:99/0.8, Lactic Acid:1.3 mmol/L,\n LDH:339 IU/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Blood CX (): NGTD\n Pleural Fluid:\n - pH 7.45\n - LDH: 398\n - protein 3.8\n - glucose 73\n - WBC: 1333, RBC: , poly: 42, lymph: 33, macro: 20\n Fluid Protein/Serum protein = 0.64 (c/w exudate)\n Fluid LDH/Serum LDH = 1.17 (c/w exudate)\n Assessment and Plan\n 88 year old woman with sepsis, likely secondary to health care\n associated/aspiration pneumonia with large left sided pleural effusion\n with exudative\n .\n # Sepsis: Pt with hypotension, tachycardia suggestive of septic shock.\n Pt's mentation is at baseline. Urine output has been approx 30 cc/hr in\n ED. Labs suggestive of lactic acidosis with an anion gap of 21. Sepsis\n likely due to pneumonia given large pleural effusion, also consider\n UTI/urosepsis. Pt now s/p 3L IVF in ED.\n - Continue norepinephrine with goal MAP>60\n - Bolus with IVF prn to try to wean norepinephrine\n - Broadly culture (blood, urine, sputum)\n - Place a-line to monitor BP's\n - CVP>12\n - Check mixed venous sat, if low consider transfusion if hct<30\n .\n # Respiratory distress: Initially pt was on NRB, was weaned down to 4L\n NC, and is now tolerating room air. be secondary to pneumonia,\n pleural effusion.\n - Check ABG\n - ATC nebs\n - Treat pneumonia with Unasyn x 10 day course for aspiration PNA (could\n transition to Augmentin)\n - Continue O2 PRN\n .\n # Anion-gap acidosis: Pt has an anion gap of 21, with a delta-delta of\n which suggests a metabolic alkalosis as well. AG acidosis likely\n due to lactic acidosis and uremia.\n - Continue IVF for elevated lactate\n - ABG as above\n - A line for ABG monitoring\n .\n # Massive left pleural effusion: Likely infectious versus malignant\n pleural effusion. Pt has recently been on a course of levaquin and\n flagyl since for aspiration pna, which was broadened to vanc and\n zosyn on admission. Given CXR from that showed a left\n consolidation with pleural effusion, it seems possible that effusion is\n secondary to indection. Pt had mediastinal LN involvement on PET scan,\n so pleural effusion could be related to known metastatic breast cancer.\n - Continue Unasyn as above\n - Hold off on draining fluid re-accumulation at this time as pt\n minimally symptomatic; may require repeat tap if sx accelerate (with\n Pleurex catheter placement)\n - Consider high-res CT\n - F/U cytology from initial thoracentesis\n .\n # Acute renal failure: Likely ATN due to hypotension, but also may be a\n component of prerenal renal failure.\n - Check urine lytes\n - Hold ACE and diuretic\n - Renally dose meds.\n .\n # Hyperphosphatemia: Perhaps related to acute renal failure.\n - Phosphate today is normal.\n .\n # Htn: Hold home lisinopril, amlodipine and hctz while pt on pressors.\n .\n # H/o CVA: Residual L deficits.\n - Continue statin.\n # FEN: IVF, replete electrolytes, S+S evaluation today\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals, CVL\n # Communication: Patient\n # Code: Full (discussed with patient); HCP dtr \n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:56 AM\n 18 Gauge - 01:33 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Rehab Services", "chartdate": "2182-03-12 00:00:00.000", "description": "Bedside Swallowing Evaluation", "row_id": 532039, "text": "TITLE: BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 88 y/o with h/o + PPD, stage IV\nright sided breast CA s/p right partial mastectomy in (no\nchemo given poor mental status and last seen by hem/onc on\n doing well) who presented to on from\n bradycardia, hypotension, and tachypenia.\nPatient reportedly was being treated for ? aspiration pna \nfamily report of difficulty swallowing at . CXR\nupon arrival revealed large left sided pleural effusion. We were\nconsulted to evaluate patient's oral and pharyngeal swallowing\nfunction and r/o aspiration while eating and drinking.\nPatient's diet order at was changed on \nfrom regular house diet to include \"avoid cold cereals, and give\npureed fruit and pureed soups\". RN reported patient noted with\n\"pocketing\" of meds crushed with ice cream this am requiring oral\ncare.\nPatient underwent thoracentesis yesterday. RN reported yesterday\npatient continued with pocketing of meds crushed with puree. RN\nhas not tried meds today.\nPMHx:\ns/p basal ganglia CVA in \nL.carotid stenosis 60% MRI/MRA in \nvalvular heart disease\nHypertension\nOsteoarthritis\nperipheral vascular disease\ndepression\nLBBB at least since \nProlonged QTc\nStage IV right sided breast CA s/p right partial mastectomy\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed on the MICU.\nCognition, language, speech, voice: Patient was awake and alert,\noriented to self, and knows she is not at home, thinks it is \ndespite cues. Patient followed commands and participated in PO\ntrials. Speech was fluent and voice wfl.\nTeeth: Intact dentition\nSecretions: Mild, thin, watery secretions in oral cavity, dry\nbaseline cough\nORAL MOTOR EXAM:\nTongue protruded midline. Functional labial and lingual strength,\nROM, and buccal tone. Palatal elevation was symmetrical from what\nI could tell. Gag deferred to maintain rapport.\nSWALLOWING ASSESSMENT:\nPO trials included ice chips, thin liquids\n(tsp/straw/consecutive), bites of puree, ground solid, and a bite\nof cracker. Oral phase was remarkable for prolonged\ntransit and mastication. Moderate oral residue remained following\nregular solid and was cleared with sips of thin liquid. Patient\nwas aware of oral residue and continued to request water.\nLaryngeal elevation felt adequate to palpation. No overt change\nin vocal quality. No throat clearing, coughing, or choking noted.\nO2 sats remained stable at 96%/97%. Patient denied the sensation\nof PO stuck in her throat.\nSUMMARY / IMPRESSION:\nMs. was noted with slow and prolonged oral transit and\nmastication with moderate oral residue following solid, which she\nwas aware of and continued to request sips of water. No overt\ns/sx of aspiration were noted during today's evaluation.\nRecommend initiating a PO diet of thin liquids and moist soft\nsolids. Patient is ordered for pureed fruit at baseline and\nsuggest continuing to special request any fruit she would like be\npureed. Continue strict 1:1 supervision/assistance for all POs.\nIf there are concerns for aspiration on this diet, please\nreconsult and we will be happy to return.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of level 5 out of 7.\nRECOMMENDATIONS:\n1. PO diet of thin liquids and moist soft solids.\n2. Avoid cold cereals.\n3. Please order fruit or soup pureed.\n4. Pills crushed with puree.\n5. Alternate bites and sips, check oral cavity.\n6. Strict 1:1 supervision/assistance with all POs. Feed only when\nawake, alert, attentive, and sitting upright.\n7. Q6 oral care.\n8. If there are concerns for aspiration on this diet, please\nreconsult and we will be happy to return.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 1140-1155\nTotal time: 45 minutes\n" }, { "category": "Nursing", "chartdate": "2182-03-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 532043, "text": "Patient is an 88 year old woman with a history of CVA, HTN, PVD, known\n metastatic breast CA, osteoarthritis, and depression. Admitted from\n nursing home on with hypotension, respiratory distress, found to\n have large left pleural effusion and healthcare aquired vs. aspiration\n PNA. Admitted to MICU. Had Thoracentesis yesterday with 1400mls\n off. Cultures and cytology are pending.\n Alteration in Nutrition\n Assessment:\n Patient is unable to take any PO\ns due to aspiration risk.\n Action:\n Pt kept NPO due to aspiration. HOB > 30\n. Pt has been inc to DB&C while\n awake. Pt is due for speech and swallow eval today.\n Response:\n Pt unable to facilitate her own secretions and in need of freq oral\n care. Pt continues to be NPO until speech and swallow eval done.\n Patient had speech and swallow. Soft solids thin liqui8ds. Needs\n encouragement and 1:1 supervision.\n Plan:\n Aspiration precautions.\n Pleural effusion, acute\n Assessment:\n LS diminished. O2 sat 94-96% on 2 liters nasal cannula. Thorasynthesis\n done and 1400 ml removed. Patient is oriented times , needs\n frequent reorientation and encouragement with pulmonary toileting.\n Action:\n Aggressive chest PT done. Encouraged to cough and deep breathe. Pt\n noted to present with a very weak non-prod cough. Sometimes able to\n suction small amount of secretions with Yankaur.\n Response:\n Patient remains on 2 liters nasal cannula sating high 90\n Plan:\n Continue aggressive pulm toilet.\n Demographics\n Attending MD:\n MARK\n Admit diagnosis:\n PLEURAL EFFUSION;HYPOTENSION\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 79.5 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: CVA, Hypertension, PVD\n Additional history: Breast CA, Pneumonia, depression, osteoarthritis.\n Surgery / Procedure and date: Partial mastectomy .\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:151\n D:86\n Temperature:\n 97.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 76 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 906 mL\n 24h total out:\n 505 mL\n Pertinent Lab Results:\n Sodium:\n 146 mEq/L\n 04:19 AM\n Potassium:\n 3.6 mEq/L\n 04:19 AM\n Chloride:\n 110 mEq/L\n 04:19 AM\n CO2:\n 26 mEq/L\n 04:19 AM\n BUN:\n 32 mg/dL\n 04:19 AM\n Creatinine:\n 1.0 mg/dL\n 04:19 AM\n Glucose:\n 83 mg/dL\n 04:19 AM\n Hematocrit:\n 36.6 %\n 04:19 AM\n Finger Stick Glucose:\n 81\n 04:00 PM\n Valuables / Signature\n Patient valuables: Bracelet\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: \n Date & time of Transfer: 1215\n" }, { "category": "Physician ", "chartdate": "2182-03-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531806, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Patient on room air, sating in mid 90s on RA with no overnight\n events.\n - Plan for DX thoracentesis on \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:07 AM\n Piperacillin/Tazobactam (Zosyn) - 12:52 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:59 PM\n Other medications:\n Changes to medical and family history:\n No Changes.\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unchanged.\n Flowsheet Data as of 07:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 82 (72 - 86) bpm\n BP: 139/76(91) {85/40(25) - 143/76(91)} mmHg\n RR: 23 (11 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 12 (12 - 12)mmHg\n Total In:\n 5,715 mL\n 127 mL\n PO:\n TF:\n IVF:\n 2,635 mL\n 127 mL\n Blood products:\n Total out:\n 1,155 mL\n 335 mL\n Urine:\n 1,155 mL\n 335 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,560 mL\n -208 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General: Alert, oriented, no acute distress; reports that she feels\n \"lazy.\"\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Right rhonchi, left minimal breath sounds, no wheezes\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: A+Ox2 (to , , name, not oriented to year). Speech\n slow.\n CN II-XII intact\n Strength 4/5 in RUE, less in LUE\n Gait assessment deferred\n Labs / Radiology\n 381 K/uL\n 11.7 g/dL\n 72 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 37 mg/dL\n 108 mEq/L\n 144 mEq/L\n 37.4 %\n 13.2 K/uL\n [image002.jpg]\n 05:55 AM\n 03:37 AM\n WBC\n 16.7\n 13.2\n Hct\n 35.9\n 37.4\n Plt\n 399\n 381\n Cr\n 1.4\n 1.3\n Glucose\n 118\n 72\n Other labs: PT / PTT / INR:17.1/29.7/1.5, ALT / AST:6/31, Alk Phos / T\n Bili:99/0.8, Lactic Acid:1.3 mmol/L, LDH:339 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 88 year old woman with sepsis, likely secondary to health care\n associated/aspiration pneumonia with large left sided pleural effusion.\n .\n # Sepsis: Pt with hypotension, tachycardia suggestive of septic shock.\n Pt's mentation is at baseline. Urine output has been approx 30 cc/hr in\n ED. Labs suggestive of lactic acidosis with an anion gap of 21. Sepsis\n likely due to pneumonia given large pleural effusion, also consider\n UTI/urosepsis. Pt now s/p 3L IVF in ED.\n - Continue norepinephrine with goal MAP>60\n - Bolus with IVF prn to try to wean norepinephrine\n - Broadly culture (blood, urine, sputum)\n - Place a-line to monitor BP's\n - CVP>12\n - Check mixed venous sat, if low consider transfusion if hct<30\n .\n # Respiratory distress: Initially pt was on NRB, was weaned down to 4L\n NC, and is now tolerating room air. be secondary to pneumonia,\n pleural effusion.\n - Check ABG\n - ATC nebs\n - Treat pneumonia with vanc, zosyn\n .\n # Anion-gap acidosis: Pt has an anion gap of 21, with a delta-delta of\n which suggests a metabolic alkalosis as well. AG acidosis likely\n due to lactic acidosis and uremia.\n - Continue IVF for elevated lactate\n - ABG as above\n - A line for ABG monitoring\n .\n # Massive left pleural effusion: Likely infectious versus malignant\n pleural effusion. Pt has recently been on a course of levaquin and\n flagyl since for aspiration pna, which was broadened to vanc and\n zosyn on admission. Given CXR from that showed a left\n consolidation with pleural effusion, it seems possible that effusion is\n secondary to indection. Pt had mediastinal LN involvement on PET scan,\n so pleural effusion could be related to known metastatic breast cancer.\n - Continue vanc and zosyn\n - US-guided thoracentesis today\n - Consider high-res CT\n .\n # Acute renal failure: Likely ATN due to hypotension, but also may be a\n component of prerenal renal failure.\n - Check urine lytes\n - Hold ACE and diuretic\n - Renally dose meds.\n .\n # Hyperphosphatemia: Perhaps related to acute renal failure.\n - Phosphate today is normal.\n .\n # Htn: Hold home lisinopril, amlodipine and hctz while pt on pressors.\n .\n # H/o CVA: Residual L deficits.\n - Continue statin.\n # FEN: IVF, replete electrolytes, S+S\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals, CVL\n # Communication: Patient\n # Code: Full (discussed with patient); HCP dtr \n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:56 AM\n 18 Gauge - 01:33 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": "2182-03-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 532028, "text": "Patient is an 88 year old woman with a history of CVA, HTN, PVD, known\n metastatic breast CA, osteoarthritis, and depression. Admitted from\n nursing home on with hypotension, respiratory distress.\n Alteration in Nutrition\n Assessment:\n Pt found at 8 pm to be in no distress. Abd soft with (+) BS and no BM\n noted.\n Action:\n Pt kept NPO throughout the night due to aspiration. HOB > 30\n. Pt has\n been inc to DB&C while awake. Pt is due for speech and swallow eval\n today.\n Response:\n Pt unable to facilitate her own secretions and in need of freq oral\n care. Pt continues to be NPO until speech and swallow eval done.\n Plan:\n Plan for peech and swallow eval today. Please keep pt NPO (inc meds)\n until eval done.\n Pleural effusion, acute\n Assessment:\n Pt found at 8 pm to be in no resp distress. LS CTA with diminished\n bases. O2 sat 94-96% on RA. Thorasynthesis done and 1400 ml\n removed.\n Action:\n While pt was sleeping, O2sat decreased to 88% on RA and NC 2 liters\n placed w/o any effect. Pt was inc to DB&C and CP done. Pt noted to\n present with a very weak non-prod cough.\n Response:\n O2sat increased to 94-96% on 2 liters after aggressive pulm toilet. HOB\n kept > 30\n Plan:\n Continue aggressive pulm toilet.\n" }, { "category": "Nursing", "chartdate": "2182-03-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 532011, "text": "Alteration in Nutrition\n Assessment:\n Pt found at 8 pm to be in no distress. Abd soft with (+) BS and no BM\n noted.\n Action:\n Pt kept NPO throughout the night due to aspiration. HOB > 30\n. Pt has\n been inc to DB&C while awake. Pt is due for speech and swallow eval\n today.\n Response:\n Pt unable to facilitate her own secretions and in need of freq oral\n care. Pt continues to be NPO until speech and swallow eval done.\n Plan:\n Plan for peech and swallow eval today. Please keep pt NPO (inc meds)\n until eval done.\n Pleural effusion, acute\n Assessment:\n Pt found at 8 pm to be in no resp distress. LS CTA with diminished\n bases. O2 sat 94-96% on RA. Thorasynthesis done and 1400 ml\n removed.\n Action:\n While pt was sleeping, O2sat decreased to 88% on RA and NC 2 liters\n placed w/o any effect. Pt was inc to DB&C and CP done. Pt noted to\n present with a very weak non-prod cough.\n Response:\n O2sat increased to 94-96% on 2 liters after aggressive pulm toilet. HOB\n kept > 30\n Plan:\n Continue aggressive pulm toilet.\n" }, { "category": "Nursing", "chartdate": "2182-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531779, "text": "88 yo woman with stage 4 breast cancer who presented with large left\n pleural effusion, hypotension and severe HAP, possibly related to\n aspiration (pt had 1 wk h/o dysphagia).\n Pleural effusion, acute\n Assessment:\n Pt with greatly diminished BS on Left, known large pleural effusion.\n RR mid 20\ns, mildly labored. Sats 93-96 on RA. PT denies respiratory\n complaints\n Action:\n HOB elevated, continues on vanco/zosyn for presumed PNA\n Response:\n Respiratory status stable through night\n Plan:\n Pt to have thoracentesis today, continue to monitor pulmonary exam\n Alteration in Nutrition\n Assessment:\n Pt , oriented x 2, pocketing ice chips and pills this evening.\n Per family this is her baseline. Tolerating ice chips with S&S of\n aspirations, lung exam unchanged sats stable on RA.\n Action:\n Aspiration precautions, pills crushed in ice cream, NPO except for\n medications\n Response:\n Plan:\n NPO Speech and Swallow consult today\n" }, { "category": "Nursing", "chartdate": "2182-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531904, "text": "88 year old female with history of Stage IV right sided breast cancer\n (no chemo d/t poor functional status) and CVA with residual Left-sided\n weakness, now with chief complaint of lethargy. Pt was sent to ED\n from , where, , the pt was found to be\n bradycardic to 40's, and unobtainable BP on the day of admission. The\n pt was picked up by a BLS ambulance and atropine was not given. Per\n pt's family since a week prior to admission the pt has been more\n listless, less interactive and more lethargic on visits. They note that\n recently she has had difficulty with swallowing at . At\n , the pt was currently being treated for aspiration\n pneumonia with levaquin and flagyl since .\n .\n In ED, CXR showed left effusion, infectious versus malignant. Pt was\n admitted to the MICU for presumed sepsis. FULL CODE.\n Pleural effusion, acute\n Assessment:\n Pt rec\nd on RA with O2 sat 94-98%, RR shallow and regular 17-29/min.\n Lung snds clear on R, absent on L. VSS with HR 86-93SR with occas\n PVC\ns, BP 113/55-143/83. Afebrile.\n Action:\n Thoracentesis done, removing 1400ml sanguinous fluid.\n Response:\n Pt tolerated procedure well, VS have remained stable, and post XRay\n taken. Spec for cx and cytology.\n Plan:\n Pt called out to floor.\n Alteration in Nutrition\n Assessment:\n Abd soft with + BS, +flatus. Pt remains NPO with aspiration\n precautions. Oral care done, revealing lg amts old crushed meds had\n remained in oral cavity.\n Action:\n Speech/swallow deferred til after thoracentesis, prob tomorrow.\n Response:\n Stable.\n Plan:\n Cont NPO\ntil S/S test.\n" }, { "category": "Physician ", "chartdate": "2182-03-10 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 531530, "text": "TITLE:\n Chief Complaint: Lethargy\n HPI:\n 88 year old female with history of Stage IV right sided breast cancer\n (no chemo d/t poor functional status) and CVA with chief complaint of\n lethargy. Pt was sent to ED from , where, \n , the pt was found to be bradycardic to 40's, and\n unobtainable BP on the day of admission. The pt was picked up by a BLS\n ambulance and atropine was not given. Per pt's family since a week\n prior to admission the pt has been more listless, less interactive and\n more lethargic on visits. They note that recently she has had\n difficulty with swallowing at . At , the pt\n was currently being treated for aspiration pneumonia with levaquin and\n flagyl since .\n .\n In the ED, initial vs were: P 100 BP 60's systolic, 100% NRB. Pt\n received Vanc, Zosyn and rectal tylenol and norepinephrine was started\n for hypotension. Lactate was noted to be in the 5's. A CVL was placed\n in the ED. 3L NS was given. Exam notable for L sided weakness which is\n residual from old CVA. CXR showed evidence of left effusion, infectious\n versus malignant. Pt was admitted to the MICU for presumed sepsis.\n .\n On the floor, pt appears comfortable, is hypothermic, and on pressors.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:07 AM\n Piperacillin/Tazobactam (Zosyn) - 01:08 AM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n AMLODIPINE 5 mg once a day\n CARBIDOPA-LEVODOPA - 25 mg-100 mg Tablet - 1.5 Tablet(s) by mouth\n four times a day\n CLOPIDOGREL [PLAVIX] - 75 mg daily\n HYDROCHLOROTHIAZIDE - 25 mg daily\n LISINOPRIL - 20 mg DAILY\n POLYETHYLENE GLYCOL 3350 [MIRALAX]\n SIMVASTATIN 10 mg at bedtime\n ACETAMINOPHEN\n BISACODYL 10 mg Suppository\n MAGNESIUM HYDROXIDE [MILK OF MAGNESIA] 30 ml by mouth daily as\n needed for constipation\n SODIUM PHOSPHATES [FLEET ENEMA] rectally daily as needed for\n constipation 2 hours post dulcolax\n Past medical history:\n Family history:\n Social History:\n HTN\n s/p basal ganglia CVA in \n L.carotid stenosis 60% MRI/MRA in \n Mitral stenosis\n ? Parkinson's disease (patient is on carbidopa-levodopa)\n Hypercholesterolemia\n PPD positive\n depression\n LBBB since \n Prolonged QTc\n Oncologic History: stage IV (T4bN1M1) right-sided, triple-negative\n breast carcinoma\n 1. : Had an abnormal mammogram of the right breast but\n patient never followed up\n 2. : Pt noticed a lump in the right breast: grade 3,\n triple-negative invasive ductal carcinoma\n 3. : , palliative surgery to remove right breast\n tumor/skin involvement. Chemotherapy not considered given poor\n performance status. Surveillance for now.\n PET-CT :\n 1. Large FDG-avid breast mass consistent with carcinoma with\n FDG-avid cervical, right axillary and mediastinal nodal\n metastases. 2. No evidence of FDG-avid disease in the abdomen. 3.\n Enlarged uterus containing endometrial fluid and central\n FDG-avidity. Findings are concerning for endometrial hyperplasia\n or neoplasia and further evaluation with pelvic ultrasound\n is recommended. 4. Right maxillary sinus opacification.\n Diabetes, hypertension, heart disease\n Occupation:\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other: Denies tobacco, alcohol, drugs. Lived in , with\n son and daughter-in-law. Moved to to be with\n daughter. Now living in .\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Cough, Dyspnea, Tachypnea\n Neurologic: lethargy\n Flowsheet Data as of 02:36 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 86 (86 - 88) bpm\n BP: 108/52(64) {108/52(64) - 139/74(90)} mmHg\n RR: 19 (19 - 28) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 3,321 mL\n PO:\n TF:\n IVF:\n 321 mL\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,221 mL\n Respiratory\n SpO2: 100%\n Physical Examination\n General: Alert, oriented, no acute distress; reports that she feels\n \"lazy.\"\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Right rhonchi, left minimal breath sounds, no wheezes\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: A+Ox2 (to , , name, not oriented to year). Speech\n slow.\n CN II-XII intact\n Strength 4/5 in RUE, less in LUE\n Gait assessment deferred\n Labs / Radiology\n _______________________________________________________________________\n Lactate:5.9\n Comments:\n Lactate: Verified\n \n 10:10p\n _______________________________________________________________________\n LIGHT GREEN\n Trop-T: 0.11\n Comments:\n cTropnT: Verified By Replicate Analysis\n cTropnT: Notified @2320 By Zv\n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n D-Dimer: >\n 138\n [image002.gif]\n 98\n [image002.gif]\n 39\n [image004.gif]\n 117\n AGap=26\n [image005.gif]\n 4.8\n [image002.gif]\n 19\n [image002.gif]\n 1.9\n [image007.gif]\n Comments:\n Na: Anion Gap Verified\n Glucose: If Fasting, 70-100 Normal, >125 Provisional Diabetes\n estGFR: [1]25/30 (click for details)\n CK: 101\n Comments:\n CK(CPK): New Reference Interval As Of ;Upper Limit (97.5th %Ile)\n Varies With Ancestry And Gender (Male/Female);Whites 322/201 Blacks\n 801/414 Asians 641/313\n Ca: 9.3 Mg: 2.4 P: 6.1\n 79\n 14.3\n [image007.gif]\n 13.3\n [image004.gif]\n 511\n [image008.gif]\n [image004.gif]\n 41.8\n [image007.gif]\n N:88.6 L:6.3 M:4.2 E:0.6 Bas:0.3\n PT: 15.4\n PTT: 26.4\n INR: 1.4\n Assessment and Plan\n 88 year old woman with sepsis, likely secondary to health care\n associated pneumonia.\n .\n # Sepsis: Pt with hypotension, tachycardia suggestive of septic shock.\n Pt's mentation is at baseline. Urine output has been approx 30 cc/hr in\n ED. Labs suggestive of lactic acidosis with an anion gap of 21. Sepsis\n likely due to pneumonia given large pleural effusion, also consider\n UTI/urosepsis. Pt now s/p 3L IVF in ED.\n - Continue norepinephrine with goal MAP>60\n - Bolus with IVF prn to try to wean norepinephrine\n - Broadly culture (blood, urine, sputum)\n - Place a-line to monitor BP's\n - CVP>12\n - Check mixed venous sat, if low consider transfusion if hct<30\n .\n # Respiratory distress: Initially pt was on NRB, but has been weaned\n down to 4L NC but still tachypnic. be secondary to pneumonia,\n pleural effusion.\n - Check ABG\n - ATC nebs\n - Treat pneumonia with vanc, zosyn\n .\n # Anion-gap acidosis: Pt has an anion gap of 21, with a delta-delta of\n which suggests a metabolic alkalosis as well. AG acidosis likely\n due to lactic acidosis and uremia.\n - Continue IVF for elevated lactate\n - ABG as above\n - A line for ABG monitoring\n .\n # Massive left pleural effusion: Likely infectious versus malignant\n pleural effusion. Pt has recently been on a course of levaquin and\n flagyl since for aspiration pna, which was broadened to vanc and\n zosyn on admission. Given CXR from that showed a left\n consolidation with pleural effusion, it seems possible that effusion is\n secondary to indection. Pt had mediastinal LN involvement on PET scan,\n so pleural effusion could be related to known metastatic breast cancer.\n - Continue vanc and zosyn\n - Consider US-guided thoracentesis\n - Consider high-res CT\n .\n # Acute renal failure: Likely ATN due to hypotension, but also may be a\n component of prerenal renal failure.\n - Check urine lytes\n - Hold ACE and diuretic\n - Renally dose meds.\n .\n # Hyperphosphatemia: Perhaps related to acute renal failure.\n - Repeat phos.\n .\n # Htn: Hold home lisinopril, amlodipine and hctz while pt on pressors.\n .\n # H/o CVA: Residual L deficits.\n - Continue statin.\n # FEN: IVF, replete electrolytes, S+S\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals, CVL\n # Communication: Patient\n # Code: Full (discussed with patient); HCP dtr \n # Disposition: ICU pending clinical improvement\n .\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 12:56 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\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\nReferences\n 1. /\n" }, { "category": "Nursing", "chartdate": "2182-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531965, "text": "Alteration in Nutrition\n Assessment:\n Pt found at 8 pm to be in no distress. Abd soft with (+) BS and no BM\n noted.\n Action:\n Pt kept NPO throughout the night due to aspiration. HOB > 30\n. Pt has\n been inc to DB&C while awake. Pt is due for speech and swallow eval\n today.\n Response:\n Pt unable to facilitate her own secretions and in need of freq oral\n care. Pt continues to be NPO until speech and swallow eval done.\n Plan:\n Plan for peech and swallow eval today. Please keep pt NPO (inc meds)\n until eval done.\n Pleural effusion, acute\n Assessment:\n Pt found at 8 pm to be in no resp distress. LS CTA with diminished\n bases. O2 sat 94-96% on RA. Thorasynthesis done and 1400 ml\n removed.\n Action:\n While pt was sleeping, O2sat decreased to 88% on RA and NC 2 liters\n placed w/o any effect. Pt was inc to DB&C and CP done. Pt noted to\n present with a very weak non-prod cough.\n Response:\n O2sat increased to 94% on 2 liters after aggressive pulm toilet. HOB\n kept > 30\n Plan:\n Continue aggressive pulm toilet.\n" }, { "category": "Nursing", "chartdate": "2182-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531661, "text": "88 year old female with history of Stage IV right sided breast cancer\n (no chemo d/t poor functional status) and CVA with residual Left-sided\n weakness, now with chief complaint of lethargy. Pt was sent to ED\n from , where, , the pt was found to be\n bradycardic to 40's, and unobtainable BP on the day of admission. The\n pt was picked up by a BLS ambulance and atropine was not given. Per\n pt's family since a week prior to admission the pt has been more\n listless, less interactive and more lethargic on visits. They note that\n recently she has had difficulty with swallowing at . At\n , the pt was currently being treated for aspiration\n pneumonia with levaquin and flagyl since .\n .\n In the ED, initial vs were: P 100 BP 60's systolic, 100% NRB. Pt\n received Vanc, Zosyn and rectal tylenol and norepinephrine was started\n for hypotension. Lactate was noted to be in the 5's. A CVL was placed\n in the ED. 3L NS was given. CXR showed evidence of left effusion,\n infectious versus malignant. Pt was admitted to the MICU for presumed\n sepsis\n Pleural effusion, acute\n Assessment:\n Pt rec\nd on 2l NC, but she had taken NC off and O2 sat on RA 98-100%.\n RR 19-31 and shallow. Lung snds clear on R, diminished throughout on L.\n AM CXR showed complete white-out on L. Pt with weak, non-productive\n cough. Afebrile. AM WBC 16.7 with Lactic acid down to 1.3.\n Action:\n Pt cont on Zosyn, Vancomycin,\n Response:\n Family reports pt more interactive,\nlivelier\n today. She remains O X\n , cooperative, follows commands.\n Plan:\n Cont antibiotic tx. Thoracentesis ? later today. Cont emotional support\n to pt and family.\n Sepsis without organ dysfunction\n Assessment:\n Pt rec\nd on Levophed @ .03mcg/kg/min. VSS with HR 73-85SR with occas\n PVC\ns, BP 85/46-121/40. CVP 12.\n Action:\n Levo weaned to off @ 0900 while maintaining MAP>65.\n Response:\n Stable.\n Plan:\n Cont to monitor BP, CVP, using fluid bolus to maintain within goal\n limits.\n" }, { "category": "Nursing", "chartdate": "2182-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531663, "text": "88 year old female with history of Stage IV right sided breast cancer\n (no chemo d/t poor functional status) and CVA with residual Left-sided\n weakness, now with chief complaint of lethargy. Pt was sent to ED\n from , where, , the pt was found to be\n bradycardic to 40's, and unobtainable BP on the day of admission. The\n pt was picked up by a BLS ambulance and atropine was not given. Per\n pt's family since a week prior to admission the pt has been more\n listless, less interactive and more lethargic on visits. They note that\n recently she has had difficulty with swallowing at . At\n , the pt was currently being treated for aspiration\n pneumonia with levaquin and flagyl since .\n .\n In the ED, initial vs were: P 100 BP 60's systolic, 100% NRB. Pt\n received Vanc, Zosyn and rectal tylenol and norepinephrine was started\n for hypotension. Lactate was noted to be 5.9. A CVL was placed in the\n ED. 3L NS was given. CXR showed evidence of left effusion, infectious\n versus malignant. Pt was admitted to the MICU for presumed sepsis\n Pleural effusion, acute\n Assessment:\n Pt rec\nd on 2l NC, but she had taken NC off and O2 sat on RA 98-100%.\n RR 19-31 and shallow. Lung snds clear on R, diminished throughout on L.\n AM CXR showed complete white-out on L. Pt with weak, non-productive\n cough. Afebrile. AM WBC 16.7 with Lactic acid down to 1.3.\n Action:\n Pt cont on Zosyn, Vancomycin,\n Response:\n Family reports pt more interactive,\nlivelier\n today. She remains O X\n , cooperative, follows commands.\n Plan:\n Cont antibiotic tx. Thoracentesis ? later today. Cont emotional support\n to pt and family.\n Sepsis without organ dysfunction\n Assessment:\n Pt rec\nd on Levophed @ .03mcg/kg/min. VSS with HR 73-85SR with occas\n PVC\ns, BP 85/46-121/40. CVP 12.\n Action:\n Levo weaned to off @ 0900 while maintaining MAP>65.\n Response:\n Stable.\n Plan:\n Cont to monitor BP, CVP, using fluid bolus to maintain within goal\n limits.\n" }, { "category": "Physician ", "chartdate": "2182-03-10 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 531518, "text": "TITLE:\n Chief Complaint: Lethargy\n HPI:\n 88 year old female with history of Stage IV right sided breast cancer\n (no chemo d/t poor functional status) and CVA with chief complaint of\n lethargy. Pt was sent to ED from , where, \n , the pt was found to be bradycardic to 40's, and\n unobtainable BP on the day of admission. The pt was picked up by a BLS\n ambulance and atropine was not given. Per pt's family since a week\n prior to admission the pt has been more listless, less interactive and\n more lethargic on visits. They note that recently she has had\n difficulty with swallowing at . At , the pt\n was currently being treated for aspiration pneumonia with levaquin and\n flagyl since .\n .\n In the ED, initial vs were: P 100 BP 60's systolic, 100% NRB. Pt\n received Vanc, Zosyn and rectal tylenol and norepinephrine was started\n for hypotension. Lactate was noted to be in the 5's. A CVL was placed\n in the ED. 3L NS was given. Exam notable for L sided weakness which is\n residual from old CVA. CXR showed evidence of left effusion, infectious\n versus malignant. Pt was admitted to the MICU for presumed sepsis.\n .\n On the floor, pt appears comfortable, is hypothermic, and on pressors.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:07 AM\n Piperacillin/Tazobactam (Zosyn) - 01:08 AM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n AMLODIPINE 5 mg once a day\n CARBIDOPA-LEVODOPA - 25 mg-100 mg Tablet - 1.5 Tablet(s) by mouth\n four times a day\n CLOPIDOGREL [PLAVIX] - 75 mg daily\n HYDROCHLOROTHIAZIDE - 25 mg daily\n LISINOPRIL - 20 mg DAILY\n POLYETHYLENE GLYCOL 3350 [MIRALAX]\n SIMVASTATIN 10 mg at bedtime\n ACETAMINOPHEN\n BISACODYL 10 mg Suppository\n MAGNESIUM HYDROXIDE [MILK OF MAGNESIA] 30 ml by mouth daily as\n needed for constipation\n SODIUM PHOSPHATES [FLEET ENEMA] rectally daily as needed for\n constipation 2 hours post dulcolax\n Past medical history:\n Family history:\n Social History:\n HTN\n s/p basal ganglia CVA in \n L.carotid stenosis 60% MRI/MRA in \n Mitral stenosis\n ? Parkinson's disease (patient is on carbidopa-levodopa)\n Hypercholesterolemia\n PPD positive\n depression\n LBBB since \n Prolonged QTc\n Oncologic History: stage IV (T4bN1M1) right-sided, triple-negative\n breast carcinoma\n 1. : Had an abnormal mammogram of the right breast but\n patient never followed up\n 2. : Pt noticed a lump in the right breast: grade 3,\n triple-negative invasive ductal carcinoma\n 3. : , palliative surgery to remove right breast\n tumor/skin involvement. Chemotherapy not considered given poor\n performance status. Surveillance for now.\n PET-CT :\n 1. Large FDG-avid breast mass consistent with carcinoma with\n FDG-avid cervical, right axillary and mediastinal nodal\n metastases. 2. No evidence of FDG-avid disease in the abdomen. 3.\n Enlarged uterus containing endometrial fluid and central\n FDG-avidity. Findings are concerning for endometrial hyperplasia\n or neoplasia and further evaluation with pelvic ultrasound\n is recommended. 4. Right maxillary sinus opacification.\n Diabetes, hypertension, heart disease\n Occupation:\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other: Denies tobacco, alcohol, drugs. Lived in , with\n son and daughter-in-law. Moved to to be with\n daughter. Now living in .\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Cough, Dyspnea, Tachypnea\n Neurologic: lethargy\n Flowsheet Data as of 02:36 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 86 (86 - 88) bpm\n BP: 108/52(64) {108/52(64) - 139/74(90)} mmHg\n RR: 19 (19 - 28) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 3,321 mL\n PO:\n TF:\n IVF:\n 321 mL\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,221 mL\n Respiratory\n SpO2: 100%\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 _______________________________________________________________________\n Lactate:5.9\n Comments:\n Lactate: Verified\n \n 10:10p\n _______________________________________________________________________\n LIGHT GREEN\n Trop-T: 0.11\n Comments:\n cTropnT: Verified By Replicate Analysis\n cTropnT: Notified @2320 By Zv\n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n D-Dimer: >\n 138\n [image002.gif]\n 98\n [image002.gif]\n 39\n [image004.gif]\n 117\n AGap=26\n [image005.gif]\n 4.8\n [image002.gif]\n 19\n [image002.gif]\n 1.9\n [image007.gif]\n Comments:\n Na: Anion Gap Verified\n Glucose: If Fasting, 70-100 Normal, >125 Provisional Diabetes\n estGFR: [1]25/30 (click for details)\n CK: 101\n Comments:\n CK(CPK): New Reference Interval As Of ;Upper Limit (97.5th %Ile)\n Varies With Ancestry And Gender (Male/Female);Whites 322/201 Blacks\n 801/414 Asians 641/313\n Ca: 9.3 Mg: 2.4 P: 6.1\n 79\n 14.3\n [image007.gif]\n 13.3\n [image004.gif]\n 511\n [image008.gif]\n [image004.gif]\n 41.8\n [image007.gif]\n N:88.6 L:6.3 M:4.2 E:0.6 Bas:0.3\n PT: 15.4\n PTT: 26.4\n INR: 1.4\n Assessment and Plan\n 88 year old woman with sepsis, likely secondary to health care\n associated pneumonia.\n .\n # Sepsis: Pt with hypotension, tachycardia suggestive of septic shock.\n Pt's mentation is at baseline. Urine output has been approx 30 cc/hr in\n ED. Labs suggestive of lactic acidosis with an anion gap of 21. Sepsis\n likely due to pneumonia given large pleural effusion, also consider\n UTI/urosepsis. Pt now s/p 3L IVF in ED.\n - Continue norepinephrine with goal MAP>60\n - Bolus with IVF prn to try to wean norepinephrine\n - Broadly culture (blood, urine, sputum)\n - Place a-line to monitor BP's\n .\n # Respiratory distress: Initially pt was on NRB, but has been weaned\n down to 4L NC but still tachypnic. be secondary to pneumonia,\n pleural effusion.\n - Check ABG\n - ATC nebs\n - Treat pneumonia with vanc, zosyn\n .\n # Anion-gap acidosis: Pt has an anion gap of 21, with a delta-delta of\n which suggests a metabolic alkalosis as well. AG acidosis likely\n due to lactic acidosis and uremia.\n - Continue IVF for elevated lactate\n - ABG as above\n - A line for ABG monitoring\n .\n # Massive left pleural effusion: Likely infectious versus malignant\n pleural effusion. Pt has recently been on a course of levaquin and\n flagyl since for aspiration pna, which was broadened to vanc and\n zosyn on admission. Given CXR from that showed a left\n consolidation with pleural effusion, it seems possible that effusion is\n secondary to indection. Pt had mediastinal LN involvement on PET scan,\n so pleural effusion could be related to known metastatic breast cancer.\n - Continue vanc and zosyn\n - Consider US-guided thoracentesis\n - Consider high-res CT\n .\n # Acute renal failure: Likely ATN due to hypotension, but also may be a\n component of prerenal renal failure.\n - Check urine lytes\n - Hold ACE and diuretic\n - Renally dose meds.\n .\n # Hyperphosphatemia: Perhaps related to acute renal failure.\n - Repeat phos.\n .\n # Htn: Hold home lisinopril, amlodipine and hctz while pt on pressors.\n .\n # H/o CVA: Residual L deficits.\n - Continue statin.\n # FEN: IVF, replete electrolytes, regular diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals\n # Communication: Patient\n # Code: Full (discussed with patient); HCP dtr \n # Disposition: ICU pending clinical improvement\n .\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 12:56 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\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\nReferences\n 1. /\n" }, { "category": "Physician ", "chartdate": "2182-03-12 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 532068, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 08:30 AM\n THORACENTESIS - At 05:00 PM\n 1400ml fluid taken off\n CALLED OUT\n Patient s/p thoracentesis with 1400ml of serosanguinous fluid removed.\n Tolerated procedure well with improvement in respiratory status.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:09 AM\n Vancomycin - 08:34 PM\n Ampicillin/Sulbactam (Unasyn) - 12:44 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 77 (74 - 93) bpm\n BP: 135/72(87) {107/51(67) - 144/103(107)} mmHg\n RR: 11 (11 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (12 - 15)mmHg\n Total In:\n 670 mL\n 278 mL\n PO:\n TF:\n IVF:\n 640 mL\n 278 mL\n Blood products:\n Total out:\n 2,370 mL\n 310 mL\n Urine:\n 970 mL\n 310 mL\n NG:\n Stool:\n Drains:\n 1,400 mL\n Balance:\n -1,700 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95% on 2L NC\n ABG: ///26/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Right rhonchi, left minimal breath sounds, no wheezes\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: A+Ox2 (to , , name, not oriented to year)\n Labs / Radiology\n 387 K/uL\n 11.6 g/dL\n 83 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 32 mg/dL\n 110 mEq/L\n 146 mEq/L\n 36.6 %\n 13.1 K/uL\n [image002.jpg]\n 05:55 AM\n 03:37 AM\n 04:19 AM\n WBC\n 16.7\n 13.2\n 13.1\n Hct\n 35.9\n 37.4\n 36.6\n Plt\n 399\n 381\n 387\n Cr\n 1.4\n 1.3\n 1.0\n Glucose\n 118\n 72\n 83\n Other labs: PT / PTT / INR:15.6/28.2/1.4,\n ALT / AST:6/31, Alk Phos / T Bili:99/0.8, Lactic Acid:1.3 mmol/L,\n LDH:339 IU/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Blood CX (): NGTD\n Pleural Fluid:\n - pH 7.45\n - LDH: 398\n - protein 3.8\n - glucose 73\n - WBC: 1333, RBC: , poly: 42, lymph: 33, macro: 20\n Fluid Protein/Serum protein = 0.64 (c/w exudate)\n Fluid LDH/Serum LDH = 1.17 (c/w exudate)\n Assessment and Plan\n 88 year old woman with sepsis, likely secondary to health care\n associated/aspiration pneumonia with large left sided pleural effusion\n with exudative\n .\n # Sepsis: Pt with hypotension, tachycardia suggestive of septic shock.\n Pt's mentation is at baseline. Urine output has been approx 30 cc/hr in\n ED. Labs suggestive of lactic acidosis with an anion gap of 21. Sepsis\n likely due to pneumonia given large pleural effusion, also consider\n UTI/urosepsis. Pt now s/p 3L IVF in ED.\n - Continue norepinephrine with goal MAP>60\n - Bolus with IVF prn to try to wean norepinephrine\n - Broadly culture (blood, urine, sputum)\n - Place a-line to monitor BP's\n - CVP>12\n - Check mixed venous sat, if low consider transfusion if hct<30\n .\n # Respiratory distress: Initially pt was on NRB, was weaned down to 4L\n NC, and is now tolerating room air. be secondary to pneumonia,\n pleural effusion.\n - Check ABG\n - ATC nebs\n - Treat pneumonia with Unasyn x 10 day course for aspiration PNA (could\n transition to Augmentin)\n - Continue O2 PRN\n .\n # Anion-gap acidosis: Pt has an anion gap of 21, with a delta-delta of\n which suggests a metabolic alkalosis as well. AG acidosis likely\n due to lactic acidosis and uremia.\n - Continue IVF for elevated lactate\n - ABG as above\n - A line for ABG monitoring\n .\n # Massive left pleural effusion: Likely infectious versus malignant\n pleural effusion. Pt has recently been on a course of levaquin and\n flagyl since for aspiration pna, which was broadened to vanc and\n zosyn on admission. Given CXR from that showed a left\n consolidation with pleural effusion, it seems possible that effusion is\n secondary to indection. Pt had mediastinal LN involvement on PET scan,\n so pleural effusion could be related to known metastatic breast cancer.\n - Continue Unasyn as above\n - Hold off on draining fluid re-accumulation at this time as pt\n minimally symptomatic; may require repeat tap if sx accelerate (with\n Pleurex catheter placement)\n - Consider high-res CT\n - F/U cytology from initial thoracentesis\n .\n # Acute renal failure: Likely ATN due to hypotension, but also may be a\n component of prerenal renal failure.\n - Check urine lytes\n - Hold ACE and diuretic\n - Renally dose meds.\n .\n # Hyperphosphatemia: Perhaps related to acute renal failure.\n - Phosphate today is normal.\n .\n # Htn: Hold home lisinopril, amlodipine and hctz while pt on pressors.\n .\n # H/o CVA: Residual L deficits.\n - Continue statin.\n # FEN: IVF, replete electrolytes, S+S evaluation today\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals, CVL\n # Communication: Patient\n # Code: Full (discussed with patient); HCP dtr \n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:56 AM\n 18 Gauge - 01:33 AM\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: 88F advanced breast cancer, CVA, likely\n aspiration pneumonia with L effusion. Initially hypotensive c lactic\n acidosis - improved with volume and abx. Tap 1.4L exudative effusion\n from L lung yesterday with improvment in resp status and CXR, no PTX.\n Exam notable for Tm 97.7 BP 150/80 HR 76 RR 21 with sat 96 on 4LNC. WD\n woman, awake, follows commands, denies SOB, mood much brighter today.\n BS on L. RRR s1s2. Soft +BS. No edema. Labs notable for WBC 13K,\n HCT 36, K+ 3.9, Cr 1.0. CXR with smaller L effusion.\n Agree with plan to continue unasyn x10d total course for likely\n aspiration pneumonia. Effusion may be malignant, tap not c/w empyema\n and rapid reaccumulation with neg pleural pressure post tap raise\n concern for trapped lung; will d/w IP following return of cytology, may\n bebefit from pleurex catheter. ARF has resolved. Remainder of plan as\n outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 03:08 PM ------\n" }, { "category": "Nursing", "chartdate": "2182-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531633, "text": "88 year old female with history of Stage IV right sided breast cancer\n (no chemo d/t poor functional status) and CVA with chief complaint of\n lethargy. Pt was sent to ED from , where, \n , the pt was found to be bradycardic to 40's, and\n unobtainable BP on the day of admission. The pt was picked up by a BLS\n ambulance and atropine was not given. Per pt's family since a week\n prior to admission the pt has been more listless, less interactive and\n more lethargic on visits. They note that recently she has had\n difficulty with swallowing at . At , the pt\n was currently being treated for aspiration pneumonia with levaquin and\n flagyl since .\n .\n In the ED, initial vs were: P 100 BP 60's systolic, 100% NRB. Pt\n received Vanc, Zosyn and rectal tylenol and norepinephrine was started\n for hypotension. Lactate was noted to be in the 5's. A CVL was placed\n in the ED. 3L NS was given. Exam notable for L sided weakness which is\n residual from old CVA. CXR showed evidence of left effusion, infectious\n versus malignant. Pt was admitted to the MICU for presumed sepsis\n Pleural effusion, acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2182-03-10 00:00:00.000", "description": "ICU Event Note", "row_id": 531707, "text": "Clinician: Attending\n Met with pt's daughter (who is HCP) and son to discuss clinical\n status and plans. They understand my information and had questions\n regarding next steps. I answered all questions. They agreed to\n thoracentesis and understood that the two main likely etioloties\n (infection and malignant) have different likelihoods of recurrence and\n management. The daughter informed me that pt has known pulm nodules,\n likely mets, which were not biopsied. I told them we will perform \n today or tomorrow.\n Total time spent: 30 minutes\n Patient is critically ill.\n ------ Protected Section ------\n I forgot to mention that I also discussed code status with pt\n daughter and son, and they stated that she should be full code at this\n time. They would re-visit that decision if her clinical status became\n much worse.\n ------ Protected Section Addendum Entered By: , MD\n on: 17:58 ------\n" }, { "category": "Nursing", "chartdate": "2182-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531709, "text": "88 year old female with history of Stage IV right sided breast cancer\n (no chemo d/t poor functional status) and CVA with residual Left-sided\n weakness, now with chief complaint of lethargy. Pt was sent to ED\n from , where, , the pt was found to be\n bradycardic to 40's, and unobtainable BP on the day of admission. The\n pt was picked up by a BLS ambulance and atropine was not given. Per\n pt's family since a week prior to admission the pt has been more\n listless, less interactive and more lethargic on visits. They note that\n recently she has had difficulty with swallowing at . At\n , the pt was currently being treated for aspiration\n pneumonia with levaquin and flagyl since .\n .\n In the ED, initial vs were: P 100 BP 60's systolic, 100% NRB. Pt\n received Vanc, Zosyn and rectal tylenol and norepinephrine was started\n for hypotension. Lactate was noted to be 5.9. A CVL was placed in the\n ED. 3L NS was given. CXR showed evidence of left effusion, infectious\n versus malignant. Pt was admitted to the MICU for presumed sepsis. FULL\n CODE.\n Pleural effusion, acute\n Assessment:\n Pt rec\nd on 2l NC, but she had taken NC off and O2 sat on RA 98-100%.\n RR 19-31 and shallow. Lung snds clear on R, diminished throughout on L.\n AM CXR showed complete white-out on L. Pt with weak, non-productive\n cough. Afebrile. AM WBC 16.7 with Lactic acid down to 1.3.\n Action:\n Pt cont on Zosyn, Vancomycin,\n Response:\n Family reports pt more interactive,\nlivelier\n today. She remains O X\n , cooperative, follows commands.\n Plan:\n Cont antibiotic tx. Thoracentesis ? later today. Cont emotional support\n to pt and family.\n Sepsis without organ dysfunction\n Assessment:\n Pt rec\nd on Levophed @ .03mcg/kg/min. VSS with HR 73-85SR with occas\n PVC\ns, BP 85/46-121/40. CVP 12.\n Action:\n Levo weaned to off @ 0900 while maintaining MAP>65.\n Response:\n Stable.\n Plan:\n Cont to monitor BP, CVP, using fluid bolus to maintain within goal\n limits.\n Alteration in Nutrition\n Assessment:\n Pt rec\nd NPO except for meds. Abd soft with + BS and flatus.\n Action:\n Pt took crushed meds in ice cream and appeared to have swallowed it\n after much encouragement. Pt with 2 med-lg loose brown bowel movements.\n Aspiration precautions maintained, with HOB elevated 45 degrees.\n Response:\n Stable.\n Plan:\n Speech/Swallow testing tomorrow. Pt to remain NPO until then.\n" }, { "category": "Physician ", "chartdate": "2182-03-11 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 531916, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Patient on room air, sating in mid 90s on RA with no overnight\n events.\n - Plan for DX thoracentesis on \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:07 AM\n Piperacillin/Tazobactam (Zosyn) - 12:52 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:59 PM\n Other medications:\n Changes to medical and family history:\n No Changes.\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unchanged.\n Flowsheet Data as of 07:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 82 (72 - 86) bpm\n BP: 139/76(91) {85/40(25) - 143/76(91)} mmHg\n RR: 23 (11 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 12 (12 - 12)mmHg\n Total In:\n 5,715 mL\n 127 mL\n PO:\n TF:\n IVF:\n 2,635 mL\n 127 mL\n Blood products:\n Total out:\n 1,155 mL\n 335 mL\n Urine:\n 1,155 mL\n 335 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,560 mL\n -208 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General: Alert, oriented, no acute distress; reports that she feels\n \"lazy.\"\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Right rhonchi, left minimal breath sounds, no wheezes\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: A+Ox2 (to , , name, not oriented to year). Speech\n slow.\n CN II-XII intact\n Strength 4/5 in RUE, less in LUE\n Gait assessment deferred\n Labs / Radiology\n 381 K/uL\n 11.7 g/dL\n 72 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 37 mg/dL\n 108 mEq/L\n 144 mEq/L\n 37.4 %\n 13.2 K/uL\n [image002.jpg]\n 05:55 AM\n 03:37 AM\n WBC\n 16.7\n 13.2\n Hct\n 35.9\n 37.4\n Plt\n 399\n 381\n Cr\n 1.4\n 1.3\n Glucose\n 118\n 72\n Other labs: PT / PTT / INR:17.1/29.7/1.5, ALT / AST:6/31, Alk Phos / T\n Bili:99/0.8, Lactic Acid:1.3 mmol/L, LDH:339 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 88 year old woman with sepsis, likely secondary to health care\n associated/aspiration pneumonia with large left sided pleural effusion.\n .\n # Sepsis: Pt with hypotension, tachycardia suggestive of septic shock.\n Pt's mentation is at baseline. Urine output has been approx 30 cc/hr in\n ED. Labs suggestive of lactic acidosis with an anion gap of 21. Sepsis\n likely due to pneumonia given large pleural effusion, also consider\n UTI/urosepsis. Pt now s/p 3L IVF in ED.\n - Continue norepinephrine with goal MAP>60\n - Bolus with IVF prn to try to wean norepinephrine\n - Broadly culture (blood, urine, sputum)\n - Place a-line to monitor BP's\n - CVP>12\n - Check mixed venous sat, if low consider transfusion if hct<30\n .\n # Respiratory distress: Initially pt was on NRB, was weaned down to 4L\n NC, and is now tolerating room air. be secondary to pneumonia,\n pleural effusion.\n - Check ABG\n - ATC nebs\n - Treat pneumonia with vanc, zosyn\n .\n # Anion-gap acidosis: Pt has an anion gap of 21, with a delta-delta of\n which suggests a metabolic alkalosis as well. AG acidosis likely\n due to lactic acidosis and uremia.\n - Continue IVF for elevated lactate\n - ABG as above\n - A line for ABG monitoring\n .\n # Massive left pleural effusion: Likely infectious versus malignant\n pleural effusion. Pt has recently been on a course of levaquin and\n flagyl since for aspiration pna, which was broadened to vanc and\n zosyn on admission. Given CXR from that showed a left\n consolidation with pleural effusion, it seems possible that effusion is\n secondary to indection. Pt had mediastinal LN involvement on PET scan,\n so pleural effusion could be related to known metastatic breast cancer.\n - Continue vanc and zosyn\n - US-guided thoracentesis today\n - Consider high-res CT\n .\n # Acute renal failure: Likely ATN due to hypotension, but also may be a\n component of prerenal renal failure.\n - Check urine lytes\n - Hold ACE and diuretic\n - Renally dose meds.\n .\n # Hyperphosphatemia: Perhaps related to acute renal failure.\n - Phosphate today is normal.\n .\n # Htn: Hold home lisinopril, amlodipine and hctz while pt on pressors.\n .\n # H/o CVA: Residual L deficits.\n - Continue statin.\n # FEN: IVF, replete electrolytes, S+S\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals, CVL\n # Communication: Patient\n # Code: Full (discussed with patient); HCP dtr \n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:56 AM\n 18 Gauge - 01:33 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\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: 88F advanced breast cancer, CVA, likely\n aspiration pneumonia with L effusion. Initially hypotensive c lactic\n acidosis - improved with volume and abx.\n Exam notable for Tm 97.7 BP 123/67 HR 82 RR 18 with sat 96 on 4LNC. WD\n woman, awake, follows commands, denies SOB. Dullness / absent BS on L.\n RRR s1s2. Soft +BS. No edema. Labs notable for WBC 13K, HCT 37, K+ 3.9,\n Cr 1.3. CXR with L ASD / collapse with associated effusion.\n Agree with plan to manage L effusion / collapse with USG-guided\n thoracentesis for dx/rx while continuing abx for probable aspiration\n pbeumonia - will continue vanco and change zosyn to unasyn. ARF is\n resolving with resolution of shock, continue to hold ACEI. Will recheck\n FSG now and give amp D50 if <80. Remainder of plan as outlined\n above.\n ADDENDUM\n Thoracentesis procedure explained in detail to patient and\n son, informed consent obtained. Pocket identified with USG,\n uncomplicated removal of 1400cc serosanguinous fluid without\n complication, sent for studies.\n Total time: 50 min\n" }, { "category": "Nursing", "chartdate": "2182-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531981, "text": "Alteration in Nutrition\n Assessment:\n Pt found at 8 pm to be in no distress. Abd soft with (+) BS and no BM\n noted.\n Action:\n Pt kept NPO throughout the night due to aspiration. HOB > 30\n. Pt has\n been inc to DB&C while awake. Pt is due for speech and swallow eval\n today.\n Response:\n Pt unable to facilitate her own secretions and in need of freq oral\n care. Pt continues to be NPO until speech and swallow eval done.\n Plan:\n Plan for peech and swallow eval today. Please keep pt NPO (inc meds)\n until eval done.\n Pleural effusion, acute\n Assessment:\n Pt found at 8 pm to be in no resp distress. LS CTA with diminished\n bases. O2 sat 94-96% on RA. Thorasynthesis done and 1400 ml\n removed.\n Action:\n While pt was sleeping, O2sat decreased to 88% on RA and NC 2 liters\n placed w/o any effect. Pt was inc to DB&C and CP done. Pt noted to\n present with a very weak non-prod cough.\n Response:\n O2sat increased to 94-96% on 2 liters after aggressive pulm toilet. HOB\n kept > 30\n Plan:\n Continue aggressive pulm toilet.\n" }, { "category": "Physician ", "chartdate": "2182-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531992, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 08:30 AM\n THORACENTESIS - At 05:00 PM\n 1400ml fluid taken off\n CALLED OUT\n Patient s/p thoracentesis with 1400ml of serosanguinous fluid removed.\n Tolerated procedure well with improvement in respiratory status.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:09 AM\n Vancomycin - 08:34 PM\n Ampicillin/Sulbactam (Unasyn) - 12:44 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 77 (74 - 93) bpm\n BP: 135/72(87) {107/51(67) - 144/103(107)} mmHg\n RR: 11 (11 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (12 - 15)mmHg\n Total In:\n 670 mL\n 278 mL\n PO:\n TF:\n IVF:\n 640 mL\n 278 mL\n Blood products:\n Total out:\n 2,370 mL\n 310 mL\n Urine:\n 970 mL\n 310 mL\n NG:\n Stool:\n Drains:\n 1,400 mL\n Balance:\n -1,700 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n Labs / Radiology\n 387 K/uL\n 11.6 g/dL\n 83 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 32 mg/dL\n 110 mEq/L\n 146 mEq/L\n 36.6 %\n 13.1 K/uL\n [image002.jpg]\n 05:55 AM\n 03:37 AM\n 04:19 AM\n WBC\n 16.7\n 13.2\n 13.1\n Hct\n 35.9\n 37.4\n 36.6\n Plt\n 399\n 381\n 387\n Cr\n 1.4\n 1.3\n 1.0\n Glucose\n 118\n 72\n 83\n Other labs: PT / PTT / INR:15.6/28.2/1.4,\n ALT / AST:6/31, Alk Phos / T Bili:99/0.8, Lactic Acid:1.3 mmol/L,\n LDH:339 IU/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Fluid Protein/Serum protein = 0.64 (c/w exudate)\n Fluid LDH/Serum LDH = 1.17 (c/w exudate)\n Assessment and Plan\n ALTERATION IN NUTRITION\n PLEURAL EFFUSION, ACUTE\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:56 AM\n 18 Gauge - 01:33 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": "2182-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531993, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 08:30 AM\n THORACENTESIS - At 05:00 PM\n 1400ml fluid taken off\n CALLED OUT\n Patient s/p thoracentesis with 1400ml of serosanguinous fluid removed.\n Tolerated procedure well with improvement in respiratory status.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:09 AM\n Vancomycin - 08:34 PM\n Ampicillin/Sulbactam (Unasyn) - 12:44 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 77 (74 - 93) bpm\n BP: 135/72(87) {107/51(67) - 144/103(107)} mmHg\n RR: 11 (11 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (12 - 15)mmHg\n Total In:\n 670 mL\n 278 mL\n PO:\n TF:\n IVF:\n 640 mL\n 278 mL\n Blood products:\n Total out:\n 2,370 mL\n 310 mL\n Urine:\n 970 mL\n 310 mL\n NG:\n Stool:\n Drains:\n 1,400 mL\n Balance:\n -1,700 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n Labs / Radiology\n 387 K/uL\n 11.6 g/dL\n 83 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 32 mg/dL\n 110 mEq/L\n 146 mEq/L\n 36.6 %\n 13.1 K/uL\n [image002.jpg]\n 05:55 AM\n 03:37 AM\n 04:19 AM\n WBC\n 16.7\n 13.2\n 13.1\n Hct\n 35.9\n 37.4\n 36.6\n Plt\n 399\n 381\n 387\n Cr\n 1.4\n 1.3\n 1.0\n Glucose\n 118\n 72\n 83\n Other labs: PT / PTT / INR:15.6/28.2/1.4,\n ALT / AST:6/31, Alk Phos / T Bili:99/0.8, Lactic Acid:1.3 mmol/L,\n LDH:339 IU/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Fluid Protein/Serum protein = 0.64 (c/w exudate)\n Fluid LDH/Serum LDH = 1.17 (c/w exudate)\n Assessment and Plan\n 88 year old woman with sepsis, likely secondary to health care\n associated/aspiration pneumonia with large left sided pleural effusion.\n .\n # Sepsis: Pt with hypotension, tachycardia suggestive of septic shock.\n Pt's mentation is at baseline. Urine output has been approx 30 cc/hr in\n ED. Labs suggestive of lactic acidosis with an anion gap of 21. Sepsis\n likely due to pneumonia given large pleural effusion, also consider\n UTI/urosepsis. Pt now s/p 3L IVF in ED.\n - Continue norepinephrine with goal MAP>60\n - Bolus with IVF prn to try to wean norepinephrine\n - Broadly culture (blood, urine, sputum)\n - Place a-line to monitor BP's\n - CVP>12\n - Check mixed venous sat, if low consider transfusion if hct<30\n .\n # Respiratory distress: Initially pt was on NRB, was weaned down to 4L\n NC, and is now tolerating room air. be secondary to pneumonia,\n pleural effusion.\n - Check ABG\n - ATC nebs\n - Treat pneumonia with vanc, zosyn\n .\n # Anion-gap acidosis: Pt has an anion gap of 21, with a delta-delta of\n which suggests a metabolic alkalosis as well. AG acidosis likely\n due to lactic acidosis and uremia.\n - Continue IVF for elevated lactate\n - ABG as above\n - A line for ABG monitoring\n .\n # Massive left pleural effusion: Likely infectious versus malignant\n pleural effusion. Pt has recently been on a course of levaquin and\n flagyl since for aspiration pna, which was broadened to vanc and\n zosyn on admission. Given CXR from that showed a left\n consolidation with pleural effusion, it seems possible that effusion is\n secondary to indection. Pt had mediastinal LN involvement on PET scan,\n so pleural effusion could be related to known metastatic breast cancer.\n - Continue vanc and zosyn\n - US-guided thoracentesis today\n - Consider high-res CT\n .\n # Acute renal failure: Likely ATN due to hypotension, but also may be a\n component of prerenal renal failure.\n - Check urine lytes\n - Hold ACE and diuretic\n - Renally dose meds.\n .\n # Hyperphosphatemia: Perhaps related to acute renal failure.\n - Phosphate today is normal.\n .\n # Htn: Hold home lisinopril, amlodipine and hctz while pt on pressors.\n .\n # H/o CVA: Residual L deficits.\n - Continue statin.\n # FEN: IVF, replete electrolytes, S+S\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals, CVL\n # Communication: Patient\n # Code: Full (discussed with patient); HCP dtr \n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:56 AM\n 18 Gauge - 01:33 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": "2182-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531997, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 08:30 AM\n THORACENTESIS - At 05:00 PM\n 1400ml fluid taken off\n CALLED OUT\n Patient s/p thoracentesis with 1400ml of serosanguinous fluid removed.\n Tolerated procedure well with improvement in respiratory status.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:09 AM\n Vancomycin - 08:34 PM\n Ampicillin/Sulbactam (Unasyn) - 12:44 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 77 (74 - 93) bpm\n BP: 135/72(87) {107/51(67) - 144/103(107)} mmHg\n RR: 11 (11 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (12 - 15)mmHg\n Total In:\n 670 mL\n 278 mL\n PO:\n TF:\n IVF:\n 640 mL\n 278 mL\n Blood products:\n Total out:\n 2,370 mL\n 310 mL\n Urine:\n 970 mL\n 310 mL\n NG:\n Stool:\n Drains:\n 1,400 mL\n Balance:\n -1,700 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95% on 2L NC\n ABG: ///26/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Right rhonchi, left minimal breath sounds, no wheezes\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: A+Ox2 (to , , name, not oriented to year)\n Labs / Radiology\n 387 K/uL\n 11.6 g/dL\n 83 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 32 mg/dL\n 110 mEq/L\n 146 mEq/L\n 36.6 %\n 13.1 K/uL\n [image002.jpg]\n 05:55 AM\n 03:37 AM\n 04:19 AM\n WBC\n 16.7\n 13.2\n 13.1\n Hct\n 35.9\n 37.4\n 36.6\n Plt\n 399\n 381\n 387\n Cr\n 1.4\n 1.3\n 1.0\n Glucose\n 118\n 72\n 83\n Other labs: PT / PTT / INR:15.6/28.2/1.4,\n ALT / AST:6/31, Alk Phos / T Bili:99/0.8, Lactic Acid:1.3 mmol/L,\n LDH:339 IU/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Blood CX (): NGTD\n Pleural Fluid:\n - pH 7.45\n - LDH: 398\n - protein 3.8\n - glucose 73\n - WBC: 1333, RBC: , poly: 42, lymph: 33, macro: 20\n Fluid Protein/Serum protein = 0.64 (c/w exudate)\n Fluid LDH/Serum LDH = 1.17 (c/w exudate)\n Assessment and Plan\n 88 year old woman with sepsis, likely secondary to health care\n associated/aspiration pneumonia with large left sided pleural effusion\n with exudative\n .\n # Sepsis: Pt with hypotension, tachycardia suggestive of septic shock.\n Pt's mentation is at baseline. Urine output has been approx 30 cc/hr in\n ED. Labs suggestive of lactic acidosis with an anion gap of 21. Sepsis\n likely due to pneumonia given large pleural effusion, also consider\n UTI/urosepsis. Pt now s/p 3L IVF in ED.\n - Continue norepinephrine with goal MAP>60\n - Bolus with IVF prn to try to wean norepinephrine\n - Broadly culture (blood, urine, sputum)\n - Place a-line to monitor BP's\n - CVP>12\n - Check mixed venous sat, if low consider transfusion if hct<30\n .\n # Respiratory distress: Initially pt was on NRB, was weaned down to 4L\n NC, and is now tolerating room air. be secondary to pneumonia,\n pleural effusion.\n - Check ABG\n - ATC nebs\n - Treat pneumonia with vanc, zosyn\n .\n # Anion-gap acidosis: Pt has an anion gap of 21, with a delta-delta of\n which suggests a metabolic alkalosis as well. AG acidosis likely\n due to lactic acidosis and uremia.\n - Continue IVF for elevated lactate\n - ABG as above\n - A line for ABG monitoring\n .\n # Massive left pleural effusion: Likely infectious versus malignant\n pleural effusion. Pt has recently been on a course of levaquin and\n flagyl since for aspiration pna, which was broadened to vanc and\n zosyn on admission. Given CXR from that showed a left\n consolidation with pleural effusion, it seems possible that effusion is\n secondary to indection. Pt had mediastinal LN involvement on PET scan,\n so pleural effusion could be related to known metastatic breast cancer.\n - Continue vanc and zosyn\n - US-guided thoracentesis today\n - Consider high-res CT\n .\n # Acute renal failure: Likely ATN due to hypotension, but also may be a\n component of prerenal renal failure.\n - Check urine lytes\n - Hold ACE and diuretic\n - Renally dose meds.\n .\n # Hyperphosphatemia: Perhaps related to acute renal failure.\n - Phosphate today is normal.\n .\n # Htn: Hold home lisinopril, amlodipine and hctz while pt on pressors.\n .\n # H/o CVA: Residual L deficits.\n - Continue statin.\n # FEN: IVF, replete electrolytes, S+S\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals, CVL\n # Communication: Patient\n # Code: Full (discussed with patient); HCP dtr \n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:56 AM\n 18 Gauge - 01:33 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": "2182-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531534, "text": "Pleural effusion, acute\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Pt received from EW on levophed drip. Found to be hypothermic and cool\n to the tough. Recent history of pneumonia. Low CVP.\n Action:\n Applied Bair Hugger gave 2L of fluid bolus over 5 hours. Weaned\n Levophed to .03\n Response:\n Pt maintains stable BP weaning off pressors and an improved CVP. Temp\n improving.\n Plan:\n Continue to monitor BP and titrate levophed accordingly. Monitor temp\n and apply bair hugger as needed. Monitors CVP for fluid status.\n" }, { "category": "Nursing", "chartdate": "2182-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531536, "text": "88 year old female with history of Stage IV right sided breast cancer\n (no chemo d/t poor functional status) and CVA with chief complaint of\n lethargy. Pt was sent to ED from , where, \n , the pt was found to be bradycardic to 40's, and\n unobtainable BP on the day of admission. The pt was picked up by a BLS\n ambulance and atropine was not given. Per pt's family since a week\n prior to admission the pt has been more listless, less interactive and\n more lethargic on visits. They note that recently she has had\n difficulty with swallowing at . At , the pt\n was currently being treated for aspiration pneumonia with levaquin and\n flagyl since .\n Pleural effusion, acute\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Pt received from EW on levophed drip. Found to be hypothermic and cool\n to the tough. Recent history of pneumonia. Low CVP.\n Action:\n Applied Bair Hugger gave 2L of fluid bolus over 5 hours. Weaned\n Levophed to .03\n Response:\n Pt maintains stable BP weaning off pressors and an improved CVP. Temp\n improving.\n Plan:\n Continue to monitor BP and titrate levophed accordingly. Monitor temp\n and apply bair hugger as needed. Monitors CVP for fluid status.\n" }, { "category": "Physician ", "chartdate": "2182-03-10 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 531541, "text": "TITLE:\n Chief Complaint: Lethargy\n HPI:\n 88 year old female with history of Stage IV right sided breast cancer\n (no chemo d/t poor functional status) and CVA with chief complaint of\n lethargy. Pt was sent to ED from , where, \n , the pt was found to be bradycardic to 40's, and\n unobtainable BP on the day of admission. The pt was picked up by a BLS\n ambulance and atropine was not given. Per pt's family since a week\n prior to admission the pt has been more listless, less interactive and\n more lethargic on visits. They note that recently she has had\n difficulty with swallowing at . At , the pt\n was currently being treated for aspiration pneumonia with levaquin and\n flagyl since .\n .\n In the ED, initial vs were: P 100 BP 60's systolic, 100% NRB. Pt\n received Vanc, Zosyn and rectal tylenol and norepinephrine was started\n for hypotension. Lactate was noted to be in the 5's. A CVL was placed\n in the ED. 3L NS was given. Exam notable for L sided weakness which is\n residual from old CVA. CXR showed evidence of left effusion, infectious\n versus malignant. Pt was admitted to the MICU for presumed sepsis.\n .\n On the floor, pt appears comfortable, is hypothermic, and on pressors.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:07 AM\n Piperacillin/Tazobactam (Zosyn) - 01:08 AM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n AMLODIPINE 5 mg once a day\n CARBIDOPA-LEVODOPA - 25 mg-100 mg Tablet - 1.5 Tablet(s) by mouth\n four times a day\n CLOPIDOGREL [PLAVIX] - 75 mg daily\n HYDROCHLOROTHIAZIDE - 25 mg daily\n LISINOPRIL - 20 mg DAILY\n POLYETHYLENE GLYCOL 3350 [MIRALAX]\n SIMVASTATIN 10 mg at bedtime\n ACETAMINOPHEN\n BISACODYL 10 mg Suppository\n MAGNESIUM HYDROXIDE [MILK OF MAGNESIA] 30 ml by mouth daily as\n needed for constipation\n SODIUM PHOSPHATES [FLEET ENEMA] rectally daily as needed for\n constipation 2 hours post dulcolax\n Past medical history:\n Family history:\n Social History:\n HTN\n s/p basal ganglia CVA in \n L.carotid stenosis 60% MRI/MRA in \n Mitral stenosis\n ? Parkinson's disease (patient is on carbidopa-levodopa)\n Hypercholesterolemia\n PPD positive\n depression\n LBBB since \n Prolonged QTc\n Oncologic History: stage IV (T4bN1M1) right-sided, triple-negative\n breast carcinoma\n 1. : Had an abnormal mammogram of the right breast but\n patient never followed up\n 2. : Pt noticed a lump in the right breast: grade 3,\n triple-negative invasive ductal carcinoma\n 3. : , palliative surgery to remove right breast\n tumor/skin involvement. Chemotherapy not considered given poor\n performance status. Surveillance for now.\n PET-CT :\n 1. Large FDG-avid breast mass consistent with carcinoma with\n FDG-avid cervical, right axillary and mediastinal nodal\n metastases. 2. No evidence of FDG-avid disease in the abdomen. 3.\n Enlarged uterus containing endometrial fluid and central\n FDG-avidity. Findings are concerning for endometrial hyperplasia\n or neoplasia and further evaluation with pelvic ultrasound\n is recommended. 4. Right maxillary sinus opacification.\n Diabetes, hypertension, heart disease\n Occupation:\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other: Denies tobacco, alcohol, drugs. Lived in , with\n son and daughter-in-law. Moved to to be with\n daughter. Now living in .\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Cough, Dyspnea, Tachypnea\n Neurologic: lethargy\n Flowsheet Data as of 02:36 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 86 (86 - 88) bpm\n BP: 108/52(64) {108/52(64) - 139/74(90)} mmHg\n RR: 19 (19 - 28) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 3,321 mL\n PO:\n TF:\n IVF:\n 321 mL\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,221 mL\n Respiratory\n SpO2: 100%\n Physical Examination\n General: Alert, oriented, no acute distress; reports that she feels\n \"lazy.\"\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Right rhonchi, left minimal breath sounds, no wheezes\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: A+Ox2 (to , , name, not oriented to year). Speech\n slow.\n CN II-XII intact\n Strength 4/5 in RUE, less in LUE\n Gait assessment deferred\n Labs / Radiology\n _______________________________________________________________________\n Lactate:5.9\n Comments:\n Lactate: Verified\n \n 10:10p\n _______________________________________________________________________\n LIGHT GREEN\n Trop-T: 0.11\n Comments:\n cTropnT: Verified By Replicate Analysis\n cTropnT: Notified @2320 By Zv\n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n D-Dimer: >\n 138\n [image002.gif]\n 98\n [image002.gif]\n 39\n [image004.gif]\n 117\n AGap=26\n [image005.gif]\n 4.8\n [image002.gif]\n 19\n [image002.gif]\n 1.9\n [image007.gif]\n Comments:\n Na: Anion Gap Verified\n Glucose: If Fasting, 70-100 Normal, >125 Provisional Diabetes\n estGFR: [1]25/30 (click for details)\n CK: 101\n Comments:\n CK(CPK): New Reference Interval As Of ;Upper Limit (97.5th %Ile)\n Varies With Ancestry And Gender (Male/Female);Whites 322/201 Blacks\n 801/414 Asians 641/313\n Ca: 9.3 Mg: 2.4 P: 6.1\n 79\n 14.3\n [image007.gif]\n 13.3\n [image004.gif]\n 511\n [image008.gif]\n [image004.gif]\n 41.8\n [image007.gif]\n N:88.6 L:6.3 M:4.2 E:0.6 Bas:0.3\n PT: 15.4\n PTT: 26.4\n INR: 1.4\n Assessment and Plan\n 88 year old woman with sepsis, likely secondary to health care\n associated pneumonia.\n .\n # Sepsis: Pt with hypotension, tachycardia suggestive of septic shock.\n Pt's mentation is at baseline. Urine output has been approx 30 cc/hr in\n ED. Labs suggestive of lactic acidosis with an anion gap of 21. Sepsis\n likely due to pneumonia given large pleural effusion, also consider\n UTI/urosepsis. Pt now s/p 3L IVF in ED.\n - Continue norepinephrine with goal MAP>60\n - Bolus with IVF prn to try to wean norepinephrine\n - Broadly culture (blood, urine, sputum)\n - Place a-line to monitor BP's\n - CVP>12\n - Check mixed venous sat, if low consider transfusion if hct<30\n .\n # Respiratory distress: Initially pt was on NRB, but has been weaned\n down to 4L NC but still tachypnic. be secondary to pneumonia,\n pleural effusion.\n - Check ABG\n - ATC nebs\n - Treat pneumonia with vanc, zosyn\n .\n # Anion-gap acidosis: Pt has an anion gap of 21, with a delta-delta of\n which suggests a metabolic alkalosis as well. AG acidosis likely\n due to lactic acidosis and uremia.\n - Continue IVF for elevated lactate\n - ABG as above\n - A line for ABG monitoring\n .\n # Massive left pleural effusion: Likely infectious versus malignant\n pleural effusion. Pt has recently been on a course of levaquin and\n flagyl since for aspiration pna, which was broadened to vanc and\n zosyn on admission. Given CXR from that showed a left\n consolidation with pleural effusion, it seems possible that effusion is\n secondary to indection. Pt had mediastinal LN involvement on PET scan,\n so pleural effusion could be related to known metastatic breast cancer.\n - Continue vanc and zosyn\n - Consider US-guided thoracentesis\n - Consider high-res CT\n .\n # Acute renal failure: Likely ATN due to hypotension, but also may be a\n component of prerenal renal failure.\n - Check urine lytes\n - Hold ACE and diuretic\n - Renally dose meds.\n .\n # Hyperphosphatemia: Perhaps related to acute renal failure.\n - Repeat phos.\n .\n # Htn: Hold home lisinopril, amlodipine and hctz while pt on pressors.\n .\n # H/o CVA: Residual L deficits.\n - Continue statin.\n # FEN: IVF, replete electrolytes, S+S\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals, CVL\n # Communication: Patient\n # Code: Full (discussed with patient); HCP dtr \n # Disposition: ICU pending clinical improvement\n .\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 12:56 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Patient seen and examined with the housestaff. 88y/o woman with Stage\n 4 breast cancer who presents with bradycardia (40). Noted to have\n large left pleural effusion vs collapse. Thought to have aspirated.\n WBC 14, HCT 41, Cr 1.9.\n 95.6 108/59 89 100%3L\n PLAN:\n 1. Volume resuscitate to CVP 12\n 2. Wean pressor as tolerated; keep MAP 60\n 3. Thoracic ultrasound and possible thoracentesis\n 4. Vancomycin, piperacillin tazobactam\n 5. Urinary electrolytes\n 6. Hold ace inhibitor\n ------ Protected Section Addendum Entered By: , MD\n on: 05:16 ------\nReferences\n 1. /\n" }, { "category": "Physician ", "chartdate": "2182-03-10 00:00:00.000", "description": "Attending progress note", "row_id": 531691, "text": "MICU Attending Note\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. No change in med\n histories or ROS since admission last night, except as noted below.\n 88y/o woman with Stage 4 breast cancer who presented with bradycardia\n (40) and hypotension. Noted to have large left pleural effusion.\n Dysphagia over a week. Started on Levo/flagyl for aspiration\n pneumona. Changed to vanc/zosyn last night for severe HAP/septic shock.\n Resuscitated with 5L fluids.\n Overnight lactate decreased from 5.9 to 1.\n Weaning norepinephrine, now off (since 9am).\n AG 21, decreased to 14.\n Cr reduced from 1.9 to 1.4.\n Initially required NRB but now 100% on RA.\n ROS: pt denies any discomfort, says her breathing is good. Does not\n provide history or answer questions, though this seems to be reluctance\n or aphasia and not unresponsiveness (she is interacting with family).\n T 96.2 88 100/65 98% on RA CVP 12\n Elderly woman reclining in bed, appears slightly uncomfortable with\n shallow breathing and mild accessory muscle use. RRR. Right lung CTA\n anteriorly, dullness/no breath sounds on right.\n Abd NABS soft, slightly distended, nontender.\n No edema or rashes.\n Weak hand grips bilaterally. Right , left .\n Moves LE, did not test against resistance.\n CXR opacification of left hemithorax nearly to apex, with contralateral\n shift of trachea.\n 88 yo woman with stage 4 breast cancer who presented with large left\n pleural effusion and severe HAP, possibly related to aspiration (pt had\n 1 wk h/o dysphagia). Also possible pt has lung mass underlying\n fluid/collapse. Radiography would be low yield until after\n thoracentesis. Improved septic shock, with resolution of lactic\n acidosis and off pressors.\n Therapeutic and diagnostic tap after discussion with family. Continue\n vanc/zosyn. sc heparin, statin, plavix, carbodopa.\n Other issues per resident admit note.\n Critically ill, now improved.\n 40 minutes.\n" }, { "category": "Physician ", "chartdate": "2182-03-10 00:00:00.000", "description": "ICU Event Note", "row_id": 531703, "text": "Clinician: Attending\n Met with pt's daughter (who is HCP) and son to discuss clinical\n status and plans. They understand my information and had questions\n regarding next steps. I answered all questions. They agreed to\n thoracentesis and understood that the two main likely etioloties\n (infection and malignant) have different likelihoods of recurrence and\n management. The daughter informed me that pt has known pulm nodules,\n likely mets, which were not biopsied. I told them we will perform \n today or tomorrow.\n Total time spent: 30 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2182-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531578, "text": "88 year old female with history of Stage IV right sided breast cancer\n (no chemo d/t poor functional status) and CVA with chief complaint of\n lethargy. Pt was sent to ED from , where, \n , the pt was found to be bradycardic to 40's, and\n unobtainable BP. Transferred to for further management. In EW no\n bradycardia noted but BP found to 60/40\ns. Started on Levofed drip.\n Given 3L NS, central line placed and transferred to the MICU for\n further care.\n Pleural effusion, acute/hypoxemia\n Assessment:\n Pt shows no signs of acute respiratory distress. Saturations high 90\n on 4L. Lung sounds diminished on left side crackles in base on right.\n Chest xray shows large pleural effusion on left side. Per family. was\n recently diagnosed with aspiration pneumonia and has been having\n increased difficulty with swallowing.\n Action:\n O2 weaned at 2L. Aspiration precautions.\n Response:\n Patient maintaining saturations with out SOB. Tolerating ice chips with\n out signs and symptoms of aspiration.\n Plan:\n Thoracentesis rule out malignancy vs. infection. Monitor respiratory\n status and speech and swallow consult.\n Sepsis without organ dysfunction\n Assessment:\n Pt received from EW on levophed drip 0.2 mcg. Found to be hypothermic\n to 95.3 and cool to the touch. BP on arrival was in the 130\n systolically with an HR in the high 80\ns. Lactate in ED 5.9 and WBC\n 14.3, CVP 6. SVO2 59.\n Action:\n Applied Bair Hugger gave 2L of NS. Weaned Levophed to .03\n Response:\n Pt maintains stable BP weaning off pressors and an improved CVP. Temp\n 98.8 rectally Bair hugger dc\nd. CVP 13-14 after fluid. Lactate down to\n 1.3. SVO2 now 63.\n Plan:\n Continue to monitor BP and titrate levophed accordingly. Monitor temp\n and apply bair hugger as needed. Monitors CVP for fluid status. Follow\n up on culture data ABX as ordered.\n 06:40\n" }, { "category": "Nursing", "chartdate": "2182-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531561, "text": "88 year old female with history of Stage IV right sided breast cancer\n (no chemo d/t poor functional status) and CVA with chief complaint of\n lethargy. Pt was sent to ED from , where, \n , the pt was found to be bradycardic to 40's, and\n unobtainable BP on the day of admission. The pt was picked up by a BLS\n ambulance and atropine was not given. Per pt's family since a week\n prior to admission the pt has been more listless, less interactive and\n more lethargic on visits. They note that recently she has had\n difficulty with swallowing at . At , the pt\n was currently being treated for aspiration pneumonia with levaquin and\n flagyl since .\n Pleural effusion, acute\n Assessment:\n Pt shows no signs of acute respiratory distress. Saturations high 90\n on 4L. Lung sounds diminished on left side crackles in base on right.\n Chest xray shows large pleural effusion on left side.\n Action:\n Wean patient down to 2L NC.\n Response:\n Patient maintaining saturations with out SOB or increased LOB in the\n high 90\n Plan:\n Thoracentesis rule out malignancy vs. infection. Monitor respiratory\n status.\n Sepsis without organ dysfunction\n Assessment:\n Pt received from EW on levophed drip. Found to be hypothermic and cool\n to the tough. Recent history of pneumonia. Low CVP.\n Action:\n Applied Bair Hugger gave 2L of fluid bolus over 5 hours. Weaned\n Levophed to .03\n Response:\n Pt maintains stable BP weaning off pressors and an improved CVP. Temp\n improving.\n Plan:\n Continue to monitor BP and titrate levophed accordingly. Monitor temp\n and apply bair hugger as needed. Monitors CVP for fluid status.\n" }, { "category": "ECG", "chartdate": "2182-03-11 00:00:00.000", "description": "Report", "row_id": 287727, "text": "Baseline artifact is present. Sinus rhythm. Ventricular ectopy. Left\nbundle-branch block. Compared to the previous tracing ventricular ectopy is\nnew.\n\n" }, { "category": "ECG", "chartdate": "2182-03-09 00:00:00.000", "description": "Report", "row_id": 287728, "text": "Sinus rhythm. Left bundle-branch block. Possible prior inferior myocardial\ninfarction. Compared to the previous tracing of there is no\nsignificant change.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2172-09-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424201, "text": "HPI: 44M s/p bike vs. car . Multiple facial fractures, facial\n lacerations. s/p open reduction and internal fixation \n transferred from OR on ventilator, sedated, required intermittent\n dilaudid for pain, no major issues\n : bronch for blood from trach; wean vent and transfer to the floor\n today\n Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n pt alert, follows commands, moves all extremities. Communicates via\n gestures, writing on board to trach. Unable to open eyes \n sutures. + facial edema, + periorbital edema. Calm & cooperative with\n care. + bloody secretions noted from trach, pt with good cough, intact\n gag. PEG tube clamped.\n Action:\n Dr. informed re: bloody secretions from trach; ice packs\n applied to face hourly as ordered.\n Response:\n ICU team performed bronchoscopy at bedside, drainage from facial\n surgery causing secretions from trach, no further intervention\n necessary at this time.\n Plan:\n continue to assess neuro status, assess respiratory status\n" }, { "category": "Nursing", "chartdate": "2172-09-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424207, "text": "HPI: 44M s/p bike vs. car . Multiple facial fractures, facial\n lacerations. s/p open reduction and internal fixation \n transferred from OR on ventilator, sedated, required intermittent\n dilaudid for pain, no major issues\n : bronch for blood from trach; wean vent and transfer to the floor\n today\n Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n pt alert, follows commands, moves all extremities. Communicates via\n gestures, writing on board to trach. Unable to open eyes \n sutures. + facial edema, + periorbital edema. Calm & cooperative with\n care. + bloody secretions noted from trach, pt with good cough, intact\n gag. PEG tube clamped.\n Action:\n Dr. informed re: bloody secretions from trach; ice packs\n applied to face hourly as ordered.\n Response:\n ICU team performed bronchoscopy at bedside, drainage from facial\n surgery causing secretions from trach, no further intervention\n necessary at this time.\n Plan:\n continue to assess neuro status, assess respiratory status\n Pain control\n Assessment: pt complains of\npinching\n sensation bilat eyes\n Action: pt weaned from propofol early this AM, PCA dilaudid 0.12 mg q 6\n mins with hourly limit of 1.2 mg available upon demand.\n Response: pt not using PCA, plastics team aware, pt encouraged to use\n PCA.\n Plan: continue to assess pain level, encourage PCA use\n" }, { "category": "Respiratory ", "chartdate": "2172-09-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 424227, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 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: Blood Tinged / Thick\n Sputum source/amount: Expectorated / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt. now on trach mask tolerating well. Awating floor bed.\n" }, { "category": "Nursing", "chartdate": "2172-09-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 424274, "text": "Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2172-09-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 424275, "text": "Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2172-09-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 424276, "text": "41y/o male s/p bike accident sustained multiple facial\n fractures, SDH and SAH, pulmonary contusion. Also sustained right\n basilar skull fx and anterior temple fractured. Mental status rapidly\n deteriorated and pt was intubated for airway protection. Trach and PEG\n were preformed due to prolonged recovery and further surgical\n procedures.\n Admitted to SICU to monitor following extensive reconstructive surgery\n by plastics. \n pan facial ORIF with titanium, eyes sutured closed for corneal\n protection and insertion of JP\n Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n admitted non-responsive and sedated w/propofol, both eyes sutured\n closed for corneal protection, head wrapped w/gauze and ace bandage\n (incision from ear to ear ) hemodynamics as per flow sheet\n Action:\n HOB maintained >30 to minimize swelling, bacitracin ophthalmic ointment\n to eyes, med for pain and paused propofol for neuro assesment\n Response:\n awake and moves all extremeties, slight increase in periorbital\n swelling, pain seems in control\n Plan:\n RSBI outstanding, pain manage first then d\nc propofol, keep HOB\n elevated > 30, ? ice for swelling\n Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n Stable\n Action:\n Transfer to cc6 w/telemetry for monitor of SaO2\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2172-09-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 424277, "text": "41y/o male s/p bike accident sustained multiple facial\n fractures, SDH and SAH, pulmonary contusion. Also sustained right\n basilar skull fx and anterior temple fractured. Mental status rapidly\n deteriorated and pt was intubated for airway protection. Trach and PEG\n were preformed due to prolonged recovery and further surgical\n procedures.\n Admitted to SICU to monitor following extensive reconstructive surgery\n by plastics. \n pan facial ORIF with titanium, eyes sutured closed for corneal\n protection and insertion of JP\n Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n admitted non-responsive and sedated w/propofol, both eyes sutured\n closed for corneal protection, head wrapped w/gauze and ace bandage\n (incision from ear to ear ) hemodynamics as per flow sheet\n Action:\n HOB maintained >30 to minimize swelling, bacitracin ophthalmic ointment\n to eyes, med for pain and paused propofol for neuro assesment\n Response:\n awake and moves all extremeties, slight increase in periorbital\n swelling, pain seems in control\n Plan:\n RSBI outstanding, pain manage first then d\nc propofol, keep HOB\n elevated > 30, ? ice for swelling\n Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n Stable\n Action:\n Transfer to cc6 w/telemetry for monitor of SaO2\n Response:\n Plan:\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n FACIAL FRACTOR/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 76.7 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: 41y/o male s/p bike accident sustained\n multiple facial fractures, SDH and SAH, pulmonary contusion. Also\n sustained right basilar skull fx and anterior temple fractured. Mental\n status rapidly deteriorated and pt was intubated for airway\n protection. Trach and PEG were preformed due to prolonged\n recovery and further surgical procedures.\n Surgery / Procedure and date: \n pan facial ORIF with titanium, eyes sutured closed for corneal\n protection and insertion of JP\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:120\n D:59\n Temperature:\n 99.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 11 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Trach mask\n O2 saturation:\n 99% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 3,153 mL\n 24h total out:\n 4,660 mL\n Pertinent Lab Results:\n Hematocrit:\n 24.9 %\n 04:13 AM\n Finger Stick Glucose:\n 160\n 04:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2172-09-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424217, "text": "HPI: 44M s/p bike vs. car . Multiple facial fractures, facial\n lacerations. s/p open reduction and internal fixation \n transferred from OR on ventilator, sedated, required intermittent\n dilaudid for pain, no major issues\n : bronch for blood from trach; wean vent and transfer to the floor\n today\n Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n pt alert, follows commands, moves all extremities. Communicates via\n gestures, writing on board to trach. Unable to open eyes \n sutures. + facial edema, + periorbital edema. Calm & cooperative with\n care. + bloody secretions noted from trach, pt with good cough, intact\n gag. PEG tube clamped.\n Action:\n Dr. informed re: bloody secretions from trach; ice packs\n applied to face hourly as ordered.\n Response:\n ICU team performed bronchoscopy at bedside, drainage from facial\n surgery causing secretions from trach, no further intervention\n necessary at this time.\n Plan:\n continue to assess neuro status, assess respiratory status\n Pain control\n Assessment: pt complains of\npinching\n sensation bilat eyes\n Action: pt weaned from propofol early this AM, PCA dilaudid 0.12 mg q 6\n mins with hourly limit of 1.2 mg available upon demand. Pt demonstrates\n good use of PCA.\n Response: pt not using PCA, plastics team aware, pt encouraged to use\n PCA.\n Plan: continue to assess pain level, encourage PCA use.\n" }, { "category": "Nursing", "chartdate": "2172-09-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424272, "text": "HPI: 44M s/p bike vs. car . Multiple facial fractures, facial\n lacerations. s/p open reduction and internal fixation \n transferred from OR on ventilator, sedated, required intermittent\n dilaudid for pain, no major issues\n : bronch for blood from trach; wean vent and transfer to the floor\n today\n Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n pt alert, follows commands, moves all extremities. Communicates via\n gestures, writing on board to trach. Unable to open eyes \n sutures. + facial edema, + periorbital edema. Calm & cooperative with\n care. + bloody secretions noted from trach, pt with good cough, intact\n gag. PEG tube clamped.\n Action:\n Dr. informed re: bloody secretions from trach; ice packs\n applied to face hourly as ordered.\n Response:\n ICU team performed bronchoscopy at bedside, drainage from facial\n surgery causing secretions from trach, no further intervention\n necessary at this time.\n Plan:\n continue to assess neuro status, assess respiratory status\n Pain control\n Assessment: pt complains of\npinching\n sensation bilat eyes\n Action: pt weaned from propofol early this AM, PCA dilaudid 0.12 mg q 6\n mins with hourly limit of 1.2 mg available upon demand. Pt demonstrates\n good use of PCA.\n Response: pt not using PCA, plastics team aware, pt encouraged to use\n PCA.\n Plan: continue to assess pain level, encourage PCA use.\n" }, { "category": "Nursing", "chartdate": "2172-09-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424080, "text": "41y/o male s/p bike accident sustained multiple facial\n fractures, SDH and SAH, pulmonary contusion. Also sustained right\n basilar skull fx and anterior temple fractured. Mental status rapidly\n deteriorated and pt was intubated for airway protection. Trach and PEG\n were preformed due to prolonged recovery and further surgical\n procedures.\n Admitted to SICU to monitor following extensive reconstructive surgery\n by plastics. \n pan facial ORIF with titanium, eyes sutured closed for corneal\n protection and insertion of JP\n Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n admitted non-responsive and sedated w/propofol, both eyes sutured\n closed for corneal protection, head wrapped w/gauze and ace bandage\n (incision from ear to ear ) hemodynamics as per flow sheet\n Action:\n HOB maintained >30 to minimize swelling, bacitracin ophthalmic ointment\n to eyes, med for pain and paused propofol for neuro assesment\n Response:\n awake and moves all extremeties, slight increase in periorbital\n swelling, pain seems in control\n Plan:\n RSBI outstanding, pain manage first then d\nc propofol, keep HOB\n elevated > 30, ? ice for swelling\n" }, { "category": "Respiratory ", "chartdate": "2172-09-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 424076, "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 Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 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: Continuous invasive ventilation\n :\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments: Pt. from OR ,#8 Portex perc. Trach. Placed on A/C ovrenoc.\n RSBI 15 this am. Possible trach collar today..\n" }, { "category": "Nursing", "chartdate": "2172-09-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424069, "text": "Admitted to SICU to monitor following extensive reconstructive surgery\n by plastics.\n Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2172-09-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424071, "text": "41y/o male s/p bike accident sustained multiple facial\n fractures, SDH and SAH, pulmonary contusion. Also sustained right\n basilar skull fx and anterior temple fractured. Mental status rapidly\n deteriorated and pt was intubated for airway protection. Trach and PEG\n were preformed due to prolonged recovery and further surgical\n procedures.\n Admitted to SICU to monitor following extensive reconstructive surgery\n by plastics.\n Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2172-09-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424067, "text": "Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2172-09-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424199, "text": "HPI: 44M s/p bike vs. car . Multiple facial fractures, facial\n lacerations. s/p open reduction and internal fixation \n transferred from OR on ventilator, sedated, required intermittent\n dilaudid for pain, no major issues\n : bronch for blood from trach; wean vent and transfer to the floor\n today\n Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n pt alert, follows commands, moves all extremities. Communicates via\n gestures, writing on board to trach. Unable to open eyes \n sutures. + facial edema, + periorbital edema. Calm & cooperative with\n care. + bloody secretions noted from trach, pt with good cough, intact\n gag. PEG tube clamped.\n Action:\n Dr. informed re: bloody secretions from trach; ice packs\n applied to face hourly as ordered.\n Response:\n ICU team performed bronchoscopy at bedside, drainage from facial\n surgery causing secretions from trach, no further intervention\n necessary at this time.\n Plan:\n continue to assess neuro status, assess respiratory status\n" }, { "category": "Nursing", "chartdate": "2172-09-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424193, "text": "Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2172-09-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424194, "text": "HPI: 44M s/p bike vs. car . Multiple facial fractures, facial\n lacerations. s/p open reduction and internal fixation \n transferred from OR on ventilator, sedated, required intermittent\n dilaudid for pain, no major issues\n : bronch for blood from trach; wean vent and transfer to the floor\n today\n Facial / orbital fracture (Blowout, LeFort)\n Assessment:\n pt alert, follows commands. Communicates via gestures, writing on board\n to trach. Unable to open eyes sutures. + facial edema, +\n periorbital edema.\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2172-09-29 00:00:00.000", "description": "Intensivist Note", "row_id": 424146, "text": "SICU\n HPI:\n 44M s/p bike vs. car . Multiple facial fractures, facial\n lacerations. s/p open reduction and internal fixation here for\n airway protection s/p procedure.\n Chief complaint:\n Bike vs. car collision\n PMHx:\n None\n Current medications:\n 1. 2. 1000 mL D5LR 3. Bacitracin Ophthalmic Oint 4. Chlorhexidine\n Gluconate 0.12% Oral Rinse 5. Clindamycin\n 6. Cyproheptadine 7. Dexamethasone 8. Dexamethasone 9. Dexamethasone\n 10. HYDROmorphone (Dilaudid)\n 11. HYDROmorphone (Dilaudid) 12. Heparin 13. Propofol 14. Sodium\n Chloride 0.9% Flush\n 24 Hour Events:\n OR RECEIVED - At 11:10 PM\n INVASIVE VENTILATION - START 11:10 PM\n Post operative day:\n POD#1 - s/p repair of facial fractures\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Clindamycin - 05:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:10 AM\n Other medications:\n Flowsheet Data as of 10:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 38.1\nC (100.6\n HR: 87 (78 - 103) bpm\n BP: 113/67(78) {102/55(68) - 124/68(80)} mmHg\n RR: 11 (8 - 17) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,873 mL\n 1,184 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,123 mL\n 1,184 mL\n Blood products:\n 750 mL\n Total out:\n 2,420 mL\n 2,370 mL\n Urine:\n 340 mL\n 2,330 mL\n NG:\n Stool:\n Drains:\n 40 mL\n Balance:\n 3,453 mL\n -1,186 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 660 (524 - 660) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 14\n PIP: 11 cmH2O\n Plateau: 13 cmH2O\n Compliance: 75 cmH2O/mL\n SPO2: 100%\n ABG: ////\n Ve: 6.3 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: eyes sutured shut\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, Non-distended, Non-tender, Bowel sounds present, No(t)\n Distended, No(t) Tender: , No(t) Peritoneal sign, No(t) Obese\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, Moves all extremities,\n communicates with hand gestures\n Labs / Radiology\n 686 K/uL\n 9.1 g/dL\n 24.9 %\n 13.2 K/uL\n [image002.jpg]\n 04:13 AM\n WBC\n 13.2\n Hct\n 24.9\n Plt\n 686\n Assessment and Plan\n FACIAL / ORBITAL FRACTURE (BLOWOUT, LEFORT)\n Assessment and Plan: 44M s/p bike vs. car . Multiple facial\n fractures, facial lacerations. s/p open reduction and internal fixation\n here for airway protection s/p procedure.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, PCA with adequate\n pain control\n Cardiovascular: Stable hemodynamically\n Pulmonary: Trach, Wean to trach collar. Bloody secretions from ETT\n (trach 2 wks ago). Will bronch today to make sure no tracheal bleeding\n Gastrointestinal / Abdomen:\n Nutrition: NPO, Start TF today\n Renal: Foley, Adequate UO, No issues\n Hematology: Serial Hct, Stable anemia -- Monitor\n Endocrine: RISS, Hyperglycemic. Increase RISS and if need gtt to better\n control glucose. Dexamethasoe taper dose\n Infectious Disease: Clindamycin prophylaxis. No evidence of infection\n Lines / Tubes / Drains: Foley, G-tube, Trach, Surgical drains (hemovac,\n JP)\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Plastics\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\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: 31 minutes\n" }, { "category": "Radiology", "chartdate": "2172-09-30 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 1045545, "text": " 11:03 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: please also protocol 3-D reconstruction wit these max-face i\n Admitting Diagnosis: FACIAL FRACTOR/SDA\n Field of view: 25\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man s/p pan facial fracture, please access post reduction and\n plating of bilateral ZMC fracture, R orbital floor, bilateral \n REASON FOR THIS EXAMINATION:\n please also protocol 3-D reconstruction wit these max-face images\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 6:25 AM\n Extensive reconstruction of medial maxillary vertical butresses, anatomic\n fixation of a right fontal comminuted fracture, and correction of right zygoma\n lateral angulation. Right orbital floor mesh reconstruction. Persistent\n lateral angulation of right sphenoid at orbital apex. Comminuted fractures of\n right zygomatic arch and posterior/lateral walls of maxillary sinus again\n seen. 3D reformats pending. - 5:30 am .\n ______________________________________________________________________________\n FINAL REPORT\n CT SINUS, MANDIBLE AND MAXILLOFACIAL WITHOUT CONTRAST, \n\n HISTORY: Status post reduction and plating of zygomaticomaxillary fractures.\n\n Contiguous axial images were obtained through the facial bones. Sagittal and\n coronal reformatted images were prepared. Comparison to a maxillofacial CT\n performed on .\n\n FINDINGS: The patient is status post surgical repair of the fractures\n delineated on the prior study. There has been reconstruction of the right\n orbital floor. Of note, the mesh continuing along the lateral wall of the\n orbit is displaced medially, apparently by a hematoma. This encroaches on the\n muscle cone and causes medial displacement of the optic nerve. There does\n appear to be a fat plane surrounding the nerve.\n\n There has been repair of the left orbital floor with fragments in near\n anatomic position. There has been repair of the frontal bone fractures\n bilaterally and of the right lateral orbital wall fractures. There have been\n repairs of the anterior maxillary fractures bilaterally. The small portion of\n the brain included in the study demonstrates no abnormalities. The paranasal\n sinuses demonstrate extensive fractures, including fractures through the\n anterior and posterior walls of the frontal sinus.\n\n CONCLUSION: Status post repair of extensive facial fractures. An extraconal\n hematoma causes medial displacement of the mesh reconstructing the lateral\n wall of the right orbit.\n\n (Over)\n\n 11:03 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: please also protocol 3-D reconstruction wit these max-face i\n Admitting Diagnosis: FACIAL FRACTOR/SDA\n Field of view: 25\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "ECG", "chartdate": "2172-10-06 00:00:00.000", "description": "Report", "row_id": 223923, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , heart rate faster\n\n" } ]

[ { "category": "Radiology", "chartdate": "2104-10-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1208348, "text": " 2:07 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with hyperglycemia\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON \n\n Comparison is made with a prior study from .\n\n CLINICAL HISTORY: Hyperglycemia, assess for pneumonia.\n\n FINDINGS: PA and lateral views of the chest are obtained. Clips are noted in\n the left breast. There is asymmetry in the size of the breast tissue, smaller\n on the left side. There is slight haziness projecting over the left mid to\n lower lung which is not seen on the lateral view and likely represents chest\n wall soft tissues. There is no definite sign of pneumonia or CHF. No pleural\n effusion or pneumothorax is seen. Cardiomediastinal silhouette is normal.\n Bony structures are intact.\n\n IMPRESSION: No signs of pneumonia.\n\n\n" }, { "category": "ECG", "chartdate": "2104-10-23 00:00:00.000", "description": "Report", "row_id": 248044, "text": "Sinus rhythm. Within normal limits.\n\n" }, { "category": "ECG", "chartdate": "2104-10-22 00:00:00.000", "description": "Report", "row_id": 248045, "text": "Sinus rhythm. Delayed precordial R wave transition may be a normal variant.\nCompared to the previous tracing of no diagnostic change.\n\n" } ]

[ { "category": "ECG", "chartdate": "2119-09-19 00:00:00.000", "description": "Report", "row_id": 119559, "text": "Sinus rhythm\nAnteroseptal myocardial infarct, age indeterminate\nDiffuse ST-T wave abnormalities with prolonged Q-Tc interval - cannot exclude\nin part ischemia and possibly metabolic/drug effect\nClinical correlation is suggested\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2119-09-19 00:00:00.000", "description": "Report", "row_id": 119560, "text": "Atrial fibrillation. Since the previous tracing of probably no\nsignificant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2119-09-18 00:00:00.000", "description": "Report", "row_id": 119561, "text": "Atrial fibrillation. Late R wave progression with Q waves in leads V3-V4.\nJ point and ST segment elevation with T wave inversions in the mid-precordial\nleads. Since the previous tracing of the ST-T wave pattern in the\nlateral leads is not as prominent and is als not as prominent in the inferior\nleads. The Q-T interval is longer.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2119-09-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 883623, "text": " 2:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for free air under the diaphragm.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with worsening abdominal pain and abd exam.\n REASON FOR THIS EXAMINATION:\n Please evaluate for free air under the diaphragm.\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST\n\n INDICATION: Worsening abdominal pain.\n\n Comparison is made to previous exam of .\n\n FINDINGS: Lung volumes are low, likely accounting for accentuation of the\n interstitial lung architecture. Lungs are clear, and there are no pleural\n effusions. No pneumothorax. No intraperitoneal free air is seen. Dilated\n air filled loops of small bowel are noted in the imaged upper abdomen. Heart\n size is enlarged but stable. Pulmonary vasculature is normal.\n\n IMPRESSION:\n 1. No evidence of intraperitoneal free air.\n 2. Dilated small bowel loops. Clinical correlation is advised.\n\n" }, { "category": "Radiology", "chartdate": "2119-09-18 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 883620, "text": " 2:32 PM\n PORTABLE ABDOMEN Clip # \n Reason: Please r/o obstruction or viscus perforation.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 y.o. female p/w abdominal pain and n/v/ and worsening abd exam.\n REASON FOR THIS EXAMINATION:\n Please r/o obstruction or viscus perforation.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old female presents with abdominal pain, nausea, vomiting,\n and worsening abdominal exam. Please assess for obstruction or perforation.\n\n TECHNIQUE: A single limited AP portable supine abdominal radiograph was\n obtained.\n\n FINDINGS: This is a limited supine portable radiograph, which does not\n visualize the upper abdomen and hemidiaphragms. Given this limitation, no\n definite free air is identified. There are mildly dilated loops of air-filled\n small bowel throughout the central abdomen. Air mixed with stool is seen\n throughout the colon extending into the rectum. There is no evidence of\n obstruction. There is an irregularly shaped roughly 1-cm diameter calcific\n density in the left upper quadrant of unclear significance, which may\n represent vascular calcification. Also noted are tiny punctate calcifications\n projecting over the right pelvis. The patient is status post left total hip\n arthroplasty and degenerative changes are noted in the lumbar spine.\n\n IMPRESSION: On this limited view, no definite free air and no evidence of\n obstruction. Clinical correlation is suggested with followup or CT if\n indicated.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-09-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 883687, "text": " 7:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Newly intubated.\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with worsening abdominal pain and abd exam s/p rt\n subclavian line placement\n REASON FOR THIS EXAMINATION:\n Newly intubated.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST .\n\n COMPARISON: .\n\n INDICATION: Right subclavian line placement and interval intubation.\n\n A right subclavian vascular catheter terminates in the lower superior vena\n cava with no evidence of pneumothorax. An endotracheal tube is in\n satisfactory position terminating 2.5 cm above the carina, but the cuff of the\n tube appears slightly overdistended. A nasogastric tube coils in the region\n of the GE junction with the distal tip directed cephalad. The heart is mildly\n enlarged but stable. There has been development of patchy bibasilar opacities\n as well as the linear area of opacity in the left lung base, and a small left\n pleural effusion. There is mild gastric distention present.\n\n IMPRESSION:\n 1. Endotracheal tube in satisfactory position, but cuff is slightly\n overdistended. Coiling of nasogastric tube as described.\n\n 2. New patchy bibasilar opacities, which may relate to atelectasis or\n aspiration.\n\n 3. Small left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-09-18 00:00:00.000", "description": "CHEST SGL VIEW/LINE PLACEMENT", "row_id": 883649, "text": " 5:29 PM\n CHEST SGL VIEW/LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate rihght subclavian line placement after pulling back\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with abd pain, bloody diarrhea s/p right subclavian line\n placemtn, pulled back 7 cm\n REASON FOR THIS EXAMINATION:\n evaluate rihght subclavian line placement after pulling back\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old woman with abdominal pain status post subclavian CVL\n placement. CVL was repositioned.\n\n COMPARISON: at 4:15 p.m.\n\n FINDINGS: Compared to exam of one hour earlier, the right subclavian CVL has\n been withdrawn. The tip is now in the SVC. There is no evidence of\n pneumothorax. The appearance of the chest is otherwise stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-09-18 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 883637, "text": " 4:28 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Please evaluate mesenteric ischemia. Please give IV contrast\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with atrial fibrillation presents with acute onset of\n abdominal pain, nausea and vomting.\n REASON FOR THIS EXAMINATION:\n Please evaluate mesenteric ischemia. Please give IV contrast even though her\n creatinine is 1.3.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FKh MON 6:07 PM\n Bowel ischemia.\n Left renal and splenic infarcts.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain, nausea, vomiting.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: 64-MDCT axial images of the abdomen and pelvis without and with IV\n contrast. The contrast was obtained in the arterial and venous phases.\n\n 150 cc of Optiray-350 were used. Nonionic IV contrast was used due to rapid\n bolus necessary for the study.\n\n CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: Lung bases are clear. There\n are no pleural effusions or focal consolidations. There is cardiomegaly. The\n right atrium is massively enlarged. There is reflux of contrast in the\n hepatic veins.\n\n There is complete or near complete occlusion of the origin of the celiac\n artery. The origin of the SMA is patent. However, it is completely occluded\n distally the pancreaticoduodenal due to a clot which is located approximately\n 3 cm from the origin. The is diminutive in caliber and irregular\n consistent with a atherosclerotic disease. There is differential\n opacification of the mesenteric vein branches which is also suggestive of\n bowel ischemia. The bowel loops are dilated and there is severe pneumatosis of\n loops of small bowel in the bilateral lower quadrants. There is large amount\n of gas in the mesenteric veins within the mesentery. These findings are\n consistent with a bowel ischemia. The colon is within normal limits. The\n portal vein is patent but there is decreased flow in the left portal vein of\n unknown etiology. There is also a large infarct in the mid pole of the right\n kidney and 2 small splenic infarcts. The adrenal glands are normal. There\n are severe calcifications of the splenic artery. The liver is fatty\n containing multiple geographic hypodense areas of differential enhancement.\n The adreanal glands are enhancing suggestive of shock. There are dependent\n atelectasis in the lungs. There is no free fluid or free air in the abdomen.\n\n CT OF THE PELVIS WITHOUT AND WITH IV CONTRAST: As described above, there is\n (Over)\n\n 4:28 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Please evaluate mesenteric ischemia. Please give IV contrast\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pneumatosis of several small bowel loops and air in the mesentery. There is a\n normal amount of fluid in the pelvis.\n\n BONE WINDOWS: There are no suspicious lytic or blastic lesions. There is a\n hip prosthesis in the left hip.\n\n Multiplanar reconstructions were important to better visualize the bowel.\n\n IMPRESSION:\n 1. Findings consistent with widespread embolic disease.\n 1. Likely acute thrombus within the SMA causing bowel ischemia. There is also\n chronic disease of the celiac and the . The origin of the celiac is\n completely or almost completely occluded.\n 3. Right renal infarct.\n 4. Splenic infarcts.\n 5. Fatty liver.\n 6. Decreased flow in the left portal vein of unknown etiology. It does not\n appear to represent blood clot.\n 7. Renal cysts.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2119-09-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 883632, "text": " 4:06 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate right subclavian line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with worsening abdominal pain and abd exam s/p rt subclavian\n line placement\n REASON FOR THIS EXAMINATION:\n evaluate right subclavian line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old female with worsening abdominal pain status post\n subclavian line placement.\n\n COMPARISONS: Comparison is made to , one hour earlier.\n\n TECHNIQUE: AP single view of the chest.\n\n FINDINGS: There is interval placement of a right subclavian central line with\n the tip in the right atrium. Recommend withdrawing the line approximately 6-\n 7 cm. There is interval development of interstitial opacities likely due to\n pulmonary edema.\n\n IMPRESSION:\n 1. Line tip is in the right atrium. Recommend withdrawing 6-7cm.\n 2. Interval development of interstitial pulmonary edema.\n\n" }, { "category": "Nursing/other", "chartdate": "2119-09-19 00:00:00.000", "description": "Report", "row_id": 1414462, "text": "Nursing Progress Note 7p-7a\n\nNEURO: A&Ox3, communicates appropriately however, tries to get out of bed without assistance. c/o insomnia. Left side weakness at baseline, good strength otherwise. PERL.\n\nCV: c/o left side chest pain with movement. Medicated with 1mg MSO4 with acceptable pain relief. Slight elevation of CK/CK-MB. Pt has chronic A-fib. Borderline BP with MAP 55-70. CVP 6-9. Weak distal pulses, no edema. Heparin gtt @ 500u/h. Last PTT 90.3. Afebrile currently, received tylenol in ED.\n\nRESP: O2 sat low to mid 90s on 5L NC. Lungs CTA, diminished bases. Pt is tachyneic, RR at 35-40. Denies SOB.\n\nGI: Abd. slightly firm and distended. Left side tenderness with palpation. BS not audible. NPO. No melena or hematemsis.\n\nGU: UOP decreasing,10cc/h for last few hours. 250cc fld bolus but no improvement.\n\nSOCIAL: Lives w/daughter. Supportive family. Pt is FULL CODE at this time.\n\nISSUE/PLAN: ECHO pending to r/o endocarditis. CT confirmed bowel ischemia with kidney/spleen involvement. Pt declined surgical intervention. Family conference needed to address care issue/plan. Last lactate level 8.8.\n\n" }, { "category": "Nursing/other", "chartdate": "2119-09-19 00:00:00.000", "description": "Report", "row_id": 1414463, "text": "Event note\nEntered room at 0650, pt found hypotensive. When aroused, pt did not respond although eyes were open. O2 sat 89-90%. MD . Fld. bolus started. Put on 100% NRB. Stat labs sent and EKG done. Levophed gtt started at 0700. Pt responded to name when stimulated again. Anesthesia paged and pt intubated at 0715. Vent CMV 100% 500/22/5.\n" }, { "category": "Nursing/other", "chartdate": "2119-09-19 00:00:00.000", "description": "Report", "row_id": 1414464, "text": "Respiratory Care Note\nPt intubated at 7:15am with #7.0ETT. BS are clear and equal after intubation with a positive ETCO2 color change. Pt placed on AC as noted. Follow up ABG's show metabolic acidosis with good oxygenation. Plan to remain on current settings at this time. Emergency equipment at the bedside.\n" }, { "category": "Nursing/other", "chartdate": "2119-09-19 00:00:00.000", "description": "Report", "row_id": 1414465, "text": "NPN 7A-7P\n*******SHIFT EVENTS********\nAt start of shift Pt reported to be unresponsive, hypotensive, and decreasing sats. Fluid bolus implemented w/ out much effect, Pt intubated with out event. Levophed and Neo gtt started. Family and asked to come in, as per Dr. family wishes to make Pt , but is waiting for family before withdrawing care.\n\nNeuro:>> Pt sedated on propofol gtt at 20mcg/kg/min. Perrl 3mm/sluggish. wdw to painful stimuli. MOrphine gtt at bedside as above awaiting arrival of priest before implementing gtt, and once everyone has arrived will page the team and they will d/c gtts and write for .\nResp:>> Pt intubated this AM as above: 100%/450/20/5. Sats 92-100%. see carevue additional objective data. LS clear upper, diminished lower. RR 30's.\nCV:>> Pt on 0.3mcg/kg/min of Levophed, and 3.0 mcg/kg/min of Neo to maintains map >60. Pt in afib rate 85-101. no ectopy noted. received 3L NS fluid bolus at begining of shift, little effect on BP or u/o. weak pp. On bcrb gtt (100cc/hr) for ph of 7.09 and Co2 of 10.\nGI/Gu:>> PT admit w/ ischemic bowel w/ spleen and kidney infarts. (Pt and family refused surgery in ED) abd +BS, firm and distended. Foley in place small u/o, amber in color. (Translocation of gut bacteria high probability)\nEndo: RISS\nSkin: cool, dry, intact.\nID: lactate 9.0 ,hypothermic. (did not implement bair hugger vasodilatory effect compromising effect of pressors in setting of\n supporting Pt until arrives.) On Levoflox and flagyl.\nSocial: all of family present at bedside, in and out of room. Would like to implement Comfort measures once evangelist arrives. Morphine gtt at bedside.\nA/P: Tx w/ supportive measures until arrives. Then Page DR. # once arrives to write for and d/c pressors.\n" }, { "category": "Nursing/other", "chartdate": "2119-09-19 00:00:00.000", "description": "Report", "row_id": 1414466, "text": "RN note\nStarted comfort measures only @ per family request. MD notified and all gtts turned off. Decline in BP noted. Pt extubated @ . Decline in HR shortly after and asystole on monitor @ 2040. Death pronounced per Dr. @ 2045. Support given to family. Grieving appropriately. Post-mortem care complete.\n" } ]

[ { "category": "Respiratory ", "chartdate": "2192-08-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 343523, "text": "Demographics\n Day of mechanical ventilation: 1\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\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: Tachypneic (RR> 35 b/min);\n Comments: pt weaned to PS tachypneic at times, but most of the time RR\n remains in the low 30's.\n Assessment of breathing comfort:\n Dysynchrony assessment: Frequent alarms (High rate, Low min.\n ventilation)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying\n condition not resolve.\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Interventional radiology\n 1130\n no complications\n" }, { "category": "Physician ", "chartdate": "2192-08-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 343427, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:19 AM\n -found to be pulseless on medicine , bradycardic.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:37 AM\n Amikacin - 08:37 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:01 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 06:09 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: 37.7\nC (99.8\n HR: 83 (83 - 117) bpm\n BP: 99/47(58) {99/47(58) - 129/104(109)} mmHg\n RR: 16 (16 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Mixed Venous O2% Sat: 87 - 87\n Total In:\n 11 mL\n PO:\n TF:\n IVF:\n 11 mL\n Blood products:\n Total out:\n 0 mL\n 120 mL\n Urine:\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -109 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.43/41/276/22/3\n Ve: 9.9 L/min\n PaO2 / FiO2: 276\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 312 K/uL\n 9.4 g/dL\n 216 mg/dL\n 1.1 mg/dL\n 22 mEq/L\n 4.7 mEq/L\n 12 mg/dL\n 103 mEq/L\n 140 mEq/L\n 28.7 %\n 26.1 K/uL\n [image002.jpg]\n 07:59 PM\n 03:58 AM\n 05:43 PM\n 08:36 PM\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n 04:35 AM\n 05:32 AM\n WBC\n 22.8\n 24.0\n 26.1\n Hct\n 26.8\n 26.1\n 28.7\n Plt\n 133\n 195\n 312\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n 0.9\n 1.1\n TCO2\n 24\n 28\n 27\n 28\n Glucose\n 61\n 90\n 104\n 141\n 69\n 216\n Other labs: PT / PTT / INR:15.7/37.7/1.4, CK / CKMB /\n Troponin-T:32/4/0.14, ALT / AST:13/18, Alk Phos / T Bili:108/0.3,\n Differential-Neuts:83.0 %, Band:3.0 %, Lymph:8.0 %, Mono:5.0 %, Eos:0.0\n %, Fibrinogen:661 mg/dL, Lactic Acid:4.6 mmol/L, Albumin:2.5 g/dL,\n LDH:161 IU/L, Ca++:7.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:19 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": "2192-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343430, "text": "Cardiac arrest\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2192-08-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 343718, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 59 None\n Ideal tidal volume: 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: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments: ETT repositioned, retaped.\n Lung sounds\n RLL Lung Sounds: Crackles\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: pt has large amounts of oral secretions requires frequent\n oral suctioning\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:\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:\n" }, { "category": "Nursing", "chartdate": "2192-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343767, "text": "Altered mental status (not Delirium)\n Assessment:\n Unarousable and having frequent periods of apnea\n Action:\n Changed from cpap to cmv ventilation after discussion with H.O.\n Response:\n Apnea resolved\n Plan:\n Discuss Plan of care with HCP later today.\n Electrolyte & fluid disorder, other\n Assessment:\n Edematous.\n Action:\n Lasix 40 mg iv given\n Response:\n Good hourly uop. Entering negative fluid balance.\n Plan:\n To have negative fluid balance.\n" }, { "category": "Physician ", "chartdate": "2192-08-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 344046, "text": "Chief Complaint: 82 year old female with h/o breast ca, cva, htn, who\n initially presented with urosepsis and pneumonia then transferred out\n of the unit, re-transferred after PEA arrest on the floor without\n significant improvement in mental status.\n 24 Hour Events:\n Family meeting was suppose to happen yesterday and did not. Plan for\n family meeting today. Patient went for head CT without incident.\n Started on scopolamine patch to decrease secretions. also started on\n tca as well. Goal yesterday was -500-1L negative.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:27 AM\n Amikacin - 08:39 AM\n Metronidazole - 12:30 PM\n Levofloxacin - 06:10 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:45 AM\n Heparin Sodium (Prophylaxis) - 09:00 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 06:50 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: 37.2\nC (99\n HR: 88 (64 - 88) bpm\n BP: 171/71(97) {133/55(77) - 171/72(97)} mmHg\n RR: 30 (14 - 35) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 1,846 mL\n 135 mL\n PO:\n TF:\n 876 mL\n IVF:\n 640 mL\n 65 mL\n Blood products:\n Total out:\n 2,440 mL\n 190 mL\n Urine:\n 2,440 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n -594 mL\n -55 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 360 (360 - 360) mL\n Vt (Spontaneous): 319 (260 - 385) mL\n PS : 12 cmH2O\n RR (Spontaneous): 36\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 328\n SpO2: 99%\n ABG: 7.47/47/65/32/8\n Ve: 9.8 L/min\n PaO2 / FiO2: 163\n Physical Examination\n General Appearance: tachypneic\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Diminished: at bases bilaterally,\n Rhonchorous: right upper lobe)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Noxious stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 781 K/uL\n 8.3 g/dL\n 148 mg/dL\n 1.0 mg/dL\n 32 mEq/L\n 4.4 mEq/L\n 15 mg/dL\n 102 mEq/L\n 138 mEq/L\n 25.9 %\n 18.4 K/uL\n [image002.jpg]\n 02:07 AM\n 04:35 AM\n 05:32 AM\n 04:12 AM\n 08:43 AM\n 02:53 PM\n 05:54 AM\n 04:28 PM\n 04:00 AM\n 05:08 AM\n WBC\n 16.1\n 15.7\n 15.4\n 18.4\n Hct\n 22.5\n 23.4\n 24.9\n 25.9\n Plt\n 583\n 548\n 666\n 781\n Cr\n 1.1\n 1.1\n 1.0\n 1.1\n 1.0\n 1.0\n TropT\n 0.10\n TCO2\n 27\n 28\n 35\n Glucose\n 2\n 150\n 148\n Other labs: PT / PTT / INR:15.3/27.6/1.4, CK / CKMB /\n Troponin-T:37/3/0.10, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:1.2 mmol/L, Albumin:2.5 g/dL, LDH:256 IU/L, Ca++:7.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after likely PEA arrest now\n with worsening mental status than on previous transfer now 48 hours\n after the event.\n # Cardiopulmomary Arrest: Patient found pulseless, ashen, and cool,\n down for no longer than 10 minutes. Patient not monitored on telemetry\n at the time of the event. She quickly regained rhythm after intubation\n and 1gm epinephrine w/ CPR. In the setting of underlying RLL\n infiltrate, concern for worsening pulmonary edema on the floor, most\n likely etiology respiratory arrest w/ mucous plug. No further events\n since admission to ICU, although continues to have episodes of apnea\n while on PS.\n - treat underlying cause of PNA, provide respiratory support with\n ventilator for now\n - trend lactate\n - monitor on telemetry, patient appears to be hemodynamically stable\n -CT head to evaluate for any acute insults that may be causing her\n apneic periods - CT head done no official read uet\n .\n # Hypercarbic Respiratory Failure: S/p intubation x2. Hypercarbic\n likely to arrest d/t pulmonary etiology (mucus plugging, apneic\n period). Started on scopolamine patch yesterday for secretions. still\n requiring frequent suctioning. Currently tachypneic and likely not\n candidate for extubation today. Will discuss goals of care with niece\n this morning (extubation, trach placement etc.)\n - outline goals of care\n - Wean FIO2 as tolerated, to PS as tolerate\n - weak cough, no gag per RT\n - suction prn, nebs prn\n # HAP/Aspiration PNA/sepsis: Patient on broad spectrum coverage since\n admission, has grown GPC pairs/clusters in sputum and E.coli in blood\n and urine. CT from showed persistent RLL infiltrate. CBC showing\n new bands on diff in setting of code.\n - continue vanc/levo/flagyl patient currently on day 12 of ABX, (2 more\n days)\n - sputum from - GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND\n CLUSTERS.\n RESPIRATORY CULTURE (Preliminary): NO GROWTH.\n .- only positive blood culture so far from - ESCHERICHIA COLI\n |\n AMPICILLIN------------ =>32 R\n AMPICILLIN/SULBACTAM-- 4 S\n CEFAZOLIN------------- <=4 S\n CEFEPIME-------------- <=1 S\n CEFTAZIDIME----------- <=1 S\n CEFTRIAXONE----------- <=1 S\n CEFUROXIME------------ 4 S\n CIPROFLOXACIN--------- =>4 R\n GENTAMICIN------------ <=1 S\n MEROPENEM-------------<=0.25 S\n PIPERACILLIN/TAZO----- <=4 S\n TOBRAMYCIN------------ <=1 S\n TRIMETHOPRIM/SULFA---- <=1 S\n .\n # Urosepsis: E.coli bacteremia, and e.coli/providencia UTI. Repeat\n cultures have been negative. Has been on amikacin, last day .\n - amikacin levels from are still pending\n .\n # Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6 currently\n 1.0 appears to be improving with some diuresis. likely relative\n hypoperfusion.\n - suspect that some of renal failure is likely due to poor forward flow\n and patient looks volume overloaded by physical exam\n - trend creatinine\n - goal I/O is negative 1 liter per day, would give lasix as needed to\n achieve this (40 IV yesterday => -500 cc)\n - will start with 40 IV lasix this morning and then check afternoon\n # Hypertension: On lisinopril, metoprolol as outpatient\n - increase lisinopril todya\n - lasix 40mg IV qd, monitor UOP\n - metoprolol 100 mg PO TID\n .\n # Dementia: Currently intubated without need for sedative medications.\n Concern for possible cerebral ischemic insult during her PEA arrest\n that may be causing her apnea.\n - continue namenda and aricept\n - -CT head as above\n - history of CVA - for secondary stroke prevention should be on aspirin\n and statin; currently on neither one will start statin today, listed as\n having aspirin allergy of unknown type in the chart, however on\n previous admissions appears to have taken it so will consider\n restarting it, although utility at this point given mental status\n likely low\n .\n FEN: tubes feeds, monitor electrolytes, repleted K aggressively this\n morning for K of 2.6, K now 4.4\n .\n # Prophylaxis: SC heparin, d/c bowel regimen in the setting of\n persistent diarrhea, PPI\n .\n # Communcation: Sister .\n # Code: FC - plan to reassess with sister today\n .\n # Disposition: ICU care for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:15 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": "2192-08-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 343686, "text": "Chief Complaint: 82 year old female with a history of breast cancer,\n CVA, HTN who presents from rehab with pneumonia, uti and sepsis\n physiology transferred to the floor and then subsequently back to the\n unit s/p episode of unresponsiveness/pulselessness.\n 24 Hour Events:\n ANGIOGRAPHY - At 01:00 PM\n PICC placement under flouro\n PICC LINE - START 01:15 PM\n MULTI LUMEN - STOP 01:30 PM\n Patient maintained on broad spectrum antibiotics. intubated, sedated.\n no new troponins from event. Patient still with + diarrhea this\n morning. Holding bowel regimen in this setting. Tube feeds were\n restarted this morning. Dr. spoke with family this morning\n regarding plan for trach vs. extubation. Family to make a decision by\n tomorrow and get back to us.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:28 AM\n Levofloxacin - 06:19 PM\n Amikacin - 09:00 PM\n Metronidazole - 04:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:04 AM\n Heparin Sodium (Prophylaxis) - 08:32 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:51 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: 37.2\nC (98.9\n HR: 71 (61 - 79) bpm\n BP: 146/64(83) {129/50(70) - 162/66(87)} mmHg\n RR: 23 (11 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 945 mL\n 227 mL\n PO:\n 100 mL\n TF:\n IVF:\n 785 mL\n 227 mL\n Blood products:\n Total out:\n 850 mL\n 175 mL\n Urine:\n 850 mL\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 95 mL\n 52 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): 354 (311 - 596) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 111\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 10.2 L/min\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Wheezes : expiratory wheezes,\n Rhonchorous: b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: No(t) Attentive, Responds to: Not assessed, Movement: Not\n assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 583 K/uL\n 7.2 g/dL\n 83 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 2.6 mEq/L\n 14 mg/dL\n 105 mEq/L\n 142 mEq/L\n 22.5 %\n 16.1 K/uL\n [image002.jpg]\n 03:58 AM\n 05:43 PM\n 08:36 PM\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n 04:35 AM\n 05:32 AM\n 04:12 AM\n WBC\n 22.8\n 24.0\n 26.1\n 16.1\n Hct\n 26.8\n 26.1\n 28.7\n 22.5\n Plt\n 133\n 195\n 312\n 583\n Cr\n 0.7\n 0.8\n 0.9\n 0.9\n 1.1\n 1.1\n TCO2\n 24\n 28\n 27\n 28\n Glucose\n 90\n 104\n 141\n 69\n 216\n 83\n Other labs: PT / PTT / INR:15.5/27.6/1.4, CK / CKMB /\n Troponin-T:32/2/0.14, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:4.6 mmol/L, Albumin:2.3 g/dL, LDH:256 IU/L, Ca++:6.5 mg/dL,\n Mg++:1.7 mg/dL, PO4:3.1 mg/dL\n Chest x-ray from yesterday -\n ETT tip is hard to localize, may be 8 mm above the carina but should be\n further evaluated in a more standard position if of any clinical\n concern.\n Right PICC was installed, probably in good position. A nasogastric tube\n ends\n in the stomach. Right internal jugular catheter was removed.\n No overall change in large mass effect at the right hilar and\n infrahilar\n regions and left basilar consolidation.\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after likely PEA arrest now\n with worsening mental status than on previous transfer now 48 hours\n after the event.\n # Cardiopulmomary Arrest: Patient found pulseless, ashen, and cool,\n down for no longer than 10 minutes. Patient not monitored on telemetry\n at the time of the event. She quickly regained rhythm after intubation\n and 1gm epinephrine w/ CPR. In the setting of underlying RLL\n infiltrate, concern for worsening pulmonary edema on the floor, most\n likely etiology respiratory arrest w/ mucous plug.\n - treat underlying cause of PNA, provide respiratory support with\n ventilator for now\n - no troponins were drawn, so unclear if primary process is cardiac,\n however CK-MBs were flat so unlikely that acute ischemic event\n - continue to trend lactate\n - monitor on telemetry, patient appears to be hemodynamically stable\n .\n # Hypercarbic Respiratory Failure: Now s/p intubation with resolution\n in hypercarbia, no evidence of hypoxia. Will wean oxygen as tolerated.\n Likely secondary to cardiopulonary arrest.\n - intubated, currently on pressure support of . last rsbi > 100, so\n unlikely ready for extubation today, will continue to monitor\n - will plan to wean fi02 today to 40% (from 50%)\n - weak cough, no gag\n - also suspect that extrapulmonary source of respiratory\n stable\n .\n # HAP/Aspiration PNA/sepsis: Patient on broad spectrum coverage since\n admission. CT from showed persistent RLL infiltrate. CBC showing\n new bands on diff in setting of code.\n - continue vanc/levo/flagyl, patient currently on day 10 of ABX, but\n given poor clinical response will continue for additional 4 days\n - sputum from - GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND\n CLUSTERS.\n RESPIRATORY CULTURE (Preliminary): NO GROWTH.\n- only positive blood culture so far from - ESCHERICHIA COLI\n |\nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 4 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCEFUROXIME------------ 4 S\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n .\n # Urosepsis: W. e.coli bacteremia, and e.coli/providencia UTI. Repeat\n cultures have been negative. Has been on appropriate abx since ,\n will plan for 7 day course from this date.\n - continue amikacin, f/u send out level\n .\n # Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6, still\n currently 1.1. Had been >2 on initial presentation and was improving\n prior to arrest. Likely prerenal in etiology secondary to episode of\n hypoperfusion.\n - suspect that some of renal failure is likely due to poor forward flow\n and patient looks volume overloaded by physical exam\n - trend creatinine\n - goal I/O is negative 1 liter per day, would give lasix as\n needed to achieve this\n .\n # Hypertension: On lisinopril, metoprolol as outpatient\n - restart lisinopril today, uptitrate as tolerated\n .\n # Dementia: Currently intubated without need for sedative medications\n - continue namenda and aricept\n - suspect that only only is there a component of dementia but\n also a component of acute cerebral insult secondary to cardiopulmonary\n arrest that has likely\n .\n FEN: tubes feeds, monitor electrolytes, repleted K aggressively this\n morning for K of 2.6\n .\n # Prophylaxis: SC heparin, d/c bowel regimen in the setting of\n persistent diarrhea, PPI\n .\n # Communcation: Sister , will decide on trach in\n the morning\n .\n # Code: FC - plan to reassess with sister, suspect that this is likely\n inappropriate in this context\n .\n # Disposition: ICU care for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:15 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": "2192-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343585, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after cardiopulmonary\n resuscitation for pulselessness\n" }, { "category": "Nursing", "chartdate": "2192-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343586, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after cardiopulmonary\n resuscitation for pulselessness at 0400 on . had been transferred\n to floor . this morning 0400 found unresponsive and pulseless code\n blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated and transferred to ICU for further management\n" }, { "category": "Nursing", "chartdate": "2192-08-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 344043, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt considerably less responsive to stimulation e.g. mouth care,\n turning, ROM exercises, than she was when previously care for by this\n RN on Mon, . Multiple old infarcts visible on CT yesterday.\n Action:\n Neuro checks, stimulated; Dr. aware\n Response:\n No change\n Plan:\n Continue neuron checks, stimulation. Readdress code status\n .H/O hypertension, benign\n Assessment:\n SBP climbing to 171\n Action:\n 100mg lopressor as ordered at ; Lisinopril 5mg x1, 100mg metoprolol\n administered early\n Response:\n awaiting\n Plan:\n Monitor am BP\ns, lisinopril due again @0800; may need to review\n cardiac medsl\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Rhoncii in upper lobes, LL diminished b/l. Sat >95% on CPAP 40%/\n but tachypneic w/ RR in high 20\ns and 30\ns. Copious oral secretions\n Action:\n Sxn prn for small amts thick, yellow secretions, abg sent this am.\n Scopolamine patch placed at 0600\n Response:\n Metabolic alkalosis,\n Plan:\n Awaiting recommended vent changes if any, continue on IV abx\n K+, Mg++ WNL, serum calcium low, replete prn\n Family meeting is scheduled for today re: code status in this declining\n pt.\n" }, { "category": "Physician ", "chartdate": "2192-08-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 343691, "text": "Chief Complaint: 82 year old female with a history of breast cancer,\n CVA, HTN who presents from rehab with pneumonia, uti and sepsis\n physiology transferred to the floor and then subsequently back to the\n unit s/p episode of unresponsiveness/pulselessness.\n 24 Hour Events:\n ANGIOGRAPHY - At 01:00 PM\n PICC placement under flouro\n PICC LINE - START 01:15 PM\n MULTI LUMEN - STOP 01:30 PM\n Patient maintained on broad spectrum antibiotics. intubated, sedated.\n no new troponins from event. Patient still with + diarrhea this\n morning. Holding bowel regimen in this setting. Tube feeds were\n restarted this morning. Dr. spoke with family this morning\n regarding plan for trach vs. extubation. Family to make a decision by\n tomorrow and get back to us.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:28 AM\n Levofloxacin - 06:19 PM\n Amikacin - 09:00 PM\n Metronidazole - 04:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:04 AM\n Heparin Sodium (Prophylaxis) - 08:32 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:51 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: 37.2\nC (98.9\n HR: 71 (61 - 79) bpm\n BP: 146/64(83) {129/50(70) - 162/66(87)} mmHg\n RR: 23 (11 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 945 mL\n 227 mL\n PO:\n 100 mL\n TF:\n IVF:\n 785 mL\n 227 mL\n Blood products:\n Total out:\n 850 mL\n 175 mL\n Urine:\n 850 mL\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 95 mL\n 52 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): 354 (311 - 596) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 111\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 10.2 L/min\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Wheezes : expiratory wheezes,\n Rhonchorous: b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: No(t) Attentive, Responds to: Not assessed, Movement: Not\n assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 583 K/uL\n 7.2 g/dL\n 83 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 2.6 mEq/L\n 14 mg/dL\n 105 mEq/L\n 142 mEq/L\n 22.5 %\n 16.1 K/uL\n [image002.jpg]\n 03:58 AM\n 05:43 PM\n 08:36 PM\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n 04:35 AM\n 05:32 AM\n 04:12 AM\n WBC\n 22.8\n 24.0\n 26.1\n 16.1\n Hct\n 26.8\n 26.1\n 28.7\n 22.5\n Plt\n 133\n 195\n 312\n 583\n Cr\n 0.7\n 0.8\n 0.9\n 0.9\n 1.1\n 1.1\n TCO2\n 24\n 28\n 27\n 28\n Glucose\n 90\n 104\n 141\n 69\n 216\n 83\n Other labs: PT / PTT / INR:15.5/27.6/1.4, CK / CKMB /\n Troponin-T:32/2/0.14, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:4.6 mmol/L, Albumin:2.3 g/dL, LDH:256 IU/L, Ca++:6.5 mg/dL,\n Mg++:1.7 mg/dL, PO4:3.1 mg/dL\n Chest x-ray from yesterday -\n ETT tip is hard to localize, may be 8 mm above the carina but should be\n further evaluated in a more standard position if of any clinical\n concern.\n Right PICC was installed, probably in good position. A nasogastric tube\n ends\n in the stomach. Right internal jugular catheter was removed.\n No overall change in large mass effect at the right hilar and\n infrahilar\n regions and left basilar consolidation.\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after likely PEA arrest now\n with worsening mental status than on previous transfer now 48 hours\n after the event.\n # Cardiopulmomary Arrest: Patient found pulseless, ashen, and cool,\n down for no longer than 10 minutes. Patient not monitored on telemetry\n at the time of the event. She quickly regained rhythm after intubation\n and 1gm epinephrine w/ CPR. In the setting of underlying RLL\n infiltrate, concern for worsening pulmonary edema on the floor, most\n likely etiology respiratory arrest w/ mucous plug.\n - treat underlying cause of PNA, provide respiratory support with\n ventilator for now\n - no troponins were drawn, so unclear if primary process is cardiac,\n however CK-MBs were flat so unlikely that acute ischemic event\n - continue to trend lactate\n - monitor on telemetry, patient appears to be hemodynamically stable\n .\n # Hypercarbic Respiratory Failure: Now s/p intubation with resolution\n in hypercarbia, no evidence of hypoxia. Will wean oxygen as tolerated.\n Likely secondary to cardiopulonary arrest.\n - intubated, currently on pressure support of . last rsbi > 100, so\n unlikely ready for extubation today, will continue to monitor\n - will plan to wean fi02 today to 40% (from 50%)\n - weak cough, no gag\n - also suspect that extrapulmonary source of respiratory\n stable\n .\n # HAP/Aspiration PNA/sepsis: Patient on broad spectrum coverage since\n admission. CT from showed persistent RLL infiltrate. CBC showing\n new bands on diff in setting of code.\n - continue vanc/levo/flagyl, patient currently on day 10 of ABX, but\n given poor clinical response will continue for additional 4 days\n - sputum from - GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND\n CLUSTERS.\n RESPIRATORY CULTURE (Preliminary): NO GROWTH.\n- only positive blood culture so far from - ESCHERICHIA COLI\n |\nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 4 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCEFUROXIME------------ 4 S\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n .\n # Urosepsis: W. e.coli bacteremia, and e.coli/providencia UTI. Repeat\n cultures have been negative. Has been on appropriate abx since ,\n will plan for 7 day course from this date.\n - continue amikacin, f/u send out level\n .\n # Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6, still\n currently 1.1. Had been >2 on initial presentation and was improving\n prior to arrest. Likely prerenal in etiology secondary to episode of\n hypoperfusion.\n - suspect that some of renal failure is likely due to poor forward flow\n and patient looks volume overloaded by physical exam\n - trend creatinine\n - goal I/O is negative 1 liter per day, would give lasix as\n needed to achieve this\n .\n # Hypertension: On lisinopril, metoprolol as outpatient\n - restart lisinopril today, uptitrate as tolerated\n .\n # Dementia: Currently intubated without need for sedative medications\n - continue namenda and aricept\n - suspect that only only is there a component of dementia but\n also a component of acute cerebral insult secondary to cardiopulmonary\n arrest that has likely\n .\n FEN: tubes feeds, monitor electrolytes, repleted K aggressively this\n morning for K of 2.6\n .\n # Prophylaxis: SC heparin, d/c bowel regimen in the setting of\n persistent diarrhea, PPI\n .\n # Communcation: Sister , will decide on trach in\n the morning\n .\n # Code: FC - plan to reassess with sister, suspect that this is likely\n inappropriate in this context\n .\n # Disposition: ICU care for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:15 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 Patient with acute crit drop this morning. No obvious source of\n bleeding. Will re-check crit this afternoon\n may be in the setting of\n fluid resuscitation. Will guaic stool and continue to follow\n ------ Protected Section Addendum Entered By: , MD\n on: 16:17 ------\n" }, { "category": "Nursing", "chartdate": "2192-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343711, "text": "Nsg notes from 1500-1900hrs.\n Pls read nsg note from at 1500hrs for more detailed notes\n as there is nothing much changes after that.\n Pt remained same with vent settings.position changed.all hygienic\n needs attended. PM labs drawn ,all lytes within normal range except\n calcium .need to replete calcium. Team spoke with niece over the phone\n and decided for a family meeting tomorrow for possible trache for more\n pulm toileting and rehab care.\n" }, { "category": "Rehab Services", "chartdate": "2192-08-27 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 343511, "text": " 3:30 p.m\n Attempted to see pt for PT treatment. Pt intubated, not currently\n appropriate for PT. Will continue to follow and re-assess once\n appropriate. Thank you.\n" }, { "category": "Rehab Services", "chartdate": "2192-08-27 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 343512, "text": " 3:35 p.m\n Attempted to see pt for PT treatment. Pt remains intubated, not yet\n appropriate for PT intervention. Will continue to follow and re-assess\n as appropriate. Thank you.\n" }, { "category": "Nutrition", "chartdate": "2192-08-27 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 343517, "text": "Subjective\n Intubated.\n Objective\n Pertinent medications: meds noted.\n Labs:\n Value\n Date\n Glucose\n 216 mg/dL\n 04:35 AM\n Glucose Finger Stick\n 123\n 12:00 PM\n BUN\n 12 mg/dL\n 04:35 AM\n Creatinine\n 1.1 mg/dL\n 04:35 AM\n Sodium\n 140 mEq/L\n 04:35 AM\n Potassium\n 4.7 mEq/L\n 04:35 AM\n Chloride\n 103 mEq/L\n 04:35 AM\n TCO2\n 22 mEq/L\n 04:35 AM\n PO2 (arterial)\n 276 mm Hg\n 05:32 AM\n PCO2 (arterial)\n 41 mm Hg\n 05:32 AM\n pH (arterial)\n 7.43 units\n 05:32 AM\n pH (urine)\n 5.0 units\n 08:36 PM\n CO2 (Calc) arterial\n 28 mEq/L\n 05:32 AM\n Albumin\n 2.5 g/dL\n 04:35 AM\n Calcium non-ionized\n 7.2 mg/dL\n 04:35 AM\n Phosphorus\n 4.3 mg/dL\n 04:35 AM\n Ionized Calcium\n 1.17 mmol/L\n 03:31 AM\n Magnesium\n 2.3 mg/dL\n 04:35 AM\n ALT\n 13 IU/L\n 04:35 AM\n Alkaline Phosphate\n 108 IU/L\n 04:35 AM\n AST\n 18 IU/L\n 04:35 AM\n Total Bilirubin\n 0.3 mg/dL\n 04:35 AM\n WBC\n 26.1 K/uL\n 01:47 AM\n Hgb\n 9.4 g/dL\n 01:47 AM\n Hematocrit\n 28.7 %\n 01:47 AM\n Current diet order / nutrition support: NPO/TF: Fibersource HN at\n 55mL/hr with 150mL free water flushes Q 8hrs via NGT (on Hold)\n Assessment of Nutritional Status/Plan:\n Specifics:\n Recommend restart TF via NGT: FS Fibersource HN, start at 15mL/hr,\n advance by 10-15mL Q4-6 hrs or as tolerated to goal of55mL/hr. Monitor\n residuals Q 4hrs, hold x1hr if >150mL. Adjust free water flushes PRN\n per hydration. Monitor & replete lytes PRN. Will continue to follow.\n" }, { "category": "Nursing", "chartdate": "2192-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343643, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor (transferred there )\n after cardiopulmonary resuscitation for pulselessness at 0400 on .\n Code blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated. Likely respiratory related arrest as rapid return to\n circulation with intubation and only single dose of EPI; ?mucus plug\n and hypoxemic respiratory failure. She has ongoing findings consistent\n with persistent peumonia and pneumonitis in the RML and RLL\n distribution. Transferred to ICU for further management.\n Code status to be readdressed with family today.\n Altered mental status (not Delirium)\n Assessment:\n Pt remains minimally responsive and seems to have posturing movements\n with deep painful stimuli.\n Action:\n Response:\n Plan:\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Remains intubated with copious amts thich white secretions via ETT and\n copious oral secretions requiring suctioning Q30 minutes to 1hr. Lungs\n coarse throughout.\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Pt K+ 2.6, Mag 1.7, Calcium 6.5 with this AM labs.\n Action:\n Pt\ns electrolytes repleted aggressively this AM through her PICC line.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2192-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343699, "text": "2 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor (transferred there )\n after cardiopulmonary resuscitation for pulselessness at 0400 on .\n Code blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated. Likely respiratory related arrest as rapid return to\n circulation with intubation and only single dose of EPI; ?mucus plug\n and hypoxemic respiratory failure. She has ongoing findings consistent\n with persistent peumonia and pneumonitis in the RML and RLL\n distribution. Transferred to ICU for further management.\n" }, { "category": "Physician ", "chartdate": "2192-08-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 343636, "text": "Chief Complaint: 82 year old female with a history of breast cancer,\n CVA, HTN who presents from rehab with pneumonia, uti and sepsis\n physiology transferred to the floor and then subsequently back to the\n unit s/p episode of unresponsiveness/pulselessness.\n 24 Hour Events:\n ANGIOGRAPHY - At 01:00 PM\n PICC placement under flouro\n PICC LINE - START 01:15 PM\n MULTI LUMEN - STOP 01:30 PM\n Patient maintained on broad spectrum antibiotics. intubated, sedated.\n no new troponins from event.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:28 AM\n Levofloxacin - 06:19 PM\n Amikacin - 09:00 PM\n Metronidazole - 04:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:04 AM\n Heparin Sodium (Prophylaxis) - 08:32 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:51 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: 37.2\nC (98.9\n HR: 71 (61 - 79) bpm\n BP: 146/64(83) {129/50(70) - 162/66(87)} mmHg\n RR: 23 (11 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 945 mL\n 227 mL\n PO:\n 100 mL\n TF:\n IVF:\n 785 mL\n 227 mL\n Blood products:\n Total out:\n 850 mL\n 175 mL\n Urine:\n 850 mL\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 95 mL\n 52 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): 354 (311 - 596) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 111\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 10.2 L/min\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Wheezes : expiratory wheezes,\n Rhonchorous: b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: No(t) Attentive, Responds to: Not assessed, Movement: Not\n assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 583 K/uL\n 7.2 g/dL\n 83 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 2.6 mEq/L\n 14 mg/dL\n 105 mEq/L\n 142 mEq/L\n 22.5 %\n 16.1 K/uL\n [image002.jpg]\n 03:58 AM\n 05:43 PM\n 08:36 PM\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n 04:35 AM\n 05:32 AM\n 04:12 AM\n WBC\n 22.8\n 24.0\n 26.1\n 16.1\n Hct\n 26.8\n 26.1\n 28.7\n 22.5\n Plt\n 133\n 195\n 312\n 583\n Cr\n 0.7\n 0.8\n 0.9\n 0.9\n 1.1\n 1.1\n TCO2\n 24\n 28\n 27\n 28\n Glucose\n 90\n 104\n 141\n 69\n 216\n 83\n Other labs: PT / PTT / INR:15.5/27.6/1.4, CK / CKMB /\n Troponin-T:32/2/0.14, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:4.6 mmol/L, Albumin:2.3 g/dL, LDH:256 IU/L, Ca++:6.5 mg/dL,\n Mg++:1.7 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after cardiopulmonary\n resuscitation for pulselessness.\n .\n # Cardiopulmomary Arrest: Patient found pulseless, ashen, and cool,\n down for no longer than 10 minutes. Patient not monitored on telemetry\n at the time of the event. She quickly regained rhythm after intubation\n and 1gm epinephrine w/ CPR. In the setting of underlying RLL\n infiltrate, concern for worsening pulmonary edema on the floor, most\n likely etiology respiratory arrest w/ mucous plug.\n - treat underlying cause of PNA, provide respiratory support with\n ventilator for now\n - no troponins were drawn, so unclear if primary process is cardiac,\n will draw troponins now\n - lactate rising\n - monitor on telemetry, patient appears to be hemodynamically stable\n .\n # Hypercarbic Respiratory Failure: Now s/p intubation with resolution\n in hypercarbia, no evidence of hypoxia. Will wean oxygen as tolerated.\n Likely secondary to cardiopulonary arrest.\n - intubated, currently on pressure support of . last rsbi > 100, so\n unlikely ready for extubation today, will continue to monitor\n - wean FiO2 as tolerated\n .\n # HAP/Aspiration PNA: Patient on broad spectrum coverage since\n admission. CT from showed persistent RLL infiltrate. CBC showing\n new bands on diff in setting of code.\n - continue vanc/levo/flagyl, patient currently on day 10 of ABX, but\n given poor clinical response will continue for additional 4 days\n - consider reeval w/ bronchoscopy/BAL to continue infectious workup\n - repeat sputum cultures\n - follow blood cultures\n .\n # Urosepsis: W. e.coli bacteremia, and e.coli/providencia UTI. Repeat\n cultures have been negative. Has been on appropriate abx since ,\n will plan for 7 day course from this date.\n - continue amikacin, f/u send out level\n .\n # Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6, still\n currently 1.1. Had been >2 on initial presentation and was improving\n prior to arrest. Likely prerenal in etiology secondary to episode of\n hypoperfusion.\n - IVF boluses to maintain urine output\n - trend creatinine\n .\n # Hypertension: On lisinopril, metoprolol\n - resume as HR and BP tolerate\n .\n # Dementia: Currently intubated without need for sedative medications\n - continue namenda and aricept\n .\n # FEN: IVF as above, monitor electrolytes, NGT in place so will start\n tube feeds this am\n .\n # Prophylaxis: SC heparin, bowel regimen, PPI\n .\n # Communcation: Sister \n .\n # Code: FC - plan to reassess with sister, suspect that this is likely\n inappropriate in this context\n .\n # Disposition: ICU care for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:15 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": "2192-08-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 343658, "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 ANGIOGRAPHY - At 01:00 PM\n PICC placement under flouro\n PICC LINE - START 01:15 PM\n MULTI LUMEN - STOP 01:30 PM\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 06:19 PM\n Amikacin - 07:30 AM\n Vancomycin - 08:00 AM\n Metronidazole - 11:37 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\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 Respiratory: Tachypnea\n Flowsheet Data as of 12:14 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: 37.3\nC (99.2\n HR: 70 (61 - 79) bpm\n BP: 150/63(84) {129/50(70) - 165/71(96)} mmHg\n RR: 29 (14 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 945 mL\n 1,397 mL\n PO:\n 100 mL\n TF:\n 46 mL\n IVF:\n 785 mL\n 1,081 mL\n Blood products:\n Total out:\n 850 mL\n 370 mL\n Urine:\n 850 mL\n 370 mL\n NG:\n Stool:\n Drains:\n Balance:\n 95 mL\n 1,027 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 348 (311 - 354) mL\n PS : 10 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 111\n SpO2: 100%\n ABG: ///30/\n Ve: 9.6 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Noxious stimuli, Movement: Not assessed, Tone:\n Not assessed. Patient has no response to verbal stimulation. With\n noxious stimulation she will have withdrawl response.\n Labs / Radiology\n 7.5 g/dL\n 548 K/uL\n 83 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 2.6 mEq/L\n 14 mg/dL\n 105 mEq/L\n 142 mEq/L\n 23.4 %\n 15.7 K/uL\n [image002.jpg]\n 05:43 PM\n 08:36 PM\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n 04:35 AM\n 05:32 AM\n 04:12 AM\n 08:43 AM\n WBC\n 24.0\n 26.1\n 16.1\n 15.7\n Hct\n 26.1\n 28.7\n 22.5\n 23.4\n Plt\n 195\n 312\n 583\n 548\n Cr\n 0.8\n 0.9\n 0.9\n 1.1\n 1.1\n TropT\n 0.10\n TCO2\n 24\n 28\n 27\n 28\n Glucose\n 104\n 141\n 69\n 216\n 83\n Other labs: PT / PTT / INR:15.5/27.6/1.4, CK / CKMB /\n Troponin-T:37/3/0.10, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:4.6 mmol/L, Albumin:2.3 g/dL, LDH:256 IU/L, Ca++:6.5 mg/dL,\n Mg++:1.7 mg/dL, PO4:3.1 mg/dL\n Imaging: CXR--Lines in reasonable position, prominent right sided\n infiltrate noted and may be slight decrease in size of infiltrates.\n Assessment and Plan\n 82 yo female now with recurrent respiratory failure while being cared\n for on the medical floor. She had subsequent PEA arrest and successful\n resuscitation with intubation. The concerning issue is that the\n primary insult is likely recurrent aspiration in the setting of\n incapacity to protect her airway in the setting of what is likley\n background levels of secretions and persistenly impaired mental\n status. We have not identified a new fully reversible insult and would\n expect her to remain at risk for acute respiratory failure going\n forward.\n 1)Respiratory Failure Acute-\n -Will keep fluid balance negative\n -Avoid sedating medications\n -Persistent secretions noted with frequent suctioning\n -Will continue with antibiotics--Amikacin/Flagyl/Levofloxacin/Vanco\n -Barriers to extubation are primarily impaired mental status which has\n worsened following arrest event with persistent dense impairment of\n sensorium. This is in addition to her pulmonary secretions.\n -Will need to clarify goals of care with family prior to extubation\n attempt.\n 2)Anemia-Does have an acute change and will need to\n -OB stool\n -Repeat HCT today\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:43 AM 20 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:15 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2192-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343664, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor (transferred there )\n after cardiopulmonary resuscitation for pulselessness at 0400 on .\n Code blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated. Likely respiratory related arrest as rapid return to\n circulation with intubation and only single dose of EPI; ?mucus plug\n and hypoxemic respiratory failure. She has ongoing findings consistent\n with persistent peumonia and pneumonitis in the RML and RLL\n distribution. Transferred to ICU for further management.\n Code status to be readdressed with family today.\n Altered mental status (not Delirium)\n Assessment:\n Pt remains minimally responsive and seems to have posturing movements\n with deep painful stimuli. Absent gag and weak cough. Not able to clear\n copious secretions on her own.\n Action:\n Remains intubated for copious secretions to maintain airway. Complete\n care given as pt is dependent for all ADL\n Response:\n No change in mental status.\n Plan:\n Continue to provide support for pt and family. Team wants to talk to\n the family. Pt\ns sister, , who is 80y.o. herself, is her proxy\n so pt\n is helping her mother make decisions.\n Family came in today but team was on rounds. The team have \n cell number and plan to call her to speak about long term goals and\n address code status.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Remains intubated with copious amts thick white/clear secretions via\n ETT and copious oral secretions requiring suctioning Q30 minutes to\n 1hr. Lungs coarse throughout. Pt has remained on PSV 10/5 with good O2\n sats\n Action:\n FIO2 weaned to 40% from 50%. Pt remains intubated for airway\n protection.\n Response:\n Continues to require frequent oral/ETT suctioning.\n Plan:\n Provide good pulmonary toilet as needed.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt K+ 2.6, Mag 1.7, Calcium 6.5 with this AM labs.\n Action:\n Pt\ns electrolytes repleted aggressively this AM. Given 100meq total\n Kcl, 2gm magnesium and 4gm IV calcium.\n Response:\n Repeat labs to be drawn at 1500.\n Plan:\n Continue to follow labs closely and replete as needed. I will draw 3PM\n labs, please follow results.\n" }, { "category": "Nursing", "chartdate": "2192-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343674, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor (transferred there )\n after cardiopulmonary resuscitation for pulselessness at 0400 on .\n Code blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated. Likely respiratory related arrest as rapid return to\n circulation with intubation and only single dose of EPI; ?mucus plug\n and hypoxemic respiratory failure. She has ongoing findings consistent\n with persistent peumonia and pneumonitis in the RML and RLL\n distribution. Transferred to ICU for further management.\n Code status to be readdressed with family today.\n Altered mental status (not Delirium)\n Assessment:\n Pt remains minimally responsive and seems to have posturing movements\n with deep painful stimuli. Absent gag and weak cough. Not able to clear\n copious secretions on her own.\n Action:\n Remains intubated for copious secretions to maintain airway. Complete\n care given as pt is dependent for all ADL\n Response:\n No change in mental status.\n Plan:\n Continue to provide support for pt and family. Team wants to talk to\n the family. Pt\ns sister, , who is 80y.o. herself, is her proxy\n so pt\n is helping her mother make decisions.\n Family came in today but team was on rounds. The team have \n cell number and plan to call her to speak about long term goals and\n address code status.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Remains intubated with copious amts thick white/clear secretions via\n ETT and copious oral secretions requiring suctioning Q30 minutes to\n 1hr. Lungs coarse throughout. Pt has remained on PSV 10/5 with good O2\n sats\n Action:\n FIO2 weaned to 40% from 50%. Pt remains intubated for airway\n protection.\n Response:\n Continues to require frequent oral/ETT suctioning.\n Plan:\n Provide good pulmonary toilet as needed.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt K+ 2.6, Mag 1.7, Calcium 6.5 with this AM labs.\n Action:\n Pt\ns electrolytes repleted aggressively this AM. Given 100meq total\n Kcl, 2gm magnesium and 4gm IV calcium.\n Response:\n Repeat labs to be drawn at 1500.\n Plan:\n Continue to follow labs closely and replete as needed. I will draw 3PM\n labs, please follow results.\n" }, { "category": "Physician ", "chartdate": "2192-08-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 343879, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 03:08 PM\n -40mg IV lasix with good urine output (approx 500cc)\n -medications changed to PO if possible to avoid excess urine, decreased\n free water flushes with TFs\n -switched to AC overnight for persistent apnea\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 06:19 PM\n Vancomycin - 08:00 AM\n Metronidazole - 09:06 PM\n Amikacin - 09:07 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 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: 37.2\nC (98.9\n HR: 73 (57 - 78) bpm\n BP: 144/58(81) {128/51(71) - 165/71(96)} mmHg\n RR: 15 (11 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 2,294 mL\n 358 mL\n PO:\n TF:\n 324 mL\n 238 mL\n IVF:\n 1,400 mL\n 71 mL\n Blood products:\n Total out:\n 2,400 mL\n 790 mL\n Urine:\n 2,400 mL\n 790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -106 mL\n -432 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 430 (319 - 480) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 3\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 18 cmH2O\n Plateau: 16 cmH2O\n SpO2: 100%\n ABG: ///32/\n Ve: 7.3 L/min\n Physical Examination\n GEN: Intubated, sedated\n HEENT: NCAT MMM anicteric pale conjunctiva\n CV: RRR S1S2\n PULM: rhonchi at mid-lung fields, likely intubation otherwise clear\n while supine\n ABD: soft, distended, nontender +bs no palp masses\n EXT: WWP 1+ bipedal edema 1+dp pulses no cyanosis\n SKIN: no new lesions, rashes noted\n Labs / Radiology\n 666 K/uL\n 8.0 g/dL\n 152 mg/dL\n 1.1 mg/dL\n 32 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 102 mEq/L\n 138 mEq/L\n 24.9 %\n 15.4 K/uL\n [image002.jpg]\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n 04:35 AM\n 05:32 AM\n 04:12 AM\n 08:43 AM\n 02:53 PM\n 05:54 AM\n WBC\n 24.0\n 26.1\n 16.1\n 15.7\n 15.4\n Hct\n 26.1\n 28.7\n 22.5\n 23.4\n 24.9\n Plt\n 195\n 312\n 583\n 548\n 666\n Cr\n 0.9\n 0.9\n 1.1\n 1.1\n 1.0\n 1.1\n TropT\n 0.10\n TCO2\n 28\n 27\n 28\n Glucose\n 141\n 69\n 216\n 83\n 105\n 152\n Other labs: PT / PTT / INR:15.5/27.6/1.4, CK / CKMB /\n Troponin-T:37/3/0.10, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:1.0 mmol/L, Albumin:2.3 g/dL, LDH:256 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after likely PEA arrest now\n with worsening mental status than on previous transfer now 48 hours\n after the event.\n # Cardiopulmomary Arrest: Patient found pulseless, ashen, and cool,\n down for no longer than 10 minutes. Patient not monitored on telemetry\n at the time of the event. She quickly regained rhythm after intubation\n and 1gm epinephrine w/ CPR. In the setting of underlying RLL\n infiltrate, concern for worsening pulmonary edema on the floor, most\n likely etiology respiratory arrest w/ mucous plug. No further events\n since admission to ICU, although continues to have episodes of apnea\n while on PS.\n - treat underlying cause of PNA, provide respiratory support with\n ventilator for now\n - continue to trend lactate\n - monitor on telemetry, patient appears to be hemodynamically stable\n -CT head to evaluate for any acute insults that may be causing her\n apneic periods\n .\n # Hypercarbic Respiratory Failure: S/p intubation x2. Hypercarbic\n likely to arrest d/t pulmonary etiology (mucus plugging, apneic\n period). Overnight with significant secretions needing frequent\n suctioning. Will continue to wean as tolerated to PS although not ready\n for extubation. Will discuss goals of care with niece this morning\n (extubation, trach placement etc.)\n - Wean FIO2 as tolerated, to PS\n - weak cough, no gag per RT\n - suction prn, nebs prn\n - -d/w family re: trach\n .\n # HAP/Aspiration PNA/sepsis: Patient on broad spectrum coverage since\n admission, has grown GPC pairs/clusters in sputum and E.coli in blood\n and urine. CT from showed persistent RLL infiltrate. CBC showing\n new bands on diff in setting of code.\n - continue vanc/levo/flagyl, patient currently on day 11 of ABX, (3\n more days)\n - sputum from - GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND\n CLUSTERS.\n RESPIRATORY CULTURE (Preliminary): NO GROWTH.\n- only positive blood culture so far from - ESCHERICHIA COLI\n |\nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 4 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCEFUROXIME------------ 4 S\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n .\n # Urosepsis: E.coli bacteremia, and e.coli/providencia UTI. Repeat\n cultures have been negative. Has been on amikacin, last day .\n - f/u amikacin levels this morning\n .\n # Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6, currently\n on CVVH. Likely prerenal in etiology secondary to episode of\n hypoperfusion.\n - suspect that some of renal failure is likely due to poor forward flow\n and patient looks volume overloaded by physical exam\n - trend creatinine\n - goal I/O is negative 1 liter per day, would give lasix as\n needed to achieve this\n .\n # Hypertension: On lisinopril, metoprolol as outpatient\n - restart lisinopril today, uptitrate as tolerated\n - lasix 40mg IV qd, monitor UOP\n .\n # Dementia: Currently intubated without need for sedative medications.\n Concern for possible cerebral ischemic insult during her PEA arrest\n that may be causing her apnea.\n - continue namenda and aricept\n - -CT head as above\n .\n FEN: tubes feeds, monitor electrolytes, repleted K aggressively this\n morning for K of 2.6\n .\n # Prophylaxis: SC heparin, d/c bowel regimen in the setting of\n persistent diarrhea, PPI\n .\n # Communcation: Sister , will decide on trach in\n the morning\n .\n # Code: FC - plan to reassess with sister today\n .\n # Disposition: ICU care for now\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:32 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2192-08-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 343808, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 59 None\n Ideal tidal volume: 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 Lung sounds\n RLL Lung Sounds: Crackles\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 / Copious\n Comments/Plan\n Vent support changed to AC mode overnight for persistent apnea\n alarming. No RSBI done secondary to apneas. See flowsheet for further\n pt data. Will follow.\n 05:46\n" }, { "category": "Respiratory ", "chartdate": "2192-08-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 344034, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 59 None\n Ideal tidal volume: 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 Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments/Plan\n No vent changes made overnight. Pt noted to have persistent\n tachypnea. ABG obtained-> 7.47-47-65. No changes made on vent thus\n far. RSBI=300\ns this am. See flowsheet for further pt data. Will\n follow.\n 06:03\n" }, { "category": "Nursing", "chartdate": "2192-08-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 344143, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor (transferred there )\n after cardiopulmonary resuscitation for pulselessness at 0400 on .\n Code blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated. Likely respiratory related arrest as rapid return to\n circulation with intubation and only single dose of EPI; ?mucus plug\n and hypoxemic respiratory failure. She has ongoing findings consistent\n with persistent peumonia and pneumonitis in the RML and RLL\n distribution. Transferred to ICU for further management\n Family meeting today to discuss goals of care. After discussing the\n high likelihood that pt would not recover from massive insult with Dr.\n , the family decided that they would withdraw care\n tomorrow in AM including extubation.\n Altered mental status (not Delirium)\n Assessment:\n Unarousable to deep painful stimuli, no movement or posturing. No gag\n or cough reflex. Pupils pinpoint and non-reactive bilaterally.\n Extremities flaccid.\n Action:\n Family mtg\n Response:\n Pt. to be made CMO tomorrow in AM after family has been able to say\n their good-byes. Continuing TF and abx overnight.\n Plan:\n Terminal extubation and CMO tomorrow AM.\n" }, { "category": "Nursing", "chartdate": "2192-08-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342361, "text": "Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Large amt of thick secretions upon suctioning\n Action:\n Aggressive pulm toileting suction q 3-4 hrs\n Response:\n Maint sats @ 100% tol PSV @ 40%\n Plan:\n Cont mech vent support cont to wean as tolerated\n .H/O hypertension, benign\n Assessment:\n Pt hypertensive up inot 160-170\n Action:\n Increased lopressor to 50 mg TID\n Response:\n Pt bp now 150-160\ns w/ better rate control\n Plan:\n Cont to assess hemodynamics\n" }, { "category": "Physician ", "chartdate": "2192-08-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 343872, "text": "Chief Complaint: Respiratory Failure\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 03:08 PM\n Recurrent Fevers noted\n Initial discussions with family in regards to DNI status continued\n PSV trial clouded by apnea\n History obtained from Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 06:19 PM\n Metronidazole - 09:06 PM\n Amikacin - 09:07 PM\n Vancomycin - 08:27 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:05 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: 37.4\nC (99.3\n HR: 70 (57 - 79) bpm\n BP: 147/63(83) {128/51(71) - 160/68(90)} mmHg\n RR: 27 (11 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 2,294 mL\n 846 mL\n PO:\n TF:\n 324 mL\n 396 mL\n IVF:\n 1,400 mL\n 360 mL\n Blood products:\n Total out:\n 2,400 mL\n 870 mL\n Urine:\n 2,400 mL\n 870 mL\n NG:\n Stool:\n Drains:\n Balance:\n -106 mL\n -24 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 360 (360 - 450) mL\n Vt (Spontaneous): 360 (319 - 480) mL\n PS : 12 cmH2O\n RR (Set): 12\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 18 cmH2O\n Plateau: 16 cmH2O\n SpO2: 100%\n ABG: ///32/\n Ve: 8.6 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right: Trace, Left: Trace\n Musculoskeletal: Unable to stand\n Skin: Not assessed\n Neurologic: Responds to: Noxious stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.0 g/dL\n 666 K/uL\n 152 mg/dL\n 1.1 mg/dL\n 32 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 102 mEq/L\n 138 mEq/L\n 24.9 %\n 15.4 K/uL\n [image002.jpg]\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n 04:35 AM\n 05:32 AM\n 04:12 AM\n 08:43 AM\n 02:53 PM\n 05:54 AM\n WBC\n 24.0\n 26.1\n 16.1\n 15.7\n 15.4\n Hct\n 26.1\n 28.7\n 22.5\n 23.4\n 24.9\n Plt\n 195\n 312\n 583\n 548\n 666\n Cr\n 0.9\n 0.9\n 1.1\n 1.1\n 1.0\n 1.1\n TropT\n 0.10\n TCO2\n 28\n 27\n 28\n Glucose\n 141\n 69\n 216\n 83\n 105\n 152\n Other labs: PT / PTT / INR:15.4/27.4/1.4, CK / CKMB /\n Troponin-T:37/3/0.10, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:1.0 mmol/L, Albumin:2.3 g/dL, LDH:256 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR-PICC and ETT in good position. There is increased\n opacities in Right lung in basal segments\n Assessment and Plan\n 82 yo female with recurrent acute respiratory failure in the setting of\n persistent dementia, secretions and incapacity to maintain patent\n airway and management of secretions. She has had persistent\n ventilatory requirement and limited improvement in mental status.\n 1)Respiratory Failure-\n -Vanco/Levoflox/Flagyl\n -Continue with PSV support\n -Patient with continued oral secretions and incapacity to maintain gag\n reflex to prevent ongoing large volume of aspiration\n -Mental status remains primary barrier to extubation\n -Will need to consider goals of care prior to decision to extubate as\n risk factors for acute respiratory failure are persistent.\n 2)Alteration of Awareness-\n -Concern for persistent dense imparied sensorium\nwill pursue CT head\n -No sedation given\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:32 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:15 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\nwill need to readdress with family\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2192-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343804, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor (transferred there )\n after cardiopulmonary resuscitation for pulselessness at 0400 on .\n Code blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated. Likely respiratory related arrest as rapid return to\n circulation with intubation and only single dose of EPI; ?mucus plug\n and hypoxemic respiratory failure. She has ongoing findings consistent\n with persistent peumonia and pneumonitis in the RML and RLL\n distribution. Transferred to ICU for further management\n Code status and plan of care to be determined by hcp today.\n Altered mental status (not Delirium)\n Assessment:\n Unarousable and having frequent periods of apnea\n Action:\n Changed from cpap to cmv ventilation after discussion with H.O.\n Response:\n Apnea resolved\n Plan:\n Discuss Plan of care with HCP later today.\n Electrolyte & fluid disorder, other\n Assessment:\n Edematous.\n Action:\n Lasix 40 mg iv given\n Response:\n Good hourly uop. Entering negative fluid balance.\n Plan:\n To have negative fluid balance.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Cmv ventilation. Moderate amt secretions noted. amt. oral and\n nasal drainage\n Action:\n Suctioned frequently\n Response:\n Lungs with rhonchi. O2 sats maintained in high 90\n Plan:\n Continue w pulmonary toilet, antibiotic rx\n" }, { "category": "Nursing", "chartdate": "2192-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343806, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor (transferred there )\n after cardiopulmonary resuscitation for pulselessness at 0400 on .\n Code blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated. Likely respiratory related arrest as rapid return to\n circulation with intubation and only single dose of EPI; ?mucus plug\n and hypoxemic respiratory failure. She has ongoing findings consistent\n with persistent peumonia and pneumonitis in the RML and RLL\n distribution. Transferred to ICU for further management\n Code status and plan of care to be determined by hcp today.\n Altered mental status (not Delirium)\n Assessment:\n Unarousable except to pain and having frequent periods of apnea\n Action:\n Changed from cpap to cmv ventilation after discussion with H.O.\n Response:\n Apnea resolved\n Plan:\n Discuss Plan of care with HCP later today.\n Electrolyte & fluid disorder, other\n Assessment:\n Edematous.\n Action:\n Lasix 40 mg iv given\n Response:\n Good hourly uop. Entering negative fluid balance (.\n liter )\n Plan:\n To remain in negative fluid balance.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Cmv ventilation. Moderate amt secretions noted. amt. oral and\n nasal drainage\n Action:\n Suctioned frequently\n Response:\n Lungs with rhonchi. O2 sats maintained in high 90\n Plan:\n Continue w pulmonary toilet, antibiotic rx\n" }, { "category": "Physician ", "chartdate": "2192-08-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 344306, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n Family decided to make dnr/dni\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 06:10 PM\n Metronidazole - 04:10 AM\n Vancomycin - 08:00 AM\n Amikacin - 09:03 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Furosemide (Lasix) - 09:35 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 12:19 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.7\nC (99.9\n HR: 75 (68 - 93) bpm\n BP: 157/66(88) {127/57(73) - 164/72(93)} mmHg\n RR: 18 (15 - 38) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 1,987 mL\n 545 mL\n PO:\n TF:\n 1,187 mL\n 10 mL\n IVF:\n 540 mL\n 455 mL\n Blood products:\n Total out:\n 1,115 mL\n 395 mL\n Urine:\n 1,115 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n 872 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 293 (293 - 293) mL\n PS : 20 cmH2O\n RR (Set): 12\n RR (Spontaneous): 37\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 95%\n ABG: ///34/\n Ve: 7.7 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 875 K/uL\n 8.7 g/dL\n 102 mg/dL\n 1.0 mg/dL\n 34 mEq/L\n 3.5 mEq/L\n 19 mg/dL\n 97 mEq/L\n 138 mEq/L\n 27.0 %\n 20.2 K/uL\n [image002.jpg]\n 04:35 AM\n 05:32 AM\n 04:12 AM\n 08:43 AM\n 02:53 PM\n 05:54 AM\n 04:28 PM\n 04:00 AM\n 05:08 AM\n 05:41 AM\n WBC\n 16.1\n 15.7\n 15.4\n 18.4\n 20.2\n Hct\n 22.5\n 23.4\n 24.9\n 25.9\n 27.0\n Plt\n 583\n 548\n 666\n 781\n 875\n Cr\n 1.1\n 1.1\n 1.0\n 1.1\n 1.0\n 1.0\n 1.0\n TropT\n 0.10\n TCO2\n 28\n 35\n Glucose\n 2\n 150\n 148\n 102\n Other labs: PT / PTT / INR:15.4/28.9/1.4, CK / CKMB /\n Troponin-T:37/3/0.10, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:1.2 mmol/L, Albumin:2.6 g/dL, LDH:256 IU/L, Ca++:7.5 mg/dL,\n Mg++:1.8 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after likely PEA arrest now\n with worsening mental status than on previous transfer now 48 hours\n after the event.\n # Hypercarbic Respiratory Failure: S/p intubation x2. Hypercarbic\n likely to arrest d/t pulmonary etiology (mucus plugging, apneic\n period). Started on scopolamine patch yesterday for secretions. still\n requiring frequent suctioning. Currently tachypneic and likely not\n candidate for extubation today. Will discuss goals of care with niece\n this morning (extubation, trach placement etc.)\n - family said patient is now DNR/DNI\n - Wean FIO2 as tolerated, to PS as tolerate\n # HAP/Aspiration PNA/sepsis: Patient on broad spectrum coverage since\n admission, has grown GPC pairs/clusters in sputum and E.coli in blood\n and urine. CT from showed persistent RLL infiltrate. CBC showing\n new bands on diff in setting of code.\n - continue vanc/levo/flagyl patient currently on day 12 of ABX, (2 more\n days)\n - sputum from - GRAM STAIN (Final ):\n .\n # Urosepsis: E.coli bacteremia, and e.coli/providencia UTI. Repeat\n cultures have been negative. Has been on amikacin, last day .\n - amikacin levels from are still pending\n .\n # Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6 currently\n 1.0 appears to be improving with some diuresis. likely relative\n hypoperfusion.\n - suspect that some of renal failure is likely due to poor forward flow\n and patient looks volume overloaded by physical exam\n - trend creatinine\n - goal I/O is negative 1 liter per day, would give lasix as needed to\n achieve this (40 IV yesterday => -500 cc)\n - will start with 40 IV lasix this morning and then check afternoon\n # Hypertension: On lisinopril, metoprolol as outpatient\n - increase lisinopril today to 10\n - lasix 40mg IV qd, monitor UOP\n - metoprolol 100 mg PO TID\n .# Dementia: Currently intubated without need for sedative\n medications. No evidence of acute infarct on CT however suspect global\n anoxia as metabolic insult.\n - d/c namenda and aricept as likely not helpful anymore\n -\n FEN: tubes feeds, monitor electrolytes, repleted K aggressively this\n morning for K of 2.6, K now 4.4\n # Prophylaxis: SC heparin, d/c bowel regimen in the setting of\n persistent diarrhea, PPI\n .\n # Communcation: Sister .\n # Code: Plan. Now DNR/DNI. Plan to extubate today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2192-08-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 344308, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\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:\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 made CMO, extubated to room air by nurse at 1340, expired\n around 1500.\n" }, { "category": "Nursing", "chartdate": "2192-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343732, "text": "Nsg notes from 1500-1900hrs.\n Pls read nsg note from at 1500hrs for more detailed notes\n as there is nothing much changes after that.\n Pt remained same with vent settings.position changed.all hygienic\n needs attended. PM labs drawn ,all lytes within normal range except\n calcium .need to replete calcium. Lasix 20mg iv given with good\n effect.Team spoke with niece over the phone and decided for a family\n meeting tomorrow for possible trache for more pulm toileting and rehab\n care.\n" }, { "category": "Respiratory ", "chartdate": "2192-08-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 343977, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 59 None\n Ideal tidal volume: 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: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: 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: went to CT no incidences.\n" }, { "category": "Physician ", "chartdate": "2192-08-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 344302, "text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 06:10 PM\n Metronidazole - 04:10 AM\n Vancomycin - 08:00 AM\n Amikacin - 09:03 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Furosemide (Lasix) - 09:35 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 12:19 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.7\nC (99.9\n HR: 75 (68 - 93) bpm\n BP: 157/66(88) {127/57(73) - 164/72(93)} mmHg\n RR: 18 (15 - 38) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 1,987 mL\n 545 mL\n PO:\n TF:\n 1,187 mL\n 10 mL\n IVF:\n 540 mL\n 455 mL\n Blood products:\n Total out:\n 1,115 mL\n 395 mL\n Urine:\n 1,115 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n 872 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 293 (293 - 293) mL\n PS : 20 cmH2O\n RR (Set): 12\n RR (Spontaneous): 37\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 95%\n ABG: ///34/\n Ve: 7.7 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 875 K/uL\n 8.7 g/dL\n 102 mg/dL\n 1.0 mg/dL\n 34 mEq/L\n 3.5 mEq/L\n 19 mg/dL\n 97 mEq/L\n 138 mEq/L\n 27.0 %\n 20.2 K/uL\n [image002.jpg]\n 04:35 AM\n 05:32 AM\n 04:12 AM\n 08:43 AM\n 02:53 PM\n 05:54 AM\n 04:28 PM\n 04:00 AM\n 05:08 AM\n 05:41 AM\n WBC\n 16.1\n 15.7\n 15.4\n 18.4\n 20.2\n Hct\n 22.5\n 23.4\n 24.9\n 25.9\n 27.0\n Plt\n 583\n 548\n 666\n 781\n 875\n Cr\n 1.1\n 1.1\n 1.0\n 1.1\n 1.0\n 1.0\n 1.0\n TropT\n 0.10\n TCO2\n 28\n 35\n Glucose\n 2\n 150\n 148\n 102\n Other labs: PT / PTT / INR:15.4/28.9/1.4, CK / CKMB /\n Troponin-T:37/3/0.10, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:1.2 mmol/L, Albumin:2.6 g/dL, LDH:256 IU/L, Ca++:7.5 mg/dL,\n Mg++:1.8 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:15 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": "2192-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343966, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor (transferred there )\n after cardiopulmonary resuscitation for pulselessness at 0400 on .\n Code blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated. Likely respiratory related arrest as rapid return to\n circulation with intubation and only single dose of EPI; ?mucus plug\n and hypoxemic respiratory failure. She has ongoing findings consistent\n with persistent peumonia and pneumonitis in the RML and RLL\n distribution. Transferred to ICU for further management\n Code status and plan of care was to be determined by hcp today, however\n no family members came. MD called and restated that family mtg needs to\n occur to make decisions re: goals of care.\n Altered mental status (not Delirium)\n Assessment:\n Unarousable except to deep painful stimuli. Responds by posturing.\n Frequent periods of apnea. Very impaired gag. Neurological exam\n markedly compromised.\n Action:\n Head CT today.\n Response:\n Showed no acute changes however multiple areas of previous bleeds,\n infarcts.\n Plan:\n Discuss Plan of care with HCP tomorrow at 11:30 AM.\n Electrolyte & fluid disorder, other\n Assessment:\n + pitting edema.\n Action:\n Lasix 40 mg iv given\n Response:\n Good hourly uop. Goal to be 500-1000mL negative. Currently\n negative. 1600 lytes\n K+ 3.9, repleting 1^st 20mEq\ns of 40 total per\n K+ sliding scale. Ca++ continues to be consistently low 7\ns. Calcium\n carbonate PO x1 given with minimal response. Consult team for IV\n repletion.\n Plan:\n Remain negative. lytes and repletion prn.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Placed back on CPAP today after being placed on CMV overnight for\n frequent apneic periods. Low grade temp. LS rhoncorous bilaterally.\n Moderate amt secretions noted. Copious amounts of oral and nasal\n secretions. No gag.\n Action:\n Suctioned frequently, abx as ordered.\n Response:\n Unchanged.\n Plan:\n Continue w/ pulmonary toilet, antibiotic\n" }, { "category": "Physician ", "chartdate": "2192-08-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 343847, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 03:08 PM\n -40mg IV lasix with good urine output (approx 500cc)\n -medications changed to PO if possible to avoid excess urine, decreased\n free water flushes with TFs\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 06:19 PM\n Vancomycin - 08:00 AM\n Metronidazole - 09:06 PM\n Amikacin - 09:07 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 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: 37.2\nC (98.9\n HR: 73 (57 - 78) bpm\n BP: 144/58(81) {128/51(71) - 165/71(96)} mmHg\n RR: 15 (11 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 2,294 mL\n 358 mL\n PO:\n TF:\n 324 mL\n 238 mL\n IVF:\n 1,400 mL\n 71 mL\n Blood products:\n Total out:\n 2,400 mL\n 790 mL\n Urine:\n 2,400 mL\n 790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -106 mL\n -432 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 430 (319 - 480) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 3\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 18 cmH2O\n Plateau: 16 cmH2O\n SpO2: 100%\n ABG: ///32/\n Ve: 7.3 L/min\n Physical Examination\n GEN: Intubated, sedated\n HEENT: NCAT MMM anicteric pale conjunctiva\n CV: RRR S1S2\n PULM: rhonchi at mid-lung fields, likely intubation otherwise clear\n while supine\n ABD: soft, distended, nontender +bs no palp masses\n EXT: WWP 1+ bipedal edema 1+dp pulses no cyanosis\n SKIN: no new lesions, rashes noted\n Labs / Radiology\n 666 K/uL\n 8.0 g/dL\n 152 mg/dL\n 1.1 mg/dL\n 32 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 102 mEq/L\n 138 mEq/L\n 24.9 %\n 15.4 K/uL\n [image002.jpg]\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n 04:35 AM\n 05:32 AM\n 04:12 AM\n 08:43 AM\n 02:53 PM\n 05:54 AM\n WBC\n 24.0\n 26.1\n 16.1\n 15.7\n 15.4\n Hct\n 26.1\n 28.7\n 22.5\n 23.4\n 24.9\n Plt\n 195\n 312\n 583\n 548\n 666\n Cr\n 0.9\n 0.9\n 1.1\n 1.1\n 1.0\n 1.1\n TropT\n 0.10\n TCO2\n 28\n 27\n 28\n Glucose\n 141\n 69\n 216\n 83\n 105\n 152\n Other labs: PT / PTT / INR:15.5/27.6/1.4, CK / CKMB /\n Troponin-T:37/3/0.10, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:1.0 mmol/L, Albumin:2.3 g/dL, LDH:256 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after likely PEA arrest now\n with worsening mental status than on previous transfer now 48 hours\n after the event.\n # Cardiopulmomary Arrest: Patient found pulseless, ashen, and cool,\n down for no longer than 10 minutes. Patient not monitored on telemetry\n at the time of the event. She quickly regained rhythm after intubation\n and 1gm epinephrine w/ CPR. In the setting of underlying RLL\n infiltrate, concern for worsening pulmonary edema on the floor, most\n likely etiology respiratory arrest w/ mucous plug. No further events\n since admission to ICU, although continues to have episodes of apnea\n while on PS.\n - treat underlying cause of PNA, provide respiratory support with\n ventilator for now\n - no troponins were drawn, so unclear if primary process is cardiac,\n however CK-MBs were flat so unlikely that acute ischemic event\n - continue to trend lactate\n - monitor on telemetry, patient appears to be hemodynamically stable\n .\n # Hypercarbic Respiratory Failure: S/p intubation x2. Hypercarbic\n likely to arrest d/t pulmonary etiology (mucus plugging, apneic\n period). Overnight with significant secretions needing frequent\n suctioning. Will continue to wean as tolerated to PS although not ready\n for extubation. Will discuss goals of care with niece this morning\n (extubation, trach placement etc.)\n - Wean FIO2 as tolerated, to PS\n - weak cough, no gag per RT\n - suction prn, nebs prn\n - -d/w family re: trach\n .\n # HAP/Aspiration PNA/sepsis: Patient on broad spectrum coverage since\n admission, has grown GPC pairs/clusters in sputum and E.coli in blood\n and urine. CT from showed persistent RLL infiltrate. CBC showing\n new bands on diff in setting of code.\n - continue vanc/levo/flagyl, patient currently on day 11 of ABX, (3\n more days)\n - sputum from - GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND\n CLUSTERS.\n RESPIRATORY CULTURE (Preliminary): NO GROWTH.\n- only positive blood culture so far from - ESCHERICHIA COLI\n |\nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 4 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCEFUROXIME------------ 4 S\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n .\n # Urosepsis: E.coli bacteremia, and e.coli/providencia UTI. Repeat\n cultures have been negative. Has been on amikacin, last day .\n - f/u amikacin levels this morning\n .\n # Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6, currently\n on CVVH. Likely prerenal in etiology secondary to episode of\n hypoperfusion.\n - suspect that some of renal failure is likely due to poor forward flow\n and patient looks volume overloaded by physical exam\n - trend creatinine\n - goal I/O is negative 1 liter per day, would give lasix as\n needed to achieve this\n .\n # Hypertension: On lisinopril, metoprolol as outpatient\n - restart lisinopril today, uptitrate as tolerated\n .\n # Dementia: Currently intubated without need for sedative medications\n - continue namenda and aricept\n - suspect that only only is there a component of dementia but\n also a component of acute cerebral insult secondary to cardiopulmonary\n arrest that has likely\n .\n FEN: tubes feeds, monitor electrolytes, repleted K aggressively this\n morning for K of 2.6\n .\n # Prophylaxis: SC heparin, d/c bowel regimen in the setting of\n persistent diarrhea, PPI\n .\n # Communcation: Sister , will decide on trach in\n the morning\n .\n # Code: FC - plan to reassess with sister, suspect that this is likely\n inappropriate in this context\n .\n # Disposition: ICU care for now\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:32 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:15 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": "2192-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343947, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor (transferred there )\n after cardiopulmonary resuscitation for pulselessness at 0400 on .\n Code blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated. Likely respiratory related arrest as rapid return to\n circulation with intubation and only single dose of EPI; ?mucus plug\n and hypoxemic respiratory failure. She has ongoing findings consistent\n with persistent peumonia and pneumonitis in the RML and RLL\n distribution. Transferred to ICU for further management\n Code status and plan of care was to be determined by hcp today, however\n no family members came. MD called and restated that family mtg needs to\n occur to make decisions re: goals of care.\n Altered mental status (not Delirium)\n Assessment:\n Unarousable except to deep painful stimuli. Responds by posturing.\n Frequent periods of apnea. Very impaired gag. Neurological exam\n markedly compromised.\n Action:\n Head CT today.\n Response:\n Showed no acute changes however multiple areas of previous bleeds,\n infarcts.\n Plan:\n Discuss Plan of care with HCP tomorrow at 11:30 AM.\n Electrolyte & fluid disorder, other\n Assessment:\n + pitting edema.\n Action:\n Lasix 40 mg iv given\n Response:\n Good hourly uop. Goal to be 500-1000mL negative. Currently\n negative.\n Plan:\n Remain negative. lytes and repletion prn.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Placed back on CPAP today after being placed on CMV overnight for\n frequent apneic periods. Low grade temp. LS rhoncorous bilaterally.\n Moderate amt secretions noted. Copious amounts of oral and nasal\n secretions. No gag.\n Action:\n Suctioned frequently, abx as ordered.\n Response:\n Unchanged.\n Plan:\n Continue w/ pulmonary toilet, antibiotic\n" }, { "category": "Physician ", "chartdate": "2192-08-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 344106, "text": "Chief Complaint: 82 year old female with h/o breast ca, cva, htn, who\n initially presented with urosepsis and pneumonia then transferred out\n of the unit, re-transferred after PEA arrest on the floor without\n significant improvement in mental status.\n 24 Hour Events:\n Family meeting was suppose to happen yesterday and did not. Plan for\n family meeting today. Patient went for head CT without incident.\n Started on scopolamine patch to decrease secretions. also started on\n tca as well. Goal yesterday was -500-1L negative. This morning, RT\n said that patient more tachypneic. CT head showed no evidence of acute\n infarct. Family meeting this morning decided that plan to extubate\n tomorrow morning so give family time to say goodbye.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:27 AM\n Amikacin - 08:39 AM\n Metronidazole - 12:30 PM\n Levofloxacin - 06:10 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:45 AM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 06:50 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: 37.2\nC (99\n HR: 88 (64 - 88) bpm\n BP: 171/71(97) {133/55(77) - 171/72(97)} mmHg\n RR: 30 (14 - 35) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 1,846 mL\n 135 mL\n PO:\n TF:\n 876 mL\n IVF:\n 640 mL\n 65 mL\n Blood products:\n Total out:\n 2,440 mL\n 190 mL\n Urine:\n 2,440 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n -594 mL\n -55 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 360 (360 - 360) mL\n Vt (Spontaneous): 319 (260 - 385) mL\n PS : 12 cmH2O\n RR (Spontaneous): 36\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 328\n SpO2: 99%\n ABG: 7.47/47/65/32/8\n Ve: 9.8 L/min\n PaO2 / FiO2: 163\n Physical Examination\n General Appearance: tachypneic\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Diminished: at bases bilaterally,\n Rhonchorous: right upper lobe)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: patient not on any sedating medications, does not respond\n to verbal or physical stimuli, no spontaneous movement appreciated\n Labs / Radiology\n 781 K/uL\n 8.3 g/dL\n 148 mg/dL\n 1.0 mg/dL\n 32 mEq/L\n 4.4 mEq/L\n 15 mg/dL\n 102 mEq/L\n 138 mEq/L\n 25.9 %\n 18.4 K/uL\n [image002.jpg]\n 02:07 AM\n 04:35 AM\n 05:32 AM\n 04:12 AM\n 08:43 AM\n 02:53 PM\n 05:54 AM\n 04:28 PM\n 04:00 AM\n 05:08 AM\n WBC\n 16.1\n 15.7\n 15.4\n 18.4\n Hct\n 22.5\n 23.4\n 24.9\n 25.9\n Plt\n 583\n 548\n 666\n 781\n Cr\n 1.1\n 1.1\n 1.0\n 1.1\n 1.0\n 1.0\n TropT\n 0.10\n TCO2\n 27\n 28\n 35\n Glucose\n 2\n 150\n 148\n Other labs: PT / PTT / INR:15.3/27.6/1.4, CK / CKMB /\n Troponin-T:37/3/0.10, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:1.2 mmol/L, Albumin:2.5 g/dL, LDH:256 IU/L, Ca++:7.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after likely PEA arrest now\n with worsening mental status than on previous transfer now 48 hours\n after the event.\n # Cardiopulmomary Arrest: Patient found pulseless, ashen, and cool,\n down for no longer than 10 minutes. Patient not monitored on telemetry\n at the time of the event. She quickly regained rhythm after intubation\n and 1gm epinephrine w/ CPR. In the setting of underlying RLL\n infiltrate, concern for worsening pulmonary edema on the floor, most\n likely etiology respiratory arrest w/ mucous plug. No further events\n since admission to ICU, although continues to have episodes of apnea\n while on PS.\n - treat underlying cause of PNA, provide respiratory support with\n ventilator for now\n - trend lactate\n - monitor on telemetry, patient appears to be hemodynamically stable\n -CT head to evaluate for any acute insults that may be causing her\n apneic periods - CT head done no official read uet\n # Hypercarbic Respiratory Failure: S/p intubation x2. Hypercarbic\n likely to arrest d/t pulmonary etiology (mucus plugging, apneic\n period). Started on scopolamine patch yesterday for secretions. still\n requiring frequent suctioning. Currently tachypneic and likely not\n candidate for extubation today. Will discuss goals of care with niece\n this morning (extubation, trach placement etc.)\n - outline goals of care\n - Wean FIO2 as tolerated, to PS as tolerate\n - weak cough, no gag per RT\n - suction prn, nebs prn\n # HAP/Aspiration PNA/sepsis: Patient on broad spectrum coverage since\n admission, has grown GPC pairs/clusters in sputum and E.coli in blood\n and urine. CT from showed persistent RLL infiltrate. CBC showing\n new bands on diff in setting of code.\n - continue vanc/levo/flagyl patient currently on day 12 of ABX, (2 more\n days)\n - sputum from - GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND\n CLUSTERS.\n RESPIRATORY CULTURE (Preliminary): NO GROWTH.\n .- only positive blood culture so far from - ESCHERICHIA COLI\n |\n AMPICILLIN------------ =>32 R\n AMPICILLIN/SULBACTAM-- 4 S\n CEFAZOLIN------------- <=4 S\n CEFEPIME-------------- <=1 S\n CEFTAZIDIME----------- <=1 S\n CEFTRIAXONE----------- <=1 S\n CEFUROXIME------------ 4 S\n CIPROFLOXACIN--------- =>4 R\n GENTAMICIN------------ <=1 S\n MEROPENEM-------------<=0.25 S\n PIPERACILLIN/TAZO----- <=4 S\n TOBRAMYCIN------------ <=1 S\n TRIMETHOPRIM/SULFA---- <=1 S\n .\n # Urosepsis: E.coli bacteremia, and e.coli/providencia UTI. Repeat\n cultures have been negative. Has been on amikacin, last day .\n - amikacin levels from are still pending\n .\n # Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6 currently\n 1.0 appears to be improving with some diuresis. likely relative\n hypoperfusion.\n - suspect that some of renal failure is likely due to poor forward flow\n and patient looks volume overloaded by physical exam\n - trend creatinine\n - goal I/O is negative 1 liter per day, would give lasix as needed to\n achieve this (40 IV yesterday => -500 cc)\n - will start with 40 IV lasix this morning and then check afternoon\n # Hypertension: On lisinopril, metoprolol as outpatient\n - increase lisinopril today to 10\n - lasix 40mg IV qd, monitor UOP\n - metoprolol 100 mg PO TID\n .# Dementia: Currently intubated without need for sedative\n medications. No evidence of acute infarct on CT however suspect global\n anoxia as metabolic insult.\n - d/c namenda and aricept as likely not helpful anymore\n -\n FEN: tubes feeds, monitor electrolytes, repleted K aggressively this\n morning for K of 2.6, K now 4.4\n # Prophylaxis: SC heparin, d/c bowel regimen in the setting of\n persistent diarrhea, PPI\n .\n # Communcation: Sister .\n # Code: Plan for extubation tomorrow to allow family to come. Now\n DNR/DNI.\n .\n # Disposition: ICU care for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:15 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": "2192-08-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 343841, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 03:08 PM\n -40mg IV lasix with good urine output (approx 500cc)\n -medications changed to PO if possible to avoid excess urine, decreased\n free water flushes with TFs\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 06:19 PM\n Vancomycin - 08:00 AM\n Metronidazole - 09:06 PM\n Amikacin - 09:07 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 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: 37.2\nC (98.9\n HR: 73 (57 - 78) bpm\n BP: 144/58(81) {128/51(71) - 165/71(96)} mmHg\n RR: 15 (11 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 2,294 mL\n 358 mL\n PO:\n TF:\n 324 mL\n 238 mL\n IVF:\n 1,400 mL\n 71 mL\n Blood products:\n Total out:\n 2,400 mL\n 790 mL\n Urine:\n 2,400 mL\n 790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -106 mL\n -432 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 430 (319 - 480) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 3\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 18 cmH2O\n Plateau: 16 cmH2O\n SpO2: 100%\n ABG: ///32/\n Ve: 7.3 L/min\n Physical Examination\n GEN: Intubated, sedated\n HEENT: NCAT MMM anicteric pale conjunctiva\n CV: RRR S1S2\n PULM: rhonchi at mid-lung fields, likely intubation otherwise clear\n while supine\n ABD: soft, distended, nontender +bs no palp masses\n EXT: WWP 1+ bipedal edema 1+dp pulses no cyanosis\n SKIN: no new lesions, rashes noted\n Labs / Radiology\n 666 K/uL\n 8.0 g/dL\n 152 mg/dL\n 1.1 mg/dL\n 32 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 102 mEq/L\n 138 mEq/L\n 24.9 %\n 15.4 K/uL\n [image002.jpg]\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n 04:35 AM\n 05:32 AM\n 04:12 AM\n 08:43 AM\n 02:53 PM\n 05:54 AM\n WBC\n 24.0\n 26.1\n 16.1\n 15.7\n 15.4\n Hct\n 26.1\n 28.7\n 22.5\n 23.4\n 24.9\n Plt\n 195\n 312\n 583\n 548\n 666\n Cr\n 0.9\n 0.9\n 1.1\n 1.1\n 1.0\n 1.1\n TropT\n 0.10\n TCO2\n 28\n 27\n 28\n Glucose\n 141\n 69\n 216\n 83\n 105\n 152\n Other labs: PT / PTT / INR:15.5/27.6/1.4, CK / CKMB /\n Troponin-T:37/3/0.10, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:1.0 mmol/L, Albumin:2.3 g/dL, LDH:256 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:32 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:15 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": "2192-08-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 343842, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 03:08 PM\n -40mg IV lasix with good urine output (approx 500cc)\n -medications changed to PO if possible to avoid excess urine, decreased\n free water flushes with TFs\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 06:19 PM\n Vancomycin - 08:00 AM\n Metronidazole - 09:06 PM\n Amikacin - 09:07 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 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: 37.2\nC (98.9\n HR: 73 (57 - 78) bpm\n BP: 144/58(81) {128/51(71) - 165/71(96)} mmHg\n RR: 15 (11 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 2,294 mL\n 358 mL\n PO:\n TF:\n 324 mL\n 238 mL\n IVF:\n 1,400 mL\n 71 mL\n Blood products:\n Total out:\n 2,400 mL\n 790 mL\n Urine:\n 2,400 mL\n 790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -106 mL\n -432 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 430 (319 - 480) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 3\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 18 cmH2O\n Plateau: 16 cmH2O\n SpO2: 100%\n ABG: ///32/\n Ve: 7.3 L/min\n Physical Examination\n GEN: Intubated, sedated\n HEENT: NCAT MMM anicteric pale conjunctiva\n CV: RRR S1S2\n PULM: rhonchi at mid-lung fields, likely intubation otherwise clear\n while supine\n ABD: soft, distended, nontender +bs no palp masses\n EXT: WWP 1+ bipedal edema 1+dp pulses no cyanosis\n SKIN: no new lesions, rashes noted\n Labs / Radiology\n 666 K/uL\n 8.0 g/dL\n 152 mg/dL\n 1.1 mg/dL\n 32 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 102 mEq/L\n 138 mEq/L\n 24.9 %\n 15.4 K/uL\n [image002.jpg]\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n 04:35 AM\n 05:32 AM\n 04:12 AM\n 08:43 AM\n 02:53 PM\n 05:54 AM\n WBC\n 24.0\n 26.1\n 16.1\n 15.7\n 15.4\n Hct\n 26.1\n 28.7\n 22.5\n 23.4\n 24.9\n Plt\n 195\n 312\n 583\n 548\n 666\n Cr\n 0.9\n 0.9\n 1.1\n 1.1\n 1.0\n 1.1\n TropT\n 0.10\n TCO2\n 28\n 27\n 28\n Glucose\n 141\n 69\n 216\n 83\n 105\n 152\n Other labs: PT / PTT / INR:15.5/27.6/1.4, CK / CKMB /\n Troponin-T:37/3/0.10, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:1.0 mmol/L, Albumin:2.3 g/dL, LDH:256 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after likely PEA arrest now\n with worsening mental status than on previous transfer now 48 hours\n after the event.\n # Cardiopulmomary Arrest: Patient found pulseless, ashen, and cool,\n down for no longer than 10 minutes. Patient not monitored on telemetry\n at the time of the event. She quickly regained rhythm after intubation\n and 1gm epinephrine w/ CPR. In the setting of underlying RLL\n infiltrate, concern for worsening pulmonary edema on the floor, most\n likely etiology respiratory arrest w/ mucous plug. No further events\n since admission to ICU, although continues to have episodes of apnea\n while on PS.\n - treat underlying cause of PNA, provide respiratory support with\n ventilator for now\n - no troponins were drawn, so unclear if primary process is cardiac,\n however CK-MBs were flat so unlikely that acute ischemic event\n - continue to trend lactate\n - monitor on telemetry, patient appears to be hemodynamically stable\n .\n # Hypercarbic Respiratory Failure: S/p intubation x2. Hypercarbic\n likely to arrest d/t pulmonary etiology (mucus plugging, apneic\n period). Overnight with significant secretions needing frequent\n suctioning. Will continue to wean as tolerated to PS although not ready\n for extubation. Will discuss goals of care with niece this morning\n (extubation, trach placement etc.)\n - Wean FIO2 as tolerated, to PS\n - weak cough, no gag per RT\n .\n # HAP/Aspiration PNA/sepsis: Patient on broad spectrum coverage since\n admission. CT from showed persistent RLL infiltrate. CBC showing\n new bands on diff in setting of code.\n - continue vanc/levo/flagyl, patient currently on day 10 of ABX, but\n given poor clinical response will continue for additional 4 days\n - sputum from - GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND\n CLUSTERS.\n RESPIRATORY CULTURE (Preliminary): NO GROWTH.\n- only positive blood culture so far from - ESCHERICHIA COLI\n |\nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 4 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCEFUROXIME------------ 4 S\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n .\n # Urosepsis: W. e.coli bacteremia, and e.coli/providencia UTI. Repeat\n cultures have been negative. Has been on appropriate abx since ,\n will plan for 7 day course from this date.\n - continue amikacin, f/u send out level\n .\n # Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6, still\n currently 1.1. Had been >2 on initial presentation and was improving\n prior to arrest. Likely prerenal in etiology secondary to episode of\n hypoperfusion.\n - suspect that some of renal failure is likely due to poor forward flow\n and patient looks volume overloaded by physical exam\n - trend creatinine\n - goal I/O is negative 1 liter per day, would give lasix as\n needed to achieve this\n .\n # Hypertension: On lisinopril, metoprolol as outpatient\n - restart lisinopril today, uptitrate as tolerated\n .\n # Dementia: Currently intubated without need for sedative medications\n - continue namenda and aricept\n - suspect that only only is there a component of dementia but\n also a component of acute cerebral insult secondary to cardiopulmonary\n arrest that has likely\n .\n FEN: tubes feeds, monitor electrolytes, repleted K aggressively this\n morning for K of 2.6\n .\n # Prophylaxis: SC heparin, d/c bowel regimen in the setting of\n persistent diarrhea, PPI\n .\n # Communcation: Sister , will decide on trach in\n the morning\n .\n # Code: FC - plan to reassess with sister, suspect that this is likely\n inappropriate in this context\n .\n # Disposition: ICU care for now\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:32 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2192-08-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 344171, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 59 None\n Ideal tidal volume: 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: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\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 has been on PSV for several days but today became tachypneic to\n greater than 40, requiring increased PSV. Later she had several periods\n of apnea and low minute volume alarms (? Hyperventilation with\n increased PSV). Attempt PSV again in AM.\n" }, { "category": "Nursing", "chartdate": "2192-08-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 344203, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor (transferred there )\n after cardiopulmonary resuscitation for pulselessness at 0400 on .\n Code blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated. Likely respiratory related arrest as rapid return to\n circulation with intubation and only single dose of EPI; ?mucus plug\n and hypoxemic respiratory failure. She has ongoing findings consistent\n with persistent peumonia and pneumonitis in the RML and RLL\n distribution. Transferred to ICU for further management\n Family meeting today to discuss goals of care. After discussing the\n high likelihood that pt would not recover from massive insult with Dr.\n , the family decided that they would withdraw care\n tomorrow in AM including extubation.\n -Pt\ns nephew (mother is pt\ns HCP) called tonight and spoke with Dr.\n and plan to wait until afternoon as pt\ns sister was not at family\n meeting.\n Altered mental status (not Delirium)\n Assessment:\n Pt unarousable. Does not have any spontaneous movement however\n grimaces slight with nursing care. Tears noted in pt\ns eyes with\n nursing care. PERRL and pt slightly closes eyes with light.\n Action:\n Turned Q 2-3 hours. Neuro checks Q 4 hours.\n Response:\n Pt remains unresponsive to stimulation. No movements.\n Plan:\n Pt to be CMO and terminally extubated tomorrow.\n" }, { "category": "Physician ", "chartdate": "2192-08-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 343464, "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 -Patient to medcial floor this w/e\n -Nursing check un-eventful\n -10 minutes later patient found pulseless and apneic\n -Initial rhythm upon return was junctional bradycardia.\n -As prodrome patient had low grade fever but otherwise was without\n significant events\n 24 Hour Events:\n MULTI LUMEN - START 05:19 AM\n INVASIVE VENTILATION - START 05:20 AM\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Amikacin - 08:04 AM\n Vancomycin - 08:28 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:01 AM\n Pantoprazole (Protonix) - 08:04 AM\n Heparin Sodium (Prophylaxis) - 08:04 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: Fever\n Nutritional Support: NPO\n Heme / Lymph: Anemia\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 08:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 71 (71 - 117) bpm\n BP: 145/55(76) {99/47(58) - 145/104(109)} mmHg\n RR: 16 (16 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Mixed Venous O2% Sat: 87 - 87\n Total In:\n 396 mL\n PO:\n 50 mL\n TF:\n IVF:\n 346 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 176 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 100%\n ABG: 7.43/41/276/22/3\n Ve: 7.7 L/min\n PaO2 / FiO2: 552\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : R>L, Diminished: right base, Rhonchorous:\n R>L)\n Resistance=7cm H2O/l/sec\n Compliance=40cc/cmH20\n Abdominal: Soft, Non-tender, No(t) Distended\n Extremities: Right: 1+, Left: 1+\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\nwithdraws to pain in all extremities, she has intact\n corneal reflexes but pin-point and minimal reactive pupils\n Labs / Radiology\n 9.4 g/dL\n 312 K/uL\n 216 mg/dL\n 1.1 mg/dL\n 22 mEq/L\n 4.7 mEq/L\n 12 mg/dL\n 103 mEq/L\n 140 mEq/L\n 28.7 %\n 26.1 K/uL\n [image002.jpg]\n 07:59 PM\n 03:58 AM\n 05:43 PM\n 08:36 PM\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n 04:35 AM\n 05:32 AM\n WBC\n 22.8\n 24.0\n 26.1\n Hct\n 26.8\n 26.1\n 28.7\n Plt\n 133\n 195\n 312\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n 0.9\n 1.1\n TCO2\n 24\n 28\n 27\n 28\n Glucose\n 61\n 90\n 104\n 141\n 69\n 216\n Other labs: PT / PTT / INR:15.7/37.7/1.4, CK / CKMB /\n Troponin-T:32/2/0.14, ALT / AST:13/18, Alk Phos / T Bili:108/0.3,\n Differential-Neuts:83.0 %, Band:3.0 %, Lymph:8.0 %, Mono:5.0 %, Eos:0.0\n %, Fibrinogen:661 mg/dL, Lactic Acid:4.6 mmol/L, Albumin:2.5 g/dL,\n LDH:161 IU/L, Ca++:7.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.3 mg/dL\n Fluid analysis / Other labs: 7.43/41/76\n Imaging: CXR-right sided infiltrate largely unchanged with peri-hilar\n fullness noted and LL infiltrate unchanged\n CT Scan -Right sided RML and RLL consolidation without\n endobronchial lesion.\n Microbiology: Sparse oral flora on sputum most recently\n Assessment and Plan\n 82 yo female with h/o breast CA with recent MICU admission and\n prolonged respiratory failure. She was transferred to medical floor\n extubated. Now patient found pulseless and apneic and had intubation\n and initial rhythm junctional and had rapid response to ACLS protocol.\n Upon intubation patient had minimal secretions and minimal evidence of\n bronchospasm. Intubation was completed without sedation required.\n This was fundamentally a hypercarbic respiratory arrest based upon ABG\n but antecedent history is hard to define as patient was found apneic\n and pulseless. She does have antecedent fever, rising WBC count and\n bandemia on CBC. Is likely respiratory related arrest with rapid\n return to circulation with intubation and only single dose of EPI. \n well be mucus plug and hypoxemic respiratory failure. She has ongoing\n findings consistent with persistent peumonia and pneumonitis in the RML\n and RLL distribution.\n 1)Acute Respiratory Failure-Do not see clear new overwhelming insult\n and ventilatory mechanics are reassuring\n -Pneumonia-\n Vanco/Levo/Flagyl x10 days is completed, continue for 2 week course\n total\n Will need to continue to follow CT scan to clearance of region because\n it is not completely typical for acute pneumonia in persistence\n -Hypercarbic Respiratory Failure-\n Change to PSV and attempt to wean\n Goal PCO2=40-45\n If ongoing aggressive measures are desired she will need trach to\n continue safe and effective care\n 1.5)Altered Mental Status-\n -Continue Namenda/Aricept\n -Repeat neuro exam\n 2)Leukocytosis-\n -Will check C. Diff\n -Continue to Rx pulmonary source for 4 days\n -Providencia has been treated with Amikacin\n -F/U Blood cultures\n 3)Acute Renal Failure-\n -Assure hydration\n -Minimize offending agents\n ICU Care\n Nutrition: npo\n Glycemic Control: Sliding Scale Insulin\n Lines:\n Multi Lumen - 05:19 AM\nhas been in since previous admission\n to ICU\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\nwill need to clarify future goals of care with\n sister\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2192-08-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 343465, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:19 AM\n -found to be pulseless on medicine , bradycardic. ABG\n 7.12/70/90/24\n -b/l rales on exam, 40mg IV lasix- UOP to 200cc but improvement on exam\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:37 AM\n Amikacin - 08:37 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:01 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 06:09 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: 37.7\nC (99.8\n HR: 83 (83 - 117) bpm\n BP: 99/47(58) {99/47(58) - 129/104(109)} mmHg\n RR: 16 (16 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Mixed Venous O2% Sat: 87 - 87\n Total In:\n 11 mL\n PO:\n TF:\n IVF:\n 11 mL\n Blood products:\n Total out:\n 0 mL\n 120 mL\n Urine:\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -109 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.43/41/276/22/3, lactate 3.8\n Ve: 9.9 L/min\n PaO2 / FiO2: 276\n Physical Examination\n GEN: intubated, sedated\n HEENT: anicteric, MMD, pale conjunctiva\n CV: RRR S1S2 no m/r/g no JVD\n PULM: Crackles at bilateral bases, scant rales otherwise good air flow\n ABD: soft NT, ND +bs\n GU: foley draining clear urine\n EXT: WWP 2+ radial pulses, 1+dp pulses, no cyanosis\n SKIN: bruising, scratches on R wrist; healing scars on R shoulder, no\n rashes, petechiae\n Labs / Radiology\n 312 K/uL\n 9.4 g/dL\n 216 mg/dL\n 1.1 mg/dL\n 22 mEq/L\n 4.7 mEq/L\n 12 mg/dL\n 103 mEq/L\n 140 mEq/L\n 28.7 %\n 26.1 K/uL\n [image002.jpg]\n 07:59 PM\n 03:58 AM\n 05:43 PM\n 08:36 PM\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n 04:35 AM\n 05:32 AM\n WBC\n 22.8\n 24.0\n 26.1\n Hct\n 26.8\n 26.1\n 28.7\n Plt\n 133\n 195\n 312\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n 0.9\n 1.1\n TCO2\n 24\n 28\n 27\n 28\n Glucose\n 61\n 90\n 104\n 141\n 69\n 216\n Other labs: PT / PTT / INR:15.7/37.7/1.4, CK / CKMB /\n Troponin-T:32/4/0.14, ALT / AST:13/18, Alk Phos / T Bili:108/0.3,\n Differential-Neuts:83.0 %, Band:3.0 %, Lymph:8.0 %, Mono:5.0 %, Eos:0.0\n %, Fibrinogen:661 mg/dL, Lactic Acid:4.6 mmol/L, Albumin:2.5 g/dL,\n LDH:161 IU/L, Ca++:7.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after cardiopulmonary\n resuscitation for pulselessness.\n .\n # Cardiopulmonary Arrest: Given the fact that patient quickly regained\n rhythm/pulse after intubation and 1gm epinephrine w/ CPR and in setting\n of underlying RLL infiltrate, concern for worsening pulmonary edema on\n the floor, most likely etiology respiratory arrest w/ mucous plug.\n There were no changes on EKG to support a cardiac origin of the arrest.\n -support with ventilation\n - treat underlying cause of PNA\n -IVF as needed\n - monitor on telemetry\n .\n # Hypercarbic Respiratory Failure: Patient essentially failed\n extubation trial since . Now s/p intubation with resolution in\n hypercarbia, no evidence of hypoxia. Likely etiology is mucus plug and\n pulmonary edema as above, leading to CPA. Mucus plug could have been\n dislodged during intubation which would speak to her rapid recovery\n post-intubation (as opposed to a cardiac origin). Given 40mg IV lasix\n with mild increase in urine output but significant improvement on lung\n exam. Today will work on wean oxygen as tolerated.\n - continue on AC and wean FIO2 today, try PS as tolerated\n - follow ABGs, lactate\n - f/u CXR\n - suction, nebs prn\n .\n # HAP Aspiration PNA: Patient on broad spectrum coverage since\n admission. CT from showed persistent RLL infiltrate.\n - continue vanc/levo/flagyl, patient currently on day 10 of ABX, but\n given poor clinical response will continue for additional 4 days. Also\n would benefit from bronchoscopy to further evaluate infectious\n etiology. Patient is at high risk of aspiration as well given her\n history of CVA and baseline mental status.\n - f/u pending cultures\n - consider bronchoscopy\n - repeat sputum and blood cultures\n .\n # Urosepsis: E.coli bacteremia, and E.coli/providencia UTI. Repeat\n cultures have been negative. Has been on appropriate antibiotics since\n , will plan for 2 week course from this date.\n - continue amikacin to complete course, f/u send out level\n .\n # Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6. Had been\n >2 on initial presentation and was improving prior to arrest. Likely\n prerenal in etiology secondary to episode of hypoprofusion.\n - IVF boluses to maintain urine output\n - trend creatinine\n .\n # Hypertension: Pt with hypotensive episode initially, held\n metoprolol.\n - restart metoprolol as tolerated\n - hold lisinopril\n .\n # Dementia: Currently intubated without need for sedative medications\n - continue namenda and aricept\n .\n # FEN: IVF as above, monitor electrolytes, NGT in place so will start\n tube feeds this am\n .\n # Prophylaxis: SC heparin, bowel regimen, PPI\n .\n # Communcation: Sister \n .\n # Code: FC\n .\n # Disposition: ICU care for now, possible c/o to floor tomorrow\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:19 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": "2192-08-27 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 343469, "text": "Chief Complaint: Cardiopulmonary arrest\n HPI:\n Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension with recent MICU admission from - \n who was found pulseless on the medical floor and code blue was called.\n Nursing checked on patient 10 minutes prior to being found pulseless,\n ashen, and cool. Patient was not on telemetry on the floor. Code blue\n was called and CPR was initiated without use of drugs, no significant\n secretions returned from ET tube. Patient was intubated. First rhythm\n obtained demonstrated junctional bradycardia at 20-30 bpm. Epinephrine\n 1mg was infused and CPR continued for one minute when patient was found\n to have a pulse at rate 160 bpm and SBP 220/120. Patient then received\n 5mg IV lopressor with rhythm of sinus tachycardia at 130 and SBP 200.\n Patient was transferred to the for further monitoring.\n .\n On admission, she presented from after being found to be\n in respiratory distress with oxygen saturations in the 70s to 80s on\n room air. She was intubated and started on broad-spectrum antibiotics.\n She was found to have e. coli bacteremia/urosepsis, providencia UTI,\n and RLL PNA. Patient was able to be extubated on . She has\n received 10 days of antibitoic coverage for HAP and aspiration with\n vancomycin/levo/flagyl and amikacin for resistant providencia in the\n urine.\n .\n In the interval, patient was febrile at 6PM the evening prior to the\n code to 100.6 and blood cultures were sent. Metoprolol had been\n increased to 100mg TID from 75mg TID.\n Patient admitted from: \n History obtained from Medical records, Hospitalist\n Patient unable to provide history: Unresponsive, poor baseline MS\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Amikacin - 08:04 AM\n Vancomycin - 08:28 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:01 AM\n Pantoprazole (Protonix) - 08:04 AM\n Heparin Sodium (Prophylaxis) - 08:04 AM\n Other medications:\n On transfer\n Pantoprazole 40 mg IV daily\n Calcium carbonate 500mg TID w/meals\n Namenda 10 mg \n Tylenol 650 mg Q6H:PRN\n Aricept 10 mg QHS\n levofloxacin 750mg Q48H\n Vancomycin 1000mg IV Q24H\n Metoprolol 100mg TID\n Flagyl 500mg IV Q8H\n Amikacin 500mh Q12H\n lisinopril 10mg daily\n heparin SC TID\n Mag Ox SS\n Past medical history:\n Family history:\n Social History:\n 1. Hypokalemia.\n 2. Breast cancer, status post radiation therapy with\n lumpectomy in .\n 3. Cerebrovascular accident.\n 4. History of falls.\n 5. Arthritis.\n 6. Status post hysterectomy.\n 7. Hypertension.\n 8. Recurrent urinary tract infections.\n 9. Cardiomegaly seen on chest x-ray.\n 10. Osteoporosis.\n Unable to obtain.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Comes from . Previously drank socially but no\n longer. No tobacco. No IVDU.\n Review of systems: pt non-responsive, unable to assess\n Flowsheet Data as of 09:33 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: 37.7\nC (99.8\n HR: 68 (68 - 117) bpm\n BP: 141/57(77) {99/47(58) - 145/104(109)} mmHg\n RR: 11 (11 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Mixed Venous O2% Sat: 87 - 87\n Total In:\n 405 mL\n PO:\n 50 mL\n TF:\n IVF:\n 355 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 185 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 100%\n ABG: 7.43/41/276/22/3\n Ve: 7.7 L/min\n PaO2 / FiO2: 552\n Physical Examination\n Vitals: T: 99.8 HR:117 BP: 124/104 RR: 25 O2:100% on AC 500/16/5/100%\n FiO2\n General: Intubated, minimally responsive, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: RIJ in place\n CV: tachycardia, s1 + s2, no mumurs, rubs, gallops\n Chest: Diffuse ronchi and crackles right > left, decreased Bs at right\n base\n GI: Soft, non-tender, non-distended, +BS\n GU: Foley draining dark urine\n Ext: WWP, 1+ b/l LE edema, 2+ pulses\n Neuro: Non-verbal, Pupils pinpoint, mild reactive b/l, + corneal reflex\n on left, minimal gag, withdrawing to pain in b/l LE, babinski unable to\n assess pt withdrawing, opens eyes to painful stimuli\n Labs / Radiology\n 312 K/uL\n 9.4 g/dL\n 216 mg/dL\n 1.1 mg/dL\n 12 mg/dL\n 22 mEq/L\n 103 mEq/L\n 4.7 mEq/L\n 140 mEq/L\n 28.7 %\n 26.1 K/uL\n [image002.jpg]\n \n 2:33 A9/17/ 07:59 PM\n \n 10:20 P9/18/ 03:58 AM\n \n 1:20 P9/18/ 05:43 PM\n \n 11:50 P9/18/ 08:36 PM\n \n 1:20 A9/19/ 03:46 AM\n \n 7:20 P9/19/ 09:00 PM\n 1//11/006\n 1:23 P9/20/ 01:47 AM\n \n 1:20 P9/20/ 02:07 AM\n \n 11:20 P9/22/ 04:35 AM\n \n 4:20 P9/22/ 05:32 AM\n WBC\n 22.8\n 24.0\n 26.1\n Hct\n 26.8\n 26.1\n 28.7\n Plt\n 133\n 195\n 312\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n 0.9\n 1.1\n TC02\n 24\n 28\n 27\n 28\n Glucose\n 61\n 90\n 104\n 141\n 69\n 216\n Other labs: PT / PTT / INR:15.7/37.7/1.4, CK / CKMB /\n Troponin-T:32/2/0.14, ALT / AST:13/18, Alk Phos / T Bili:108/0.3,\n Differential-Neuts:83.0 %, Band:3.0 %, Lymph:8.0 %, Mono:5.0 %, Eos:0.0\n %, Fibrinogen:661 mg/dL, Lactic Acid:4.6 mmol/L, Albumin:2.5 g/dL,\n LDH:161 IU/L, Ca++:7.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.3 mg/dL\n Imaging: CXR: improved b/l pleural effusion, RLL infiltrate\n unchanged as compared w/ , ETT 3cm above carina\n .\n CT chest :\n IMPRESSION:\n 1. Right lower lobe pneumonia. Multiple ground glass and tree-in-\n opacities in the right lower lobe and right middle lobe, which are\n likely related to ongoing infectious/inflammatory process, however\n follow-up after appropriate therapy is recommended as neoplastic\n process is not entirely excluded.\n 2. Small bilateral pleural effusions, right greater than left. Left\n lower lobe subsegmental atelectasis.\n 3. Indeterminate right adrenal nodule, unchanged from .\n .\n CT HEAD:\n IMPRESSION:\n 1. No hemorrhage.\n 2. Partial opacification of the mastoid air cells, left greater than\n right.\n Microbiology: Blood Culture, Routine (Final ):\n ESCHERICHIA COLI. OF TWO COLONIAL MORPHOLOGIES.\n FINAL SENSITIVITIES.\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n ESCHERICHIA COLI\n |\n AMPICILLIN------------ =>32 R\n AMPICILLIN/SULBACTAM-- 4 S\n CEFAZOLIN------------- <=4 S\n CEFEPIME-------------- <=1 S\n CEFTAZIDIME----------- <=1 S\n CEFTRIAXONE----------- <=1 S\n CEFUROXIME------------ 4 S\n CIPROFLOXACIN--------- =>4 R\n GENTAMICIN------------ <=1 S\n MEROPENEM-------------<=0.25 S\n PIPERACILLIN/TAZO----- <=4 S\n TOBRAMYCIN------------ <=1 S\n TRIMETHOPRIM/SULFA---- <=1 S\n 1:50 pm URINE Source: Catheter.\n ECOLI: AZTREONAM <= 1MCG/ML = SENSITIVE.\n PROV.STUARTI: AZTREONAM <= 1 MCG/ML = SENSITIVE.\n **FINAL REPORT **\n URINE CULTURE (Final ):\n ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..\n PRESUMPTIVE IDENTIFICATION.\n PROVIDENCIA STUARTII. 10,000-100,000 ORGANISMS/ML..\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n ESCHERICHIA COLI\n | PROVIDENCIA STUARTII\n | |\n AMIKACIN-------------- <=2 S\n AMPICILLIN------------ 16 I\n AMPICILLIN/SULBACTAM-- 4 S\n CEFAZOLIN------------- <=4 S\n CEFEPIME-------------- <=1 S <=1 S\n CEFTAZIDIME----------- <=1 S <=1 S\n CEFTRIAXONE----------- <=1 S <=1 S\n CEFUROXIME------------ 4 S\n CIPROFLOXACIN--------- =>4 R =>4 R\n GENTAMICIN------------ <=1 S 8 I\n MEROPENEM-------------<=0.25 S <=0.25 S\n NITROFURANTOIN-------- <=16 S 256 R\n PIPERACILLIN---------- <=4 S <=4 S\n PIPERACILLIN/TAZO----- <=4 S <=4 S\n TOBRAMYCIN------------ <=1 S 8 I\n TRIMETHOPRIM/SULFA---- <=1 S <=1 S\n ECG: Sinus with rate of 98, borderline left axis deviation, normal\n intervals, ST flattening in V5-V6, Q in V1-2, minmal change from\n .\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after cardiopulmonary\n resuscitation for pulselessness.\n .\n # Cardiopulmomary Arrest: Patient found pulseless, ashen, and cool,\n down for no longer than 10 minutes. Patient not monitored on telemetry\n at the time of the event. She quickly regained rhythm after intubation\n and 1gm epinephrine w/ CPR. In the setting of underlying RLL\n infiltrate, concern for worsening pulmonary edema on the floor, most\n likely etiology respiratory arrest w/ mucous plug.\n - treat underlying cause of PNA, provide respiratory support with\n ventilator for now\n - monitor on telemetry\n .\n # Hypercarbic Respiratory Failure: Now s/p intubation with resolution\n in hypercarbia, no evidence of hypoxia. Will wean oxygen as tolerated.\n Likely secondary to cardiopulonary arrest.\n - continue on AC 500/16/5/100% for now, repeat ABG in 1 hour\n - wean FiO2 as tolerated\n .\n # HAP/Aspiration PNA: Patient on broad spectrum coverage since\n admission. CT from showed persistent RLL infiltrate. CBC showing\n new bands on diff in setting of code.\n - continue vanc/levo/flagyl, patient currently on day 10 of ABX, but\n given poor clinical response will continue for additional 4 days\n - consider reeval w/ bronchoscopy/BAL to continue infectious workup\n - repeat sputum cultures\n - follow blood cultures\n .\n # Urosepsis: W. e.coli bacteremia, and e.coli/providencia UTI. Repeat\n cultures have been negative. Has been on appropriate abx since ,\n will plan for 7 day course from this date.\n - continue amikacin, f/u send out level\n .\n # Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6. Had been\n >2 on initial presentation and was improving prior to arrest. Likely\n prerenal in etiology secondary to episode of hypoprofusion.\n - IVF boluses to maintain urine output\n - trend creatinine\n .\n # Hypertension: On lisinopril, metoprolol\n - resume as HR and BP tolerate\n .\n # Dementia: Currently intubated without need for sedative medications\n - continue namenda and aricept\n .\n # FEN: IVF as above, monitor electrolytes, NGT in place so will start\n tube feeds this am\n .\n # Prophylaxis: SC heparin, bowel regimen, PPI\n .\n # Communcation: Sister \n .\n # Code: FC - plan to reassess with sister\n .\n # Disposition: ICU care for now\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 05:19 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Respiratory ", "chartdate": "2192-08-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 344236, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: No vent chamges done.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Pt to be CMO & terminally extuabted today.\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n" }, { "category": "Physician ", "chartdate": "2192-08-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 343455, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:19 AM\n -found to be pulseless on medicine , bradycardic. ABG\n 7.12/70/90/24\n -b/l rales on exam, 40mg IV lasix- UOP to 200cc but improvement on exam\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:37 AM\n Amikacin - 08:37 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:01 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 06:09 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: 37.7\nC (99.8\n HR: 83 (83 - 117) bpm\n BP: 99/47(58) {99/47(58) - 129/104(109)} mmHg\n RR: 16 (16 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Mixed Venous O2% Sat: 87 - 87\n Total In:\n 11 mL\n PO:\n TF:\n IVF:\n 11 mL\n Blood products:\n Total out:\n 0 mL\n 120 mL\n Urine:\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -109 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.43/41/276/22/3, lactate 3.8\n Ve: 9.9 L/min\n PaO2 / FiO2: 276\n Physical Examination\n GEN: intubated, sedated\n HEENT: anicteric, MMD, pale conjunctiva\n CV: RRR S1S2 no m/r/g no JVD\n PULM: Crackles at bilateral bases, scant rales otherwise good air flow\n ABD: soft NT, ND +bs\n GU: foley draining clear urine\n EXT: WWP 2+ radial pulses, 1+dp pulses, no cyanosis\n SKIN: bruising, scratches on R wrist; healing scars on R shoulder, no\n rashes, petechiae\n Labs / Radiology\n 312 K/uL\n 9.4 g/dL\n 216 mg/dL\n 1.1 mg/dL\n 22 mEq/L\n 4.7 mEq/L\n 12 mg/dL\n 103 mEq/L\n 140 mEq/L\n 28.7 %\n 26.1 K/uL\n [image002.jpg]\n 07:59 PM\n 03:58 AM\n 05:43 PM\n 08:36 PM\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n 04:35 AM\n 05:32 AM\n WBC\n 22.8\n 24.0\n 26.1\n Hct\n 26.8\n 26.1\n 28.7\n Plt\n 133\n 195\n 312\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n 0.9\n 1.1\n TCO2\n 24\n 28\n 27\n 28\n Glucose\n 61\n 90\n 104\n 141\n 69\n 216\n Other labs: PT / PTT / INR:15.7/37.7/1.4, CK / CKMB /\n Troponin-T:32/4/0.14, ALT / AST:13/18, Alk Phos / T Bili:108/0.3,\n Differential-Neuts:83.0 %, Band:3.0 %, Lymph:8.0 %, Mono:5.0 %, Eos:0.0\n %, Fibrinogen:661 mg/dL, Lactic Acid:4.6 mmol/L, Albumin:2.5 g/dL,\n LDH:161 IU/L, Ca++:7.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after cardiopulmonary\n resuscitation for pulselessness.\n .\n # Cardiopulmonary Arrest: Patient found pulseless, ashen, and cool,\n down for no longer than 10 minutes. Patient not monitored on telemetry\n at the time of the event. She quickly regained rhythm after intubation\n and 1gm epinephrine w/ CPR. In the setting of underlying RLL\n infiltrate, concern for worsening pulmonary edema on the floor, most\n likely etiology respiratory arrest w/ mucous plug.\n - treat underlying cause of PNA, provide respiratory support with\n ventilator for now\n - monitor on telemetry\n .\n # Hypercarbic Respiratory Failure: Now s/p intubation with resolution\n in hypercarbia, no evidence of hypoxia. Likely etiology is mucus plug\n and pulmonary edema as above, leading to CPA. Given 40mg IV lasix with\n mild increase in urine output but significant improvement on lung exam.\n Today will work on wean oxygen as tolerated.\n - continue on AC and wean FIO2 as tolerated\n - follow ABGs, lactate\n - f/u CXR\n - suction, nebs prn\n .\n # HAP Aspiration PNA: Patient on broad spectrum coverage since\n admission. CT from showed persistent RLL infiltrate.\n - continue vanc/levo/flagyl, patient currently on day 10 of ABX, but\n given poor clinical response will continue for additional 4 days\n - f/u pending cultures\n - consider bronchoscopy\n - repeat sputum and blood cultures\n .\n # Urosepsis: E.coli bacteremia, and E.coli/providencia UTI. Repeat\n cultures have been negative. Has been on appropriate abx since ,\n will plan for 2 week course from this date.\n - continue amikacin, f/u send out level\n .\n # Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6. Had been\n >2 on initial presentation and was improving prior to arrest. Likely\n prerenal in etiology secondary to episode of hypoprofusion.\n - IVF boluses to maintain urine output\n - trend creatinine\n .\n # Hypertension: Pt with hypotensive episode initially, held\n metoprolol.\n - restart metoprolol as tolerated\n .\n # Dementia: Currently intubated without need for sedative medications\n - continue namenda and aricept\n .\n # FEN: IVF as above, monitor electrolytes, NGT in place so will start\n tube feeds this am\n .\n # Prophylaxis: SC heparin, bowel regimen, PPI\n .\n # Communcation: Sister \n .\n # Code: FC\n .\n # Disposition: ICU care for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:19 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": "2192-08-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 343456, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:19 AM\n -found to be pulseless on medicine , bradycardic. ABG\n 7.12/70/90/24\n -b/l rales on exam, 40mg IV lasix- UOP to 200cc but improvement on exam\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:37 AM\n Amikacin - 08:37 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:01 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 06:09 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: 37.7\nC (99.8\n HR: 83 (83 - 117) bpm\n BP: 99/47(58) {99/47(58) - 129/104(109)} mmHg\n RR: 16 (16 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Mixed Venous O2% Sat: 87 - 87\n Total In:\n 11 mL\n PO:\n TF:\n IVF:\n 11 mL\n Blood products:\n Total out:\n 0 mL\n 120 mL\n Urine:\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -109 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.43/41/276/22/3, lactate 3.8\n Ve: 9.9 L/min\n PaO2 / FiO2: 276\n Physical Examination\n GEN: intubated, sedated\n HEENT: anicteric, MMD, pale conjunctiva\n CV: RRR S1S2 no m/r/g no JVD\n PULM: Crackles at bilateral bases, scant rales otherwise good air flow\n ABD: soft NT, ND +bs\n GU: foley draining clear urine\n EXT: WWP 2+ radial pulses, 1+dp pulses, no cyanosis\n SKIN: bruising, scratches on R wrist; healing scars on R shoulder, no\n rashes, petechiae\n Labs / Radiology\n 312 K/uL\n 9.4 g/dL\n 216 mg/dL\n 1.1 mg/dL\n 22 mEq/L\n 4.7 mEq/L\n 12 mg/dL\n 103 mEq/L\n 140 mEq/L\n 28.7 %\n 26.1 K/uL\n [image002.jpg]\n 07:59 PM\n 03:58 AM\n 05:43 PM\n 08:36 PM\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n 04:35 AM\n 05:32 AM\n WBC\n 22.8\n 24.0\n 26.1\n Hct\n 26.8\n 26.1\n 28.7\n Plt\n 133\n 195\n 312\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n 0.9\n 1.1\n TCO2\n 24\n 28\n 27\n 28\n Glucose\n 61\n 90\n 104\n 141\n 69\n 216\n Other labs: PT / PTT / INR:15.7/37.7/1.4, CK / CKMB /\n Troponin-T:32/4/0.14, ALT / AST:13/18, Alk Phos / T Bili:108/0.3,\n Differential-Neuts:83.0 %, Band:3.0 %, Lymph:8.0 %, Mono:5.0 %, Eos:0.0\n %, Fibrinogen:661 mg/dL, Lactic Acid:4.6 mmol/L, Albumin:2.5 g/dL,\n LDH:161 IU/L, Ca++:7.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after cardiopulmonary\n resuscitation for pulselessness.\n .\n # Cardiopulmonary Arrest: Patient found pulseless, ashen, and cool,\n down for no longer than 10 minutes. Patient not monitored on telemetry\n at the time of the event. She quickly regained rhythm after intubation\n and 1gm epinephrine w/ CPR. In the setting of underlying RLL\n infiltrate, concern for worsening pulmonary edema on the floor, most\n likely etiology respiratory arrest w/ mucous plug.\n - treat underlying cause of PNA, provide respiratory support with\n ventilator for now\n - monitor on telemetry\n .\n # Hypercarbic Respiratory Failure: Now s/p intubation with resolution\n in hypercarbia, no evidence of hypoxia. Likely etiology is mucus plug\n and pulmonary edema as above, leading to CPA. Given 40mg IV lasix with\n mild increase in urine output but significant improvement on lung exam.\n Today will work on wean oxygen as tolerated.\n - continue on AC and wean FIO2 as tolerated\n - follow ABGs, lactate\n - f/u CXR\n - suction, nebs prn\n .\n # HAP Aspiration PNA: Patient on broad spectrum coverage since\n admission. CT from showed persistent RLL infiltrate.\n - continue vanc/levo/flagyl, patient currently on day 10 of ABX, but\n given poor clinical response will continue for additional 4 days\n - f/u pending cultures\n - consider bronchoscopy\n - repeat sputum and blood cultures\n .\n # Urosepsis: E.coli bacteremia, and E.coli/providencia UTI. Repeat\n cultures have been negative. Has been on appropriate abx since ,\n will plan for 2 week course from this date.\n - continue amikacin, f/u send out level\n .\n # Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6. Had been\n >2 on initial presentation and was improving prior to arrest. Likely\n prerenal in etiology secondary to episode of hypoprofusion.\n - IVF boluses to maintain urine output\n - trend creatinine\n .\n # Hypertension: Pt with hypotensive episode initially, held\n metoprolol.\n - restart metoprolol as tolerated\n .\n # Dementia: Currently intubated without need for sedative medications\n - continue namenda and aricept\n .\n # FEN: IVF as above, monitor electrolytes, NGT in place so will start\n tube feeds this am\n .\n # Prophylaxis: SC heparin, bowel regimen, PPI\n .\n # Communcation: Sister \n .\n # Code: FC\n .\n # Disposition: ICU care for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:19 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": "2192-08-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 344065, "text": "Chief Complaint: 82 year old female with h/o breast ca, cva, htn, who\n initially presented with urosepsis and pneumonia then transferred out\n of the unit, re-transferred after PEA arrest on the floor without\n significant improvement in mental status.\n 24 Hour Events:\n Family meeting was suppose to happen yesterday and did not. Plan for\n family meeting today. Patient went for head CT without incident.\n Started on scopolamine patch to decrease secretions. also started on\n tca as well. Goal yesterday was -500-1L negative.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:27 AM\n Amikacin - 08:39 AM\n Metronidazole - 12:30 PM\n Levofloxacin - 06:10 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:45 AM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 06:50 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: 37.2\nC (99\n HR: 88 (64 - 88) bpm\n BP: 171/71(97) {133/55(77) - 171/72(97)} mmHg\n RR: 30 (14 - 35) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 1,846 mL\n 135 mL\n PO:\n TF:\n 876 mL\n IVF:\n 640 mL\n 65 mL\n Blood products:\n Total out:\n 2,440 mL\n 190 mL\n Urine:\n 2,440 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n -594 mL\n -55 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 360 (360 - 360) mL\n Vt (Spontaneous): 319 (260 - 385) mL\n PS : 12 cmH2O\n RR (Spontaneous): 36\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 328\n SpO2: 99%\n ABG: 7.47/47/65/32/8\n Ve: 9.8 L/min\n PaO2 / FiO2: 163\n Physical Examination\n General Appearance: tachypneic\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Diminished: at bases bilaterally,\n Rhonchorous: right upper lobe)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: patient not on any sedating medications, does not respond\n to verbal or physical stimuli, no spontaneous movement appreciated\n Labs / Radiology\n 781 K/uL\n 8.3 g/dL\n 148 mg/dL\n 1.0 mg/dL\n 32 mEq/L\n 4.4 mEq/L\n 15 mg/dL\n 102 mEq/L\n 138 mEq/L\n 25.9 %\n 18.4 K/uL\n [image002.jpg]\n 02:07 AM\n 04:35 AM\n 05:32 AM\n 04:12 AM\n 08:43 AM\n 02:53 PM\n 05:54 AM\n 04:28 PM\n 04:00 AM\n 05:08 AM\n WBC\n 16.1\n 15.7\n 15.4\n 18.4\n Hct\n 22.5\n 23.4\n 24.9\n 25.9\n Plt\n 583\n 548\n 666\n 781\n Cr\n 1.1\n 1.1\n 1.0\n 1.1\n 1.0\n 1.0\n TropT\n 0.10\n TCO2\n 27\n 28\n 35\n Glucose\n 2\n 150\n 148\n Other labs: PT / PTT / INR:15.3/27.6/1.4, CK / CKMB /\n Troponin-T:37/3/0.10, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:1.2 mmol/L, Albumin:2.5 g/dL, LDH:256 IU/L, Ca++:7.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after likely PEA arrest now\n with worsening mental status than on previous transfer now 48 hours\n after the event.\n # Cardiopulmomary Arrest: Patient found pulseless, ashen, and cool,\n down for no longer than 10 minutes. Patient not monitored on telemetry\n at the time of the event. She quickly regained rhythm after intubation\n and 1gm epinephrine w/ CPR. In the setting of underlying RLL\n infiltrate, concern for worsening pulmonary edema on the floor, most\n likely etiology respiratory arrest w/ mucous plug. No further events\n since admission to ICU, although continues to have episodes of apnea\n while on PS.\n - treat underlying cause of PNA, provide respiratory support with\n ventilator for now\n - trend lactate\n - monitor on telemetry, patient appears to be hemodynamically stable\n -CT head to evaluate for any acute insults that may be causing her\n apneic periods - CT head done no official read uet\n # Hypercarbic Respiratory Failure: S/p intubation x2. Hypercarbic\n likely to arrest d/t pulmonary etiology (mucus plugging, apneic\n period). Started on scopolamine patch yesterday for secretions. still\n requiring frequent suctioning. Currently tachypneic and likely not\n candidate for extubation today. Will discuss goals of care with niece\n this morning (extubation, trach placement etc.)\n - outline goals of care\n - Wean FIO2 as tolerated, to PS as tolerate\n - weak cough, no gag per RT\n - suction prn, nebs prn\n # HAP/Aspiration PNA/sepsis: Patient on broad spectrum coverage since\n admission, has grown GPC pairs/clusters in sputum and E.coli in blood\n and urine. CT from showed persistent RLL infiltrate. CBC showing\n new bands on diff in setting of code.\n - continue vanc/levo/flagyl patient currently on day 12 of ABX, (2 more\n days)\n - sputum from - GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND\n CLUSTERS.\n RESPIRATORY CULTURE (Preliminary): NO GROWTH.\n .- only positive blood culture so far from - ESCHERICHIA COLI\n |\n AMPICILLIN------------ =>32 R\n AMPICILLIN/SULBACTAM-- 4 S\n CEFAZOLIN------------- <=4 S\n CEFEPIME-------------- <=1 S\n CEFTAZIDIME----------- <=1 S\n CEFTRIAXONE----------- <=1 S\n CEFUROXIME------------ 4 S\n CIPROFLOXACIN--------- =>4 R\n GENTAMICIN------------ <=1 S\n MEROPENEM-------------<=0.25 S\n PIPERACILLIN/TAZO----- <=4 S\n TOBRAMYCIN------------ <=1 S\n TRIMETHOPRIM/SULFA---- <=1 S\n .\n # Urosepsis: E.coli bacteremia, and e.coli/providencia UTI. Repeat\n cultures have been negative. Has been on amikacin, last day .\n - amikacin levels from are still pending\n .\n # Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6 currently\n 1.0 appears to be improving with some diuresis. likely relative\n hypoperfusion.\n - suspect that some of renal failure is likely due to poor forward flow\n and patient looks volume overloaded by physical exam\n - trend creatinine\n - goal I/O is negative 1 liter per day, would give lasix as needed to\n achieve this (40 IV yesterday => -500 cc)\n - will start with 40 IV lasix this morning and then check afternoon\n # Hypertension: On lisinopril, metoprolol as outpatient\n - increase lisinopril todya\n - lasix 40mg IV qd, monitor UOP\n - metoprolol 100 mg PO TID\n .\n # Dementia: Currently intubated without need for sedative medications.\n Concern for possible cerebral ischemic insult during her PEA arrest\n that may be causing her apnea.\n - continue namenda and aricept\n - -CT head pending read\n - history of CVA - for secondary stroke prevention should be on aspirin\n and statin; currently on neither one will start statin today, listed as\n having aspirin allergy of unknown type in the chart, however on\n previous admissions appears to have taken it so will consider\n restarting it, although utility at this point given mental status\n likely low\n .\n FEN: tubes feeds, monitor electrolytes, repleted K aggressively this\n morning for K of 2.6, K now 4.4\n .\n # Prophylaxis: SC heparin, d/c bowel regimen in the setting of\n persistent diarrhea, PPI\n .\n # Communcation: Sister .\n # Code: FC - plan to reassess with sister today\n .\n # Disposition: ICU care for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:15 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": "2192-08-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 344091, "text": "Chief Complaint: Respiratory Failiure\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 worsening tachypnea\n Patient with worsening encephaolopathy and decreased responsiveness now\n showing minimal response to painful stimuli.\n Scopalamine patch and TCA started for aid in control of secretions\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 12:30 PM\n Levofloxacin - 06:10 PM\n Vancomycin - 07:45 AM\n Amikacin - 08:45 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:45 AM\n Lansoprazole (Prevacid) - 08:30 AM\n Heparin Sodium (Prophylaxis) - 08:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 86 (64 - 88) bpm\n BP: 175/74(99) {133/55(77) - 175/74(99)} mmHg\n RR: 28 (16 - 35) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 1,769 mL\n 998 mL\n PO:\n TF:\n 799 mL\n 433 mL\n IVF:\n 640 mL\n 405 mL\n Blood products:\n Total out:\n 2,440 mL\n 405 mL\n Urine:\n 2,440 mL\n 405 mL\n NG:\n Stool:\n Drains:\n Balance:\n -671 mL\n 593 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 312 (260 - 385) mL\n PS : 12 cmH2O\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 328\n SpO2: 97%\n ABG: 7.47/47/65/32/8\n Ve: 10 L/min\n PaO2 / FiO2: 163\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Responds to: Unresponsive, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.3 g/dL\n 781 K/uL\n 148 mg/dL\n 1.0 mg/dL\n 32 mEq/L\n 4.4 mEq/L\n 15 mg/dL\n 102 mEq/L\n 138 mEq/L\n 25.9 %\n 18.4 K/uL\n [image002.jpg]\n 02:07 AM\n 04:35 AM\n 05:32 AM\n 04:12 AM\n 08:43 AM\n 02:53 PM\n 05:54 AM\n 04:28 PM\n 04:00 AM\n 05:08 AM\n WBC\n 16.1\n 15.7\n 15.4\n 18.4\n Hct\n 22.5\n 23.4\n 24.9\n 25.9\n Plt\n 583\n 548\n 666\n 781\n Cr\n 1.1\n 1.1\n 1.0\n 1.1\n 1.0\n 1.0\n TropT\n 0.10\n TCO2\n 27\n 28\n 35\n Glucose\n 2\n 150\n 148\n Other labs: PT / PTT / INR:15.3/27.6/1.4, CK / CKMB /\n Troponin-T:37/3/0.10, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:1.2 mmol/L, Albumin:2.5 g/dL, LDH:256 IU/L, Ca++:7.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.0 mg/dL\n Imaging: CT head--no acute infarct or bleeding\n Assessment and Plan\n 82 yo female with persistent and recurrent respiratory failure in the\n setting of altered mental status and aspiration and recurrent\n respiratory failure. She has failed to have any significant\n improvement in mental status to the point of being able to reasonably\n consider extubation. In addition there has been a significant decrease\n in alertness and inability to establish response to even painful\n stimuli at this point.\n 1)Respiratory Failure--Acute and Chronic-\n -PSV to continue for support as patient unable to support ventilation\n independently\n -Vanco/Amikacin/Flagyl\n 2)Alteration of Awareness-\n -Medications in place\n -Will have to consider complete absence of meaningful improvement and\n with persistent absence of responsiveness that patient is likely to\n remain in this persistent state without reasonable expectation of\n meaningful improvement.\n 3)Disposition---Family meeting needed and scheduled for today to\n discuss plan of care in the setting of current comatose state. Current\n clinical decline would suggest that DNR status at a minimum is\n suggested to family in addition to consideration of CMO status\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:00 AM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:15 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": "Rehab Services", "chartdate": "2192-08-30 00:00:00.000", "description": "Physical Therapy Contact Note", "row_id": 344103, "text": "Attempted to follow up with patient for physical therapy. Patient\n remains intubated and not appropriate for PT. Will follow up to\n reassess patient status and re-evaluate patient as appropriate.\n" }, { "category": "Nursing", "chartdate": "2192-08-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 344248, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor (transferred there )\n after cardiopulmonary resuscitation for pulselessness at 0400 on .\n Code blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated. Likely respiratory related arrest as rapid return to\n circulation with intubation and only single dose of EPI; ?mucus plug\n and hypoxemic respiratory failure. She has ongoing findings consistent\n with persistent peumonia and pneumonitis in the RML and RLL\n distribution. Transferred to ICU for further management\n Family meeting today to discuss goals of care. After discussing the\n high likelihood that pt would not recover from massive insult with Dr.\n , the family decided that they would withdraw care\n tomorrow in AM including extubation.\n -Pt\ns nephew (mother is pt\ns HCP) called tonight and spoke with Dr.\n and plan to wait until afternoon as pt\ns sister was not at family\n meeting.\n Altered mental status (not Delirium)\n Assessment:\n Pt unarousable. Does not have any spontaneous movement however\n grimaces slight with nursing care. Tears noted in pt\ns eyes with\n nursing care. PERRL and pt slightly closes eyes with light.\n Action:\n Turned Q 2-3 hours. Neuro checks Q 4 hours.\n Response:\n Pt remains unresponsive to stimulation. No movements.\n Plan:\n Pt to be CMO and terminally extubated today.\n" }, { "category": "Physician ", "chartdate": "2192-08-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 344283, "text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 06:10 PM\n Metronidazole - 04:10 AM\n Vancomycin - 08:00 AM\n Amikacin - 09:03 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Furosemide (Lasix) - 09:35 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 12:19 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.7\nC (99.9\n HR: 75 (68 - 93) bpm\n BP: 157/66(88) {127/57(73) - 164/72(93)} mmHg\n RR: 18 (15 - 38) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 1,987 mL\n 545 mL\n PO:\n TF:\n 1,187 mL\n 10 mL\n IVF:\n 540 mL\n 455 mL\n Blood products:\n Total out:\n 1,115 mL\n 395 mL\n Urine:\n 1,115 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n 872 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 293 (293 - 293) mL\n PS : 20 cmH2O\n RR (Set): 12\n RR (Spontaneous): 37\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 95%\n ABG: ///34/\n Ve: 7.7 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 875 K/uL\n 8.7 g/dL\n 102 mg/dL\n 1.0 mg/dL\n 34 mEq/L\n 3.5 mEq/L\n 19 mg/dL\n 97 mEq/L\n 138 mEq/L\n 27.0 %\n 20.2 K/uL\n [image002.jpg]\n 04:35 AM\n 05:32 AM\n 04:12 AM\n 08:43 AM\n 02:53 PM\n 05:54 AM\n 04:28 PM\n 04:00 AM\n 05:08 AM\n 05:41 AM\n WBC\n 16.1\n 15.7\n 15.4\n 18.4\n 20.2\n Hct\n 22.5\n 23.4\n 24.9\n 25.9\n 27.0\n Plt\n 583\n 548\n 666\n 781\n 875\n Cr\n 1.1\n 1.1\n 1.0\n 1.1\n 1.0\n 1.0\n 1.0\n TropT\n 0.10\n TCO2\n 28\n 35\n Glucose\n 2\n 150\n 148\n 102\n Other labs: PT / PTT / INR:15.4/28.9/1.4, CK / CKMB /\n Troponin-T:37/3/0.10, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:1.2 mmol/L, Albumin:2.6 g/dL, LDH:256 IU/L, Ca++:7.5 mg/dL,\n Mg++:1.8 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:15 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": "2192-08-31 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 344285, "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 without significant change\n History obtained from Medical records\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 06:10 PM\n Metronidazole - 04:10 AM\n Vancomycin - 08:00 AM\n Amikacin - 09:03 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Furosemide (Lasix) - 09:35 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:24 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.7\nC (99.9\n HR: 75 (68 - 93) bpm\n BP: 157/66(88) {127/57(73) - 164/72(93)} mmHg\n RR: 18 (15 - 38) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 1,987 mL\n 545 mL\n PO:\n TF:\n 1,187 mL\n 10 mL\n IVF:\n 540 mL\n 455 mL\n Blood products:\n Total out:\n 1,115 mL\n 395 mL\n Urine:\n 1,115 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n 872 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 293 (293 - 293) mL\n PS : 20 cmH2O\n RR (Set): 12\n RR (Spontaneous): 37\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 95%\n ABG: ///34/\n Ve: 7.7 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Unresponsive, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.7 g/dL\n 875 K/uL\n 102 mg/dL\n 1.0 mg/dL\n 34 mEq/L\n 3.5 mEq/L\n 19 mg/dL\n 97 mEq/L\n 138 mEq/L\n 27.0 %\n 20.2 K/uL\n [image002.jpg]\n 04:35 AM\n 05:32 AM\n 04:12 AM\n 08:43 AM\n 02:53 PM\n 05:54 AM\n 04:28 PM\n 04:00 AM\n 05:08 AM\n 05:41 AM\n WBC\n 16.1\n 15.7\n 15.4\n 18.4\n 20.2\n Hct\n 22.5\n 23.4\n 24.9\n 25.9\n 27.0\n Plt\n 583\n 548\n 666\n 781\n 875\n Cr\n 1.1\n 1.1\n 1.0\n 1.1\n 1.0\n 1.0\n 1.0\n TropT\n 0.10\n TCO2\n 28\n 35\n Glucose\n 2\n 150\n 148\n 102\n Other labs: PT / PTT / INR:15.4/28.9/1.4, CK / CKMB /\n Troponin-T:37/3/0.10, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:1.2 mmol/L, Albumin:2.6 g/dL, LDH:256 IU/L, Ca++:7.5 mg/dL,\n Mg++:1.8 mg/dL, PO4:3.0 mg/dL\n Imaging: CXR--Persistent opacification or right lower lung fields.\n Assessment and Plan\n 82 yo female with persistent respiratory failure in the setting of\n altered mental status with persistent and severe dementia and inability\n to maintain oral secreations. She has had no findings to suggest new\n insult in CNS imaging despite worsening and persistent decline in\n responsiveness. There is no reasonable expectation of a meaningful\n recovery based upon the patient's goals of care as expressed through\n her family and primarily through the health care proxy. In this\n setting the patient has had continued venilatory support and discussion\n of the goals of care.\n 1)Respiratory Failure-\n -Amikacin/Levoflox/Flacyl\n -Maintain ventilatory support as patient unable to protect airway\n -She has increase in level of ventilatory support\n -Will move towards extubation and CMO as plan of care after family has\n had opportunity to finalize disussion and health care proxy status\n confirmed\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:15 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2192-08-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 343444, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:19 AM\n -found to be pulseless on medicine , bradycardic.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:37 AM\n Amikacin - 08:37 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:01 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 06:09 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: 37.7\nC (99.8\n HR: 83 (83 - 117) bpm\n BP: 99/47(58) {99/47(58) - 129/104(109)} mmHg\n RR: 16 (16 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Mixed Venous O2% Sat: 87 - 87\n Total In:\n 11 mL\n PO:\n TF:\n IVF:\n 11 mL\n Blood products:\n Total out:\n 0 mL\n 120 mL\n Urine:\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -109 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.43/41/276/22/3\n Ve: 9.9 L/min\n PaO2 / FiO2: 276\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 312 K/uL\n 9.4 g/dL\n 216 mg/dL\n 1.1 mg/dL\n 22 mEq/L\n 4.7 mEq/L\n 12 mg/dL\n 103 mEq/L\n 140 mEq/L\n 28.7 %\n 26.1 K/uL\n [image002.jpg]\n 07:59 PM\n 03:58 AM\n 05:43 PM\n 08:36 PM\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n 04:35 AM\n 05:32 AM\n WBC\n 22.8\n 24.0\n 26.1\n Hct\n 26.8\n 26.1\n 28.7\n Plt\n 133\n 195\n 312\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n 0.9\n 1.1\n TCO2\n 24\n 28\n 27\n 28\n Glucose\n 61\n 90\n 104\n 141\n 69\n 216\n Other labs: PT / PTT / INR:15.7/37.7/1.4, CK / CKMB /\n Troponin-T:32/4/0.14, ALT / AST:13/18, Alk Phos / T Bili:108/0.3,\n Differential-Neuts:83.0 %, Band:3.0 %, Lymph:8.0 %, Mono:5.0 %, Eos:0.0\n %, Fibrinogen:661 mg/dL, Lactic Acid:4.6 mmol/L, Albumin:2.5 g/dL,\n LDH:161 IU/L, Ca++:7.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after cardiopulmonary\n resuscitation for pulselessness.\n .\n # Cardiopulmomary Arrest: Patient found pulseless, ashen, and cool,\n down for no longer than 10 minutes. Patient not monitored on telemetry\n at the time of the event. She quickly regained rhythm after intubation\n and 1gm epinephrine w/ CPR. In the setting of underlying RLL\n infiltrate, concern for worsening pulmonary edema on the floor, most\n likely etiology respiratory arrest w/ mucous plug.\n - treat underlying cause of PNA, provide respiratory support with\n ventilator for now\n - monitor on telemetry\n .\n # Hypercarbic Respiratory Failure: Now s/p intubation with resolution\n in hypercarbia, no evidence of hypoxia. Likely etiology is mucus plug\n and pulmonary edema as above, leading to CPA. Given 40mg IV lasix with\n mild increase in urine output but significant improvement on lung exam.\n Today will work on wean oxygen as tolerated.\n - continue on AC and wean FIO2 as tolerated\n - follow ABGs, lactate\n - f/u CXR\n .\n # HAP Aspiration PNA: Patient on broad spectrum coverage since\n admission. CT from showed persistent RLL infiltrate.\n - continue vanc/levo/flagyl, patient currently on day 10 of ABX, but\n given poor clinical response will continue for additional 4 days\n - consider reeval w/ bronchoscopy\n - repeat sputum cultures\n - follow blood cultures\n .\n # Urosepsis: W. e.coli bacteremia, and e.coli/providencia UTI. Repeat\n cultures have been negative. Has been on appropriate abx since ,\n will plan for 2 week course from this date.\n - continue amikacin, f/u send out level\n .\n # Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6. Had been\n >2 on initial presentation and was improving prior to arrest. Likely\n prerenal in etiology secondary to episode of hypoprofusion.\n - IVF boluses to maintain urine output\n - trend creatinine\n .\n # Hypertension: Pt with hypotensive episode initially, held\n metoprolol.\n - restart metoprolol as tolerated\n .\n # Dementia: Currently intubated without need for sedative medications\n - continue namenda and aricept\n .\n # FEN: IVF as above, monitor electrolytes, NGT in place so will start\n tube feeds this am\n .\n # Prophylaxis: SC heparin, bowel regimen, PPI\n .\n # Communcation: Sister \n .\n # Code: FC\n .\n # Disposition: ICU care for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2192-08-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 343620, "text": "TITLE:\n Demographics\n Day of mechanical ventilation: 2\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: PSV 10/5/.5\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: comf\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: none noted\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: Cannot manage\n secretions\n" }, { "category": "Nursing", "chartdate": "2192-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343621, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor (transferred there )\n after cardiopulmonary resuscitation for pulselessness at 0400 on .\n Code blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated. Likely respiratory related arrest as rapid return to\n circulation with intubation and only single dose of EPI; ?mucus plug\n and hypoxemic respiratory failure. She has ongoing findings consistent\n with persistent peumonia and pneumonitis in the RML and RLL\n distribution. Transferred to ICU for further management.\n AM K=2.6. Newly written for K sliding scale, currently repleteing for\n a total of 60mEq. Also will replete w/ 2gm Mg as per sliding scale.\n Pt to continue on IV abx Vanco/amikacin/flagyl, levaquin PO.\n Altered mental status (not Delirium)\n Assessment:\n Unresponsive to nail bed or sternal rub initially.\n Action:\n Continued to reassess neuro status\n Response:\n Improved over course of shift. Pt responds to mouth care, occasionally\n bites tube, will open mouth, move LE\ns to stimuli b/l, opens eyes to\n painful stimuli and, rarely, spontaneously. No movement of UE\n Plan:\n Continue to monitor neuro status, stimulate and orient.\n Of note, pt\ns code status was DNR upon admission but status was\n reversed when decision to intubate made during first ICU admission.\n Code status not readdressed prior to her transfer to floor. Family,\n MD, Nursing, ?SW meeting to readdress status in this unfortunate 82yo\n resident who is minimally responsive at baseline.\n" }, { "category": "Nursing", "chartdate": "2192-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343435, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who initially presented from rehab with pneumonia, urinary tract\n infection, and septic physiology. After recent ICU adm which included\n intubation, pt had been transferred to floor . this morning 0400\n found unresponsive and pulseless code blue called, returned to\n perfusing rhythm with CPR and epi 1mg, intubated and transferred to ICU\n for further management.\n Cardiac arrest\n Assessment:\n Pt with Cardiac arrest of unknown origin as noted above, pt had\n reportably been responsive only to sternal rub and with other painful\n stimuli with moaning prior to event, found down for unknown period of\n time, events previous arrest significant for temp spike with cultures\n sent which resolved with Tylenol adm\n Action:\n Pt transferred to ICU following successful code, ABG sent, vent\n settings per previous settings while in ICU, suctioning ETT for frothy\n pink sputum, given 40mg of lasix IV given likely pulm edema, breath\n sounds clear in upper airway with crackles at bases, obtained\n results pending, EKG obtained\n Response:\n Pt now in NSR with frequent PVCs, some response noted to lasix adm, see\n flowsheet for objective data, ABG 7.43/41/276/3/28\n Plan:\n f/u am , pt to remain intubated at this time, f/u culture data,\n antibiotics as ordered, family meeting when appropriate\n Altered mental status (not Delirium)\n Assessment:\n Pt is completely unresponsive, received no meds for intubation\n Action:\n Monitoring no sedatives given at this time, pt is baseline minimally\n responsive\n Response:\n None\n Plan:\n Continue to monitor, ?sedatives if required for proper ventilation, pt\n dose not require sedation at this time\n" }, { "category": "Respiratory ", "chartdate": "2192-08-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 343436, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: Floor\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\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: Blood Tinged / Frothy\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 Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Comments: Pt. intubated on floors due to cardiac arrest, intubated and\n placed on A/C. Suctioned copious frothy sputm. Wean Fio2 as tolerated.\n" }, { "category": "Nursing", "chartdate": "2192-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343617, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor (transferred there )\n after cardiopulmonary resuscitation for pulselessness at 0400 on .\n Code blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated. Likely respiratory related arrest as rapid return to\n circulation with intubation and only single dose of EPI; ?mucus plug\n and hypoxemic respiratory failure. She has ongoing findings consistent\n with persistent peumonia and pneumonitis in the RML and RLL\n distribution. Transferred to ICU for further management.\n AM K=2.6, currently repleteing for a total of 80mEq. Also will replete\n w/ 2gm Mg as per sliding scale.\n Altered mental status (not Delirium)\n Assessment:\n Unresponsive to nail bed or sternal rub initially.\n Action:\n Continued to reassess neuro status\n Response:\n Improved over course of shift. Pt responds to mouth care, occasionally\n bites tube, will open mouth, move LE\ns to stimuli b/l, opens eyes to\n painful stimuli and, rarely, spontaneously. No movement of UE\n Plan:\n Continue to monitor neuro status, stimulate and orient.\n" }, { "category": "Nursing", "chartdate": "2192-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343619, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor (transferred there )\n after cardiopulmonary resuscitation for pulselessness at 0400 on .\n Code blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated. Likely respiratory related arrest as rapid return to\n circulation with intubation and only single dose of EPI; ?mucus plug\n and hypoxemic respiratory failure. She has ongoing findings consistent\n with persistent peumonia and pneumonitis in the RML and RLL\n distribution. Transferred to ICU for further management.\n AM K=2.6. Newly written for K sliding scale, currently repleteing for\n a total of 60mEq. Also will replete w/ 2gm Mg as per sliding scale.\n Pt to continue on IV abx Vanco/amikacin/flagyl, levaquin PO.\n Altered mental status (not Delirium)\n Assessment:\n Unresponsive to nail bed or sternal rub initially.\n Action:\n Continued to reassess neuro status\n Response:\n Improved over course of shift. Pt responds to mouth care, occasionally\n bites tube, will open mouth, move LE\ns to stimuli b/l, opens eyes to\n painful stimuli and, rarely, spontaneously. No movement of UE\n Plan:\n Continue to monitor neuro status, stimulate and orient.\n Of note, pt\ns code status was DNR upon admission but status was\n reversed when decision to intubate made during first ICU admission.\n Code status not readdressed prior to her transfer to floor. Family,\n MD, Nursing, ?SW meeting to readdress status in this unfortunate 82yo\n woman who is not verbal\n" }, { "category": "Nursing", "chartdate": "2192-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343434, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who initially presented from rehab with pneumonia, urinary tract\n infection, and septic physiology. After recent ICU adm which included\n intubation, pt had been transferred to floor . this morning 0400\n found unresponsive and pulseless code blue called, returned to\n perfusing rhythm with CPR and epi 1mg, intubated and transferred to ICU\n for further management.\n Cardiac arrest\n Assessment:\n Pt with Cardiac arrest of unknown origin as noted above, pt had\n reportably been responsive only to sternal rub and with other painful\n stimuli with moaning prior to event, found down for unknown period of\n time, events previous arrest significant for temp spike with cultures\n sent which resolved with Tylenol adm\n Action:\n Pt transferred to ICU following successful code, ABG sent, vent\n settings per previous settings while in ICU, suctioning ETT for frothy\n pink sputum, given 40mg of lasix IV given likely pulm edema, breath\n sounds clear in upper airway with crackles at bases, obtained\n results pending, EKG obtained\n Response:\n Pt now in NSR with frequent PVCs, some response noted to lasix adm, see\n flowsheet for objective data, ABG 7.43/41/276/3/28\n Plan:\n f/u am , pt to remain intubated at this time, f/u culture data,\n antibiotics as ordered, family meeting when appropriate\n Altered mental status (not Delirium)\n Assessment:\n Pt is completely unresponsive, received no meds for intubation\n Action:\n Monitoring no sedatives given at this time, pt is baseline minimally\n responsive\n Response:\n None\n Plan:\n Continue to monitor, ?sedatives if required for proper ventilation, pt\n dose not require sedation at this time\n" }, { "category": "Nursing", "chartdate": "2192-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343552, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who initially presented from rehab with pneumonia, urinary tract\n infection, and septic physiology. After recent ICU adm which included\n intubation, pt had been transferred to floor . this morning 0400\n found unresponsive and pulseless code blue called, returned to\n perfusing rhythm with CPR and epi 1mg, intubated and transferred to ICU\n for further management. Now unresponsive and throwing frequent PVC\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Pt. with persistent RLL infiltrate. Completed appropriate courses in\n Flagyl, Vanco, and Levofloxacin with Amikacin for UTI. Pt. with\n PCN/Sulfa ax. Code event most likely respiratory failure induced in\n presence of pulmonary edema. Pt. with low grade fever, LS clear uppers,\n diminished lowers.\n Action:\n Flagyl/Vanco/Levo courses to be extended to see if infiltrate responds.\n Now on CPAP.\n Response:\n awaiting\n Plan:\n Continue with team rec\ns re: abx . Daily CXR, monitor pt. closely for\n S&S of pulmonary edema, extubate if pt. continues to tolerate CPAP,\n Altered mental status (not Delirium)\n Assessment:\n According to code report, pt. unattended for no more than 10 minutes\n before being found unresponsive. Mental status already significantly\n compromised due to CVA. Now, unarousable to sternal rub, posturing with\n deep painful stimuli, yawning, very impaired gag. No sedation needed\n for intubation. Has not needed any sedation throughout the day.\n Action:\n Response:\n Plan:\n Family to visit very briefly today. Code status needs to be readdressed\n with family. Patient currently full code. Frequent neuron checks,\n possible head CT in AM to check for acute change.\n" }, { "category": "Nursing", "chartdate": "2192-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343615, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor (transferred there )\n after cardiopulmonary resuscitation for pulselessness at 0400 on .\n Code blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated and transferred to ICU for further management.\n AM K=2.9, currently repleteing for a total of 80mEq\n Altered mental status (not Delirium)\n Assessment:\n Unresponsive to sternal rub\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2192-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343616, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor (transferred there )\n after cardiopulmonary resuscitation for pulselessness at 0400 on .\n Code blue called, returned to perfusing rhythm with CPR and epi 1mg,\n intubated and transferred to ICU for further management.\n AM K=2.6, currently repleteing for a total of 80mEq. Also will replete\n w/ 2gm Mg as per sliding scale.\n Altered mental status (not Delirium)\n Assessment:\n Unresponsive to nail bed or sternal rub initially.\n Action:\n Continued to reassess neuro status\n Response:\n Improved over course of shift. Pt responds to mouth care, occasionally\n bites tube, will open mouth, move LE\ns to stimuli b/l, opens eyes to\n painful stimuli and, rarely, spontaneously. No movement of UE\n Plan:\n Continue to monitor neuro status, stimulate and orient.\n" }, { "category": "Physician ", "chartdate": "2192-08-25 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 343162, "text": "Chief Complaint: 82 year old female with h/o breast cancer, cva, htn\n who presents from rehab with pneumonia and uti with sepsis physiology.\n previously intubated, now s/p extubation yesterday.\n 24 Hour Events:\n successfully extubated yesterday afternoon. post extubation gas\n 7.43/39/99. ng tube placed. patient with frothy white => clear\n secretions. ordered for ct head/chest without contrast to eval possible\n right hilar mass seen on chest x-ray. IR requesting IV even though\n patient has RIJ. Patient again with episode of hypertension\n overnight. Given fentayl for pain. had to increase fentayl this\n morning to 25 q 2 for pain. Vanco level 20/7 this AM.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Gentamicin - 11:00 PM\n Vancomycin - 08:03 AM\n Amikacin - 08:04 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:54 PM\n Heparin Sodium - 04:18 AM\n Fentanyl - 04:19 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36\nC (96.8\n HR: 82 (69 - 96) bpm\n BP: 183/69(112) {143/52(82) - 192/77(115)} mmHg\n RR: 37 (13 - 37) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 5 (5 - 7)mmHg\n Total In:\n 959 mL\n 224 mL\n PO:\n TF:\n 339 mL\n IVF:\n 560 mL\n 224 mL\n Blood products:\n Total out:\n 5,930 mL\n 925 mL\n Urine:\n 5,870 mL\n 925 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n -4,971 mL\n -701 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 352 (352 - 422) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 18 cmH2O\n SpO2: 96%\n ABG: 7.43/39/99./26/1\n Ve: 8.2 L/min\n PaO2 / FiO2: 248\n Physical Examination\n General Appearance: No acute distress, lethargic, opens eyes, localizes\n pain\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), no murmur\n appreaciated\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: diffusely over lung\n bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: No(t) Follows simple commands, Responds to: Noxious\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 312 K/uL\n 9.4 g/dL\n 69 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.2 mEq/L\n 15 mg/dL\n 106 mEq/L\n 142 mEq/L\n 28.7 %\n 26.1 K/uL\n [image002.jpg]\n 05:33 AM\n 06:00 AM\n 07:59 PM\n 03:58 AM\n 05:43 PM\n 08:36 PM\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n WBC\n 22.8\n 24.0\n 26.1\n Hct\n 26.8\n 26.1\n 28.7\n Plt\n 133\n 195\n 312\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n 0.9\n TCO2\n 24\n 24\n 28\n 27\n Glucose\n 40\n 145\n 61\n 90\n 104\n 141\n 69\n Other labs: PT / PTT / INR:13.1/25.7/1.1, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:92.1 %, Band:5.0 %, Lymph:4.4 %, Mono:3.0 %, Eos:0.4\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.3\n mg/dL, Mg++:1.8 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology.\n Septic Shock: Patient was with SIRS with E coli in blood and urine, as\n well as providencia stuartii in urine. CXR shows bibasilar\n consolidations as well concerning for possible pneumonia. Sputum\n culture with gram + cocci however this has not grown out so far in\n speciation. Presentation lactate was 3.4, then trended down. Repeat\n urine culture now negative.\n - repeat sputum culture - GRAM STAIN (Final ): >25 PMNs and <10\n epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM\n POSITIVE COCCI. IN PAIRS AND CHAINS.\n 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Final ): SPARSE GROWTH OROPHARYNGEAL\n FLORA.\n - vanc trough 20.7 this AM so she is definitely therapeutic on vanc\n - urine culture 9./17\n no growth final\n - c. diff negative \n - Urine -urine cx - URINE CULTURE (Final ): ESCHERICHIA\n COLI. 10,000-100,000 ORGANISMS/ML.. PROVIDENCIA STUARTII.\n 10,000-100,000 ORGANISMS/ML..\n - currently on amikacin and vancomycin, allergy to PCN (previously on\n levoquin and aztreonam as well)\n levoquin was d/c in the setting of\n gram positive cocci in the sputum after 3 day course and aztreonam was\n d/c as no sensitivities identified to e. coli or providenciaa stuartii\n and aztreonam with poor gram + coverage\n - currently off all pressors, now hypertensive\n - wbc count continuese to trend up with bandemia\n repeat Ucx is clean,\n c diff negative, may suggest that pneumonia is not being adequately\n treated, however patient remains afebrile, also able to be extubated\n yesterday so clinically improved\n - chest x-ray - PFI: New right round perihilar mass concerning for\n possible loculated fluid, abscess, tumor.\n - consider ct of chest for furthur evaluation\n Respiratory Failure: Initially respiratory failure likely due to\n pneumonia/sepsis. Suspect that also be aspect of deconditioning.\n Patient now off ventilator completely breathing on roomm air. Given IV\n lasix yesterday had large diuresis\n - will hold off on additional antibiotics at this time\n -culture data and antibiotics as above\n - Suction PRN\n Mental status\n - patient is now responsive to verbal stimuli, opening her eyes. Will\n squeeze hands in response to her name. moves legs spontaneously.\n Currently not speaking, although as per at baseline\n answers with one word\n - may be in the setting of severe illness and previously being on\n sedation that patient has severe dementia at baseline\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension,\n now restarted\n - IV hydral PRN for elevated blood pressure, but trying to get on\n better beta blocker/ace regimen\n - increased lisinopril yesterday to 5, will again increase today to 10\n mg po daily\n -increased metoprolol to 75 TID yesterday, will uptitrate to 100 mg TID\n with holding parameters for HR and SBP\n - will hold off on additional lasix today for pressure control\n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since blood is prokinetic.\n Will guaiac stool when available.\n - crit is stable\n -Patient guaic positive in the ED, guiac positive stool\n - Coffee ground emesis from NG tube; guaiac negative\n - likely requires outpatient colonscopy, which is non-emergent\n - continue to follow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n baseline. Likely prerenal in etiology secondary to volume depletion\n and septic shock\n likely ATN. No cast seen in UA, but it was not\n fresh. Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with multiple negative troponins. This was\n likely demand ischemia in setting of hypotension. repeat EKG from \n EKG Sinus rhythm. Premature ventricular contractions. Poor R wave\n progression may be lead placement or possible old anterior myocardial\n infarction. Compared to the previous tracing of axis has\n shifted rightward. Ventricular ectopy is new. ECHO from -\n IMPRESSION: Mild focal LV systolic dysfunction. Mildly dilated right\n ventricle. Mild to moderate aortic regurgitation. Moderately dilated\n ascending aorta.\n Dementia: patient still with decreased mental status despite being\n off the ventilator.\n - namenda and aricept yesterday\n FEN:\n - tube feeds\n -check pm lytes, replete electrolytes as needed.\n Prophylaxis: SC heparin, holding bowel regimen for diarrhea, ppi\n Access: RIJ, will d/c a-line\n Communcation: Sister \n Code: Full Code.\n Dispo: call out to floor today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 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 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 her\n note above, including assessment and plan. PMH, SH, FH and ROS are\n unchanged from admission except where noted above.\n 82 yo female with respiratory failure and prolonged intubation with\n altered mental status.\n extubated yesterday\n autodiuresing well\n WBC rising. CDiff neg. Amikacin/vanc\n chest CT to evaluate perihilar mass\n ------ Protected Section Addendum Entered By: , MD\n on: 15:18 ------\n" }, { "category": "Respiratory ", "chartdate": "2192-08-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 342530, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 5\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ED\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\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: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: 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: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions\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": "2192-08-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 343122, "text": "Chief Complaint: 82 year old female with h/o breast cancer, cva, htn\n who presents from rehab with pneumonia and uti with sepsis physiology.\n previously intubated, now s/p extubation yesterday.\n 24 Hour Events:\n successfully extubated yesterday afternoon. post extubation gas\n 7.43/39/99. ng tube placed. patient with frothy white => clear\n secretions. ordered for ct head/chest without contrast to eval possible\n right hilar mass seen on chest x-ray. IR requesting IV even though\n patient has RIJ. Patient again with episode of hypertension\n overnight. Given fentayl for pain. had to increase fentayl this\n morning to 25 q 2 for pain.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Gentamicin - 11:00 PM\n Vancomycin - 08:03 AM\n Amikacin - 08:04 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:54 PM\n Heparin Sodium - 04:18 AM\n Fentanyl - 04:19 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: 37.9\nC (100.3\n Tcurrent: 36\nC (96.8\n HR: 82 (69 - 96) bpm\n BP: 183/69(112) {143/52(82) - 192/77(115)} mmHg\n RR: 37 (13 - 37) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 5 (5 - 7)mmHg\n Total In:\n 959 mL\n 224 mL\n PO:\n TF:\n 339 mL\n IVF:\n 560 mL\n 224 mL\n Blood products:\n Total out:\n 5,930 mL\n 925 mL\n Urine:\n 5,870 mL\n 925 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n -4,971 mL\n -701 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 352 (352 - 422) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 18 cmH2O\n SpO2: 96%\n ABG: 7.43/39/99./26/1\n Ve: 8.2 L/min\n PaO2 / FiO2: 248\n Physical Examination\n General Appearance: No acute distress, lethargic, opens eyes, localizes\n pain\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), no murmur\n appreaciated\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: diffusely over lung\n bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: No(t) Follows simple commands, Responds to: Noxious\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 312 K/uL\n 9.4 g/dL\n 69 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.2 mEq/L\n 15 mg/dL\n 106 mEq/L\n 142 mEq/L\n 28.7 %\n 26.1 K/uL\n [image002.jpg]\n 05:33 AM\n 06:00 AM\n 07:59 PM\n 03:58 AM\n 05:43 PM\n 08:36 PM\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n WBC\n 22.8\n 24.0\n 26.1\n Hct\n 26.8\n 26.1\n 28.7\n Plt\n 133\n 195\n 312\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n 0.9\n TCO2\n 24\n 24\n 28\n 27\n Glucose\n 40\n 145\n 61\n 90\n 104\n 141\n 69\n Other labs: PT / PTT / INR:13.1/25.7/1.1, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:92.1 %, Band:5.0 %, Lymph:4.4 %, Mono:3.0 %, Eos:0.4\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.3\n mg/dL, Mg++:1.8 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology.\n Septic Shock: Patient was with SIRS with E coli in blood and urine, as\n well as providencia stuartii in urine. CXR shows bibasilar\n consolidations as well concerning for possible pneumonia. Sputum\n culture with gram + cocci however this has not grown out so far in\n speciation. Presentation lactate was 3.4, then trended down. Repeat\n urine culture now negative.\n - repeat sputum culture - GRAM STAIN (Final ): >25 PMNs and <10\n epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM\n POSITIVE COCCI. IN PAIRS AND CHAINS.\n 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Final ): SPARSE GROWTH OROPHARYNGEAL\n FLORA.\n - urine culture 9./17\n no growth final\n - c. diff negative \n - Urine -urine cx - URINE CULTURE (Final ): ESCHERICHIA\n COLI. 10,000-100,000 ORGANISMS/ML.. PROVIDENCIA STUARTII.\n 10,000-100,000 ORGANISMS/ML..\n - currently on amikacin and vancomycin, allergy to PCN\n - currently off all pressors, now hypertensive\n - wbc count continuese to trend up with bandemia\n repeat Ucx is clean,\n c diff negative, may suggest that pneumonia is not being adequately\n treated, however patient remains afebrile, also able to be extubated\n yesterday\n - chest x-ray - PFI: New right round perihilar mass concerning for\n possible loculated fluid,\n abscess, tumor.\n - with concern for above findings, ordered ct chest and head\n Respiratory Failure: Initially respiratory failure likely due to\n pneumonia. Suspect that also be aspect of deconditioning. Patient on\n pressure support with 40% O2; with improved secretions, hoever\n patient remains tachypneic with significant work of breathing, patient\n with present but impaired gag reflex. Rsbi this morning 85.\n - off ventilator\n - iv lasix 20 daily as patient net > 10 liters positive, cont to\n monitor i/os\n -culture data and antibiotics as above\n - Suction PRN\n Mental status\n - decreased mental status , will check head CT\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension,\n now restarted\n - IV hydral PRN for elevated blood pressure, but trying to get on\n better beta blocker/ace regimen\n - increased lisinopril yesterday to 5, will again increase today\n -increased metoprolol to 75 TID yesterday, will continue to uptitrate\n as tolerated\n - lasix today for blood pressure control as well as fluid removal\n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since blood is prokinetic.\n Will guaiac stool when available.\n - crit is stable\n -Patient guaic positive in the ED, guiac positive stool\n - Coffee ground emesis from NG tube; guaiac negative\n - likely requires outpatient colonscopy, which is non-emergent\n - continue to follow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n baseline. Likely prerenal in etiology secondary to volume depletion\n and septic shock\n likely ATN. No cast seen in UA, but it was not\n fresh. Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with multiple negative troponins. This was\n likely demand ischemia in setting of hypotension. repeat EKG from \n EKG Sinus rhythm. Premature ventricular contractions. Poor R wave\n progression may be lead placement or possible old anterior myocardial\n infarction. Compared to the previous tracing of axis has\n shifted rightward. Ventricular ectopy is new. ECHO from -\n IMPRESSION: Mild focal LV systolic dysfunction. Mildly dilated right\n ventricle. Mild to moderate aortic regurgitation. Moderately dilated\n ascending aorta.\n Dementia: patient still with decreased mental status despite being\n off the ventilator.\n - namenda and aricept yesterday\n FEN:\n - tube feeds\n -check pm lytes, replete electrolytes as needed.\n Prophylaxis: SC heparin, holding bowel regimen for diarrhea\n Access: RIJ\n Communcation: Sister \n Code: Full Code.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 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": "2192-08-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 343158, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology. Previous on pressors, sepsis resolving with normal\n lactate. New leukocytosis, WBC 22.6 ? new UTI vs c-diff ( loose stools\n x 1 day) ARF resolved, creatinine at baseline 0.8; previous hematocrit\n drop; normocytic normochromic with iron profile sugesting chornic\n disease or infection, Coffee ground emesis from NG tube; guaiac\n negative; hct stable at 27.1 as of yesterday. Slightly increased\n troponin with ST depressions from previous EKG mostly likely demand\n ischemia related to hypotension.\n .\n .H/O hypertension, benign\n Assessment:\n Pts BP has been 160-170s, occationally decreased to the 140s, HR 80s SR\n with occational PVCs\n Action:\n Her lisinopril was increased to 10mg from 5mg, her lopressor was not\n increased. She has not required any hydralazine this shift.\n Response:\n Still hypertensive with the increase in her ace\n Plan:\n Cont to follow her BP, HR\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2192-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342216, "text": "Mrs. is an 82 year old female with a history of breast CA (s/p\n XRT), CVA, baseline dementia, HTN, reflux, & recurrent UTI\ns, who\n presented on early am from after being found to be\n in respiratory distress with oxygen sats in 70s to 80\ns on r/a. Her\n EKG per report was within normal limits. Her exam was notable for\n audible rales and abdominal distension. Sent to EW, where she\n was emergently Intubated. T103. Code sepsis not initiated as BP\n >100/systolic. Peripheral BC from EW grew 4 out of 4 bottles positive\n for gram negative rods, E coli on C&S. Urine Cx () grew E\n coli. Sputum Cx shows many organisms consistent w/oropharyngeal\n flora. Became hypotensive in MICU on afternoon, received fluid\n boluses & levophed IV. Treated w/IV levofloxacin, vanco aztreonam\n &genta. Lactate 9.0 on admission. Off levophed since 0600. On\n CPAP @ 40% FiO2 since 2100. Absent to hypoactive bowel sounds\n w/large residuals - . Kept NPO. Bowel sounds still hypoactive\n but residuals improved. Emesis guiac + . On protonix. Now\n emesis guiac -. 1^st BM since admission after fleets enema. CT\n abdomen showed stool .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 30- 130cc/hr clear light yellow urine. BUN 25 Cr 1.2\n Action:\n IV: D5\n NS @ 100cc/hr for 2L (2^nd L hanging)\n Response:\n Plan:\n Continue to monitor u/o & electrolytes, BUN & Cr.\n Altered mental status (not Delirium)\n Assessment:\n Patient made sound in back of throat during mouth care. Moved L hand &\n forearm slightly. Unrestrained all day until 2200 when movement\n observed. Pupils dilated & not responsive bilaterally. Grasped\n siderail w/L hand during turning. Tightened muscles of R forearm\n during Sx\ning but did not move it. No movement of legs.\n Action:\n Restrained L hand only (& loosely) @ 2200.\n Response:\n No further movement noted.\n Plan:\n Continue to assess for MS.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Patient remains on CPAP 40%/ 12 PS/ 5 PEEP. Lungs are clear\n w/diminished BS @ bases. Did not need Sx\ning most of night. RSBI\n <100 on . Has impaired gag & weak cough. Remained on fentanyl\n 50mcg/hr & versed 1 mg/hr.\n Action:\n ABG\ns: 7.36/34/126\n Response:\n Gag improved from absent earlier.\n Plan:\n Continue to wean.\n .H/O hypertension, benign\n Assessment:\n Patient\ns BP increased significantly after being off sedation for 6\n hours .\n Action:\n Started antihypertensives, lopressor 25mg per OGT for sBP>120/ &\n hydralazine 10mg q 6 hrs IV for sBP >140/.\n Response:\n BP remained 120\ns-150\ns/sys overnight. At 0630-0700 BP increased to\n 189-194/sys MAP 104 by A-line & 166/sys MAP 90 by cuff BP L arm after\n 2 doses 10mg hydralazine (@ 0430 & 0600).\n Plan:\n Continue to assess for pain/ anxiety. Medicate for pain. Medicate for\n hypertension.\n Troponin 0.14 & MB 4 this am.\n" }, { "category": "Nursing", "chartdate": "2192-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342218, "text": "Mrs. is an 82 year old female with a history of breast CA (s/p\n XRT), CVA, baseline dementia, HTN, reflux, & recurrent UTI\ns, who\n presented on early am from after being found to be\n in respiratory distress with oxygen sats in 70s to 80\ns on r/a. Her\n EKG per report was within normal limits. Her exam was notable for\n audible rales and abdominal distension. Sent to EW, where she\n was emergently Intubated. T103. Code sepsis not initiated as BP\n >100/systolic. Peripheral BC from EW grew 4 out of 4 bottles positive\n for gram negative rods, E coli on C&S. Urine Cx () grew E\n coli. Sputum Cx shows many organisms consistent w/oropharyngeal\n flora. Became hypotensive in MICU on afternoon, received fluid\n boluses & levophed IV. Treated w/IV levofloxacin, vanco aztreonam\n &genta. Lactate 9.0 on admission. Off levophed since 0600. On\n CPAP @ 40% FiO2 since 2100. Absent to hypoactive bowel sounds\n w/large residuals - . Kept NPO. Bowel sounds still hypoactive\n but residuals improved. Emesis guiac + . On protonix. Now\n emesis guiac -. 1^st BM since admission after fleets enema. CT\n abdomen showed stool .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 30- 130cc/hr clear light yellow urine. BUN 25(28) Cr 1.2(1.5)\n Action:\n IV: D5\n NS @ 100cc/hr for 2L (2^nd L hanging)\n Response:\n Patient\ns renal function is recovering. She is autodiuresing.\n Plan:\n Continue to monitor u/o & electrolytes, BUN & Cr.\n Altered mental status (not Delirium)\n Assessment:\n Patient made sound in back of throat during mouth care. Moved L hand &\n forearm slightly. Unrestrained all day until 2200 when movement\n observed. Pupils dilated & not responsive bilaterally. Grasped\n siderail w/L hand during turning. Tightened muscles of R forearm\n during Sx\ning but did not move it. No movement of legs.\n Action:\n Restrained L hand only (& loosely) @ 2200.\n Response:\n No further movement noted.\n Plan:\n Continue to assess for MS.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Patient remains on CPAP 40%/ 12 PS/ 5 PEEP. Lungs are clear\n w/diminished BS @ bases. Did not need Sx\ning most of night. RSBI\n <100 on . Has impaired gag & weak cough. Remained on fentanyl\n 50mcg/hr & versed 1 mg/hr.\n Action:\n ABG\ns: 7.36/34/126\n Response:\n Gag improved from absent earlier.\n Plan:\n Continue to wean.\n .H/O hypertension, benign\n Assessment:\n Patient\ns BP increased significantly after being off sedation for 6\n hours .\n Action:\n Started antihypertensives, lopressor 25mg per OGT for sBP>120/ &\n hydralazine 10mg q 6 hrs IV for sBP >140/.\n Response:\n BP remained 120\ns-150\ns/sys overnight. At 0630-0700 BP increased to\n 189-194/sys MAP 104 by A-line & 166/sys MAP 90 by cuff BP L arm after\n 2 doses 10mg hydralazine (@ 0430 & 0600).\n Plan:\n Continue to assess for pain/ anxiety. Medicate for pain. Medicate for\n hypertension.\n Troponin 0.14(no change) & MB 4(down from 8) & CPK 73(down from 135)\n this am.\n" }, { "category": "Nutrition", "chartdate": "2192-08-20 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 342223, "text": "Subjective\n Patient intubated\n Objective\n Pertinent medications: RISS, fentanyl, versed, others noted\n Labs:\n Value\n Date\n Glucose\n 83 mg/dL\n 04:45 AM\n Glucose Finger Stick\n 68\n 09:00 AM\n BUN\n 25 mg/dL\n 04:45 AM\n Creatinine\n 1.2 mg/dL\n 04:45 AM\n Sodium\n 143 mEq/L\n 04:45 AM\n Potassium\n 3.6 mEq/L\n 04:45 AM\n Chloride\n 117 mEq/L\n 04:45 AM\n TCO2\n 18 mEq/L\n 04:45 AM\n Albumin\n 2.2 g/dL\n 05:00 AM\n Calcium non-ionized\n 7.6 mg/dL\n 04:45 AM\n Phosphorus\n 2.1 mg/dL\n 04:45 AM\n Ionized Calcium\n 1.14 mmol/L\n 07:34 AM\n Magnesium\n 1.8 mg/dL\n 04:45 AM\n Current diet order / nutrition support: NPO\n GI: Abdomen soft/distended with hypoactive bowel sounds, +BM\n Assessment of Nutritional Status\n Specifics:\n 82 year old female with history of breast cancer, CVA presenting from\n rehab with respiratory failure, pneumonia and sepsis. Patient was\n unable to receive tube feedings over weekend d/t elevated residuals,\n ?ileus. Noted patient got enema yesterday with +BM. want to\n consider slowly restarting tube feedings at this point and checking\n residuals frequently.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Start Probalance/Fibersource HN at 10ml/hr, advance by 10ml\n q6H to goal rate of 55ml/hr x 24 hours\n 2. Monitor residuals closely\n 3. Monitor abdominal exam closely\n 10:21\n" }, { "category": "Nursing", "chartdate": "2192-08-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342296, "text": "82 year old female with a history of breast CA (s/p XRT), CVA, baseline\n dementia, HTN, reflux, & recurrent UTI\ns, who presented on early\n am from after being found to be in respiratory distress\n with oxygen sats in 70s to 80\ns on r/a. Her EKG per report was within\n normal limits. Her exam was notable for audible rales and abdominal\n distension. Sent to EW, where she was emergently Intubated.\n T103. Code sepsis not initiated as BP >100/systolic. Peripheral BC\n from EW grew 4 out of 4 bottles positive for gram negative rods, E coli\n on C&S. Urine Cx () grew E coli. Sputum Cx shows many\n organisms consistent w/oropharyngeal flora. Became hypotensive in MICU\n on afternoon, received fluid boluses & levophed IV. Treated w/IV\n levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission. Off\n levophed since 0600. repeat sputum cx revealed gm + cocci.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Remains Intubated on psv: 12 ps, 5 peep on 40% fi02, maintaining 02\n sats in upper 90s to 100s. lungs with scattered rhonci in right lobe,\n left lung clear, diminished at bases. No gag, impaired weak cough.\n Continues with altered mental status (has baseline dementia) and\n sedated on fentanyl 50mcg/hr and versed 1mg/hr. opens eyes to voice or\n nsg intervention. Not following commands. R hemi. Moves l side\n occasionally but not on command. No agitation noted this shift.\n Action:\n Pt rested overnight per micu team and resp. therapist on 12 psv, 5 peep\n as pt having resp. distress yesterday with attempting to wean the psv,\n appeared r/t increased secretions and a sedation issue. Tube feeds shut\n off at 5am md request in possible event pt may get extubated later\n today.\n Response:\n Tolerating current vent settings well with fi02 40%, 12 psv, 5 peep.\n Adequately sedated on fentanyl 50mcg/hr and versed 1mg/hr. psv repeat\n abg on above settings: 7.38/33/106. pt weaned to 8 psv and tolerating\n well.\n Plan:\n Attempt to wean psv further in am and lighten sedation when psv\n decreases further if pt tolerates.\n .H/O hypertension, benign\n Assessment:\n Appears to be In\nwandering atrial pacemaker with 3 different p waves\n detected.continues with slightly high sbp. In the 160s. frequent pvcs.\n Am k 3.1. md notified. Mag 1.7, phosphate 1.9.\n Action:\n Hyrdalaxiine given early at 11am d/t rising sbp in 160s. also receiving\n metoprolol via ogt. K being repleted with 60 meq iv kcl total.\n Response:\n Sbp dropping down to the 130s-140s with pt in WAP. Hr 60s-80s WAP.\n Plan:\n Monitor bp, keep sbp >120, less than 160.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinine 1.2 on . urine output dropping to as low as 15cc/hr. pt\n receiving kvo, iv abx volume, tube feedings, 150cc free water boluses\n q6hr. potassium, magnesium, and phosphate levels low last am .\n Action:\n Ivf started: d5ns started, infusing at 100cc/hr. foley flushed without\n difficulty,\n Response:\n Creatinine stabilizing. Urine output increased up to 60cc/hr.\n Plan:\n Continue to monitor creatinine level daily, continue ivf. Monitor\n hourly urine ouput.\n i\n" }, { "category": "Nursing", "chartdate": "2192-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342883, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology. Previous on pressors, sepsis resolving with normal\n lactate. New leukocytosis, WBC 22.6 ? new UTI vs c-diff ( loose stools\n x 1 day) ARF resolved, creatinine at baseline 0.8; previous hematocrit\n drop; normocytic normochromic with iron profile sugesting chornic\n disease or infection, Coffee ground emesis from NG tube; guaiac\n negative; hct stable at 27.1 as of yesterday. Slightly increased\n troponin with ST depressions from previous EKG mostly likely demand\n ischemia related to hypotension.\n .\n Respiratory Failure due to Pneumonia, bacterial, hospital acquired\n (non-VAP)\n Assessment:\n Patient on pressure support with 40% O2, sats 92-100%, moderate to\n large amount of thin clear secretions, with moderate amount from\n oral; drooling when turn on her L side, lung sounds clear, dim at\n bases. ETT 20 at the lip; repeat sputum culture with 3+ gram positive\n cocci in pairs and chains, with 2+ oropharyngeal flora, speciation\n partial only with oral flora; vanc day 2, gentamicin dc\nd yesterday,\n amikacin started.. afebrile, WBC 22 as of yesterday morning. Off\n sedation since for 24 hours now, fentanyl IV bolus for pain\n Action:\n Suctioned secretions from ETT q2-3 hours and PRN, turn to sides q2-3\n hours; continues on antibiotics ( Vanco and Amikacin) no vent setting\n change overnight.\n Response:\n Sats > 95% at same settings, sats dip down 88 % during turning; ETT\n secretions thinner and clearer than yesterday, patient now able to\n cough out secretions. ABG 7.49/31/121\n Plan:\n Culture if temp spikes, continue pulmonary toilet and antibiotics\n Altered mental status (not Delirium)\n Assessment:\n History of CVA / dementia; ? if baseline aphasic, opens eye to\n stimulation ( turning and repositioning) but not tracking, impaired\n corneal, gag and very weak coughing reflexes. Pupils pinpoint but\n reactive. Slightly withdraws to pain\n nail bed. Noticed drooling when\n on her L side.\n Action:\n Fentanyl IV push ( 12.5mcg and 25 mcg given fro ? pain) SBP 180\n Response:\n More awake, better cough reflex\n Plan:\n Continue to evaluate level of awakeness now off sedation drip ?\n extubation\n Electrolyte & fluid disorder, other\n Assessment:\n Evening lytes K- 3.5,\n Action:\n Repleted with 40 mEq KCl PO and 20 mEq IV\n Response:\n CVP 6-9; tolerating tube feeds\n Plan:\n replete lytes per sliding scale\n .H/O hypertension, benign\n Assessment:\n SBP 170\ns at start of shift, NSR occasional\n frequent PVCs\n Action:\n Electrolytes repleted, schedules 50 mgs lopressor PO given\n Response:\n BP well controlled with beta blocker and pain meds SBP 130-140\n otherwise 150-160\n Plan:\n Continue lopressor and lisinopril, pain meds\n Code status : full code as confirmed yesterday with HCP ( patient\n sister)\n Received hydralazine this am for BP 170-180\ns, responded now in the\n 140\n Tube feeds off, will try to extubated again today. Lesser and thinner\n secretions, more awake but ? if able to sustain extubated. Still has\n lots of oral secretions, drooling.\n" }, { "category": "Physician ", "chartdate": "2192-08-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 343147, "text": "Chief Complaint: 82 year old female with h/o breast cancer, cva, htn\n who presents from rehab with pneumonia and uti with sepsis physiology.\n previously intubated, now s/p extubation yesterday.\n 24 Hour Events:\n successfully extubated yesterday afternoon. post extubation gas\n 7.43/39/99. ng tube placed. patient with frothy white => clear\n secretions. ordered for ct head/chest without contrast to eval possible\n right hilar mass seen on chest x-ray. IR requesting IV even though\n patient has RIJ. Patient again with episode of hypertension\n overnight. Given fentayl for pain. had to increase fentayl this\n morning to 25 q 2 for pain. Vanco level 20/7 this AM.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Gentamicin - 11:00 PM\n Vancomycin - 08:03 AM\n Amikacin - 08:04 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:54 PM\n Heparin Sodium - 04:18 AM\n Fentanyl - 04:19 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36\nC (96.8\n HR: 82 (69 - 96) bpm\n BP: 183/69(112) {143/52(82) - 192/77(115)} mmHg\n RR: 37 (13 - 37) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 5 (5 - 7)mmHg\n Total In:\n 959 mL\n 224 mL\n PO:\n TF:\n 339 mL\n IVF:\n 560 mL\n 224 mL\n Blood products:\n Total out:\n 5,930 mL\n 925 mL\n Urine:\n 5,870 mL\n 925 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n -4,971 mL\n -701 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 352 (352 - 422) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 18 cmH2O\n SpO2: 96%\n ABG: 7.43/39/99./26/1\n Ve: 8.2 L/min\n PaO2 / FiO2: 248\n Physical Examination\n General Appearance: No acute distress, lethargic, opens eyes, localizes\n pain\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), no murmur\n appreaciated\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: diffusely over lung\n bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: No(t) Follows simple commands, Responds to: Noxious\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 312 K/uL\n 9.4 g/dL\n 69 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.2 mEq/L\n 15 mg/dL\n 106 mEq/L\n 142 mEq/L\n 28.7 %\n 26.1 K/uL\n [image002.jpg]\n 05:33 AM\n 06:00 AM\n 07:59 PM\n 03:58 AM\n 05:43 PM\n 08:36 PM\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n WBC\n 22.8\n 24.0\n 26.1\n Hct\n 26.8\n 26.1\n 28.7\n Plt\n 133\n 195\n 312\n Cr\n 0.7\n 0.7\n 0.8\n 0.9\n 0.9\n TCO2\n 24\n 24\n 28\n 27\n Glucose\n 40\n 145\n 61\n 90\n 104\n 141\n 69\n Other labs: PT / PTT / INR:13.1/25.7/1.1, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:92.1 %, Band:5.0 %, Lymph:4.4 %, Mono:3.0 %, Eos:0.4\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.3\n mg/dL, Mg++:1.8 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology.\n Septic Shock: Patient was with SIRS with E coli in blood and urine, as\n well as providencia stuartii in urine. CXR shows bibasilar\n consolidations as well concerning for possible pneumonia. Sputum\n culture with gram + cocci however this has not grown out so far in\n speciation. Presentation lactate was 3.4, then trended down. Repeat\n urine culture now negative.\n - repeat sputum culture - GRAM STAIN (Final ): >25 PMNs and <10\n epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM\n POSITIVE COCCI. IN PAIRS AND CHAINS.\n 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Final ): SPARSE GROWTH OROPHARYNGEAL\n FLORA.\n - vanc trough 20.7 this AM so she is definitely therapeutic on vanc\n - urine culture 9./17\n no growth final\n - c. diff negative \n - Urine -urine cx - URINE CULTURE (Final ): ESCHERICHIA\n COLI. 10,000-100,000 ORGANISMS/ML.. PROVIDENCIA STUARTII.\n 10,000-100,000 ORGANISMS/ML..\n - currently on amikacin and vancomycin, allergy to PCN (previously on\n levoquin and aztreonam as well)\n levoquin was d/c in the setting of\n gram positive cocci in the sputum after 3 day course and aztreonam was\n d/c as no sensitivities identified to e. coli or providenciaa stuartii\n and aztreonam with poor gram + coverage\n - currently off all pressors, now hypertensive\n - wbc count continuese to trend up with bandemia\n repeat Ucx is clean,\n c diff negative, may suggest that pneumonia is not being adequately\n treated, however patient remains afebrile, also able to be extubated\n yesterday so clinically improved\n - chest x-ray - PFI: New right round perihilar mass concerning for\n possible loculated fluid, abscess, tumor.\n - consider ct of chest for furthur evaluation\n Respiratory Failure: Initially respiratory failure likely due to\n pneumonia/sepsis. Suspect that also be aspect of deconditioning.\n Patient now off ventilator completely breathing on roomm air. Given IV\n lasix yesterday had large diuresis\n - will hold off on additional antibiotics at this time\n -culture data and antibiotics as above\n - Suction PRN\n Mental status\n - patient is now responsive to verbal stimuli, opening her eyes. Will\n squeeze hands in response to her name. moves legs spontaneously.\n Currently not speaking, although as per at baseline\n answers with one word\n - may be in the setting of severe illness and previously being on\n sedation that patient has severe dementia at baseline\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension,\n now restarted\n - IV hydral PRN for elevated blood pressure, but trying to get on\n better beta blocker/ace regimen\n - increased lisinopril yesterday to 5, will again increase today to 10\n mg po daily\n -increased metoprolol to 75 TID yesterday, will uptitrate to 100 mg TID\n with holding parameters for HR and SBP\n - will hold off on additional lasix today for pressure control\n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since blood is prokinetic.\n Will guaiac stool when available.\n - crit is stable\n -Patient guaic positive in the ED, guiac positive stool\n - Coffee ground emesis from NG tube; guaiac negative\n - likely requires outpatient colonscopy, which is non-emergent\n - continue to follow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n baseline. Likely prerenal in etiology secondary to volume depletion\n and septic shock\n likely ATN. No cast seen in UA, but it was not\n fresh. Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with multiple negative troponins. This was\n likely demand ischemia in setting of hypotension. repeat EKG from \n EKG Sinus rhythm. Premature ventricular contractions. Poor R wave\n progression may be lead placement or possible old anterior myocardial\n infarction. Compared to the previous tracing of axis has\n shifted rightward. Ventricular ectopy is new. ECHO from -\n IMPRESSION: Mild focal LV systolic dysfunction. Mildly dilated right\n ventricle. Mild to moderate aortic regurgitation. Moderately dilated\n ascending aorta.\n Dementia: patient still with decreased mental status despite being\n off the ventilator.\n - namenda and aricept yesterday\n FEN:\n - tube feeds\n -check pm lytes, replete electrolytes as needed.\n Prophylaxis: SC heparin, holding bowel regimen for diarrhea, ppi\n Access: RIJ, will d/c a-line\n Communcation: Sister \n Code: Full Code.\n Dispo: call out to floor today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2192-08-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 342286, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 59 None\n Ideal tidal volume: 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: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\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:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT and on mech vent as per Metavision.\n Lung sounds dim @ bases suct mod th tan sput. ABGs compensated\n metabolic acidosis with good oxygenation; able to wean PSV to 8cm. Cont\n wean PSV.\n" }, { "category": "Physician ", "chartdate": "2192-08-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342861, "text": "Chief Complaint: 82 year old female with history of breast cancer, CVA,\n htn, who presents from rehab with pneumonia and urosepsis.\n 24 Hour Events:\n EKG - At 12:30 AM\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Gentamicin - 11:00 PM\n Vancomycin - 08:10 AM\n Amikacin - 05:04 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:07 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Pantoprazole (Protonix) - 12:31 AM\n Fentanyl - 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 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.4\nC (97.6\n HR: 75 (65 - 93) bpm\n BP: 170/53(89) {128/48(72) - 182/75(108)} mmHg\n RR: 27 (16 - 37) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 7 (-2 - 7)mmHg\n Total In:\n 1,851 mL\n 356 mL\n PO:\n TF:\n 586 mL\n 346 mL\n IVF:\n 475 mL\n 10 mL\n Blood products:\n Total out:\n 3,470 mL\n 700 mL\n Urine:\n 3,470 mL\n 640 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n -1,619 mL\n -344 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 316 (316 - 460) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 119\n PIP: 16 cmH2O\n SpO2: 97%\n ABG: 7.49/31/121/22/2\n Ve: 9.4 L/min\n PaO2 / FiO2: 303\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 195 K/uL\n 8.7 g/dL\n 141 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 112 mEq/L\n 141 mEq/L\n 26.1 %\n 24.0 K/uL\n [image002.jpg]\n 03:31 AM\n 07:50 PM\n 04:10 AM\n 05:33 AM\n 06:00 AM\n 07:59 PM\n 03:58 AM\n 05:43 PM\n 08:36 PM\n 03:46 AM\n WBC\n 22.6\n 22.8\n 24.0\n Hct\n 27.1\n 26.8\n 26.1\n Plt\n 104\n 133\n 195\n Cr\n 0.8\n 0.7\n 0.7\n 0.8\n 0.9\n TCO2\n 20\n 22\n 24\n 24\n Glucose\n 37\n 40\n 145\n 61\n 90\n 104\n 141\n Other labs: PT / PTT / INR:13.9/26.8/1.2, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:92.1 %, Band:5.0 %, Lymph:4.4 %, Mono:3.0 %, Eos:0.4\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.3\n mg/dL, Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology.\n Septic Shock: Patient was with SIRS with E coli in blood and urine.\n CXR shows bibasilar consolidations as well concerning for possible\n pneumonia. Sputum culture with gram + cocci however this has not grown\n out so far in speciation. There is some mild enteritis as wel as CTl.\n Presentation lactate was 3.4, then trended down.\n - repeat sputum culture - GRAM STAIN (Final ): >25 PMNs and <10\n epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM\n POSITIVE COCCI. IN PAIRS AND CHAINS.\n 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Final ): SPARSE GROWTH OROPHARYNGEAL\n FLORA.\n Urine -urine cx - URINE CULTURE (Final ):\n ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..\n PRESUMPTIVE IDENTIFICATION.\n PROVIDENCIA STUARTII. 10,000-100,000 ORGANISMS/ML..\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n ESCHERICHIA COLI\n | PROVIDENCIA STUARTII\n | |\n AMIKACIN-------------- <=2 S\n AMPICILLIN------------ 16 I\n AMPICILLIN/SULBACTAM-- 4 S\n CEFAZOLIN------------- <=4 S\n CEFEPIME-------------- <=1 S <=1 S\n CEFTAZIDIME----------- <=1 S <=1 S\n CEFTRIAXONE----------- <=1 S <=1 S\n CEFUROXIME------------ 4 S\n CIPROFLOXACIN--------- =>4 R =>4 R\n GENTAMICIN------------ <=1 S 8 I\n MEROPENEM-------------<=0.25 S <=0.25 S\n NITROFURANTOIN-------- <=16 S 256 R\n PIPERACILLIN---------- <=4 S <=4 S\n PIPERACILLIN/TAZO----- <=4 S <=4 S\n TOBRAMYCIN------------ <=1 S 8 I\n TRIMETHOPRIM/SULFA---- <=1 S <=1 S\n - currently on gentamycin Day to cover for urosepsis as well as\n possible healthcare associated pneumonia, vancomycin for possible\n healthcare associated pneumonia, given sensitivities above will change\n to amikacin and keep vancomycin\n - currently off all pressors, now hypertensive\n -monitor WBC, CBC, diff\n - wbc count continuese to trend up\n will send repeat ua and urine\n culture as well as stool culture and c. diff and follow-up\n -monitor fever curve- patient initially febrile but became hypothermic\n requiring bear hugger, now normothermic\n Respiratory Failure: Initially respiratory failure thought to be due\n to pneumonia. Patient on pressure support with 40% O2; with thick\n secretions, however looks like working harder to breath with tachypnea.\n + Gag reflex prior although not too much with deep suctioning this\n morning. Patient squeezing hands this morning.\n -culture data and antibiotics as above\n - Suction PRN\n - will go up on pressure support today to 10 or 12 to improve breathing\n - continue sedation for now\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension\n - gave 10 IV hydral in the setting of hypertension to 200 may be in the\n setting of agitation, would like to get away from IV hydral and titrate\n up beta blocker as tolerated\n - lisinopril 2.5 mg daily\n -metoprolol 50 mg TID, consider furthur uptitration as tolerated\n post-extubation\n - lasix today for blood pressure control as well as fluid removal\n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since blood is prokinetic.\n Will guaiac stool when available.\n - crit is stable\n -Patient guaic positive in the ED, have not sent stool studies as\n patient has had no stool, however suspect positive\n - Coffee ground emesis from NG tube; guaiac negative\n - continue to follow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n to 0.7. Likely prerenal in etiology secondary to volume depletion and\n septic shock\n likely ATN. No cast seen in UA, but it was not fresh.\n Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n - trend creatinine\n -Maintain adequate BP and hydration\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with multiple negative troponins. This is\n likely demand ischemia in setting of hypotension. Now that BP and\n tachycardia under control, warm and perfusing, can follow-up cardiac\n function with echo.\n - repeat EKG from EKG Sinus rhythm. Premature ventricular\n contractions. Poor R wave progression may be lead placement or possible\n old anterior myocardial infarction. Compared to\n the previous tracing of axis has shifted rightward. Ventricular\n ectopy is new.\n - ECHO from - IMPRESSION: Mild focal LV systolic dysfunction.\n Mildly dilated right ventricle. Mild to moderate aortic regurgitation.\n Moderately dilated ascending aorta.\n - troponins slighlty increased, but in settig of sepsis may represent\n myocardial stunning, also echo is reassuming that there is no regional\n wall motion abnormalities\n Dementia: Currently intubated to difficult to assess mental status.\n - restart namenda and aricept yesterday\n FEN:\n - restart tube feeds\n -check pm lytes, replete electrolytes as needed.\n Prophylaxis: SC heparin, holding bowel regimen for diarrhea\n Access: RIJ\n Communcation: Sister \n Code: Full Code.\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 01:49 PM 55 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "General", "chartdate": "2192-08-24 00:00:00.000", "description": "Generic Note", "row_id": 343006, "text": "TITLE:\n Pt was extubated without incident. Positive cuff leak pre-extubation\n and no stridor post-extubation. Pt is now on 50% cool aerosol.\n" }, { "category": "Nursing", "chartdate": "2192-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343053, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology. Previous on pressors, sepsis resolving with normal\n lactate. New leukocytosis, WBC 22.6 ? new UTI vs c-diff ( loose stools\n x 1 day) ARF resolved, creatinine at baseline 0.8; previous hematocrit\n drop; normocytic normochromic with iron profile sugesting chornic\n disease or infection, Coffee ground emesis from NG tube; guaiac\n negative; hct stable at 27.1 as of yesterday. Slightly increased\n troponin with ST depressions from previous EKG mostly likely demand\n ischemia related to hypotension.\n .\n .H/O hypertension, benign\n Assessment:\n Very hypertensive at beginning of shift with sbp up to as high as 200.\n unable to tell if pt in pain although appearing uncomfortable d/t\n tachypneic up to high 40s ( see pneumonia).\n Action:\n Given 10mg iv hydralazine for htn and 12.5mcg fentanyl for pain. Ngt\n placed in l nare to give po meds and confirmed + placement via cxr.\n Response:\n Htn continues but down to 160s. still tachypneic but now down to 30s.\n Plan:\n Continue antihypertensives, iv hyralazine prn as ordered, may need more\n fentanyl if appears uncomfortable again with tachypnea.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2192-08-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342207, "text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n -Baseline status per nurse : Patient is minimally\n verbal at baseline. When you call her name she will look at you. If\n you ask her how she is she will reply \"fine\" but she can't carry on a\n conversation. She has a dense paralysis on the right side and does\n not spontaneously move unless stimulated by nursing staff.\n - RESPIRATORY CULTURE (Preliminary): No growth\n - Urine culture - E coli\n - Blood Culture, Routine (Final ): E coli\n - Asked them to add on aztreonam sensitivities - if sensitive to\n aztreonam would consider d/c of gent\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 05:00 AM\n Vancomycin - 09:06 AM\n Gentamicin - 09:30 PM\n Aztreonam - 11:50 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydralazine - 01:26 PM\n Dextrose 50% - 03:27 PM\n Heparin Sodium - 08:00 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 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36.9\nC (98.5\n HR: 86 (73 - 92) bpm\n BP: 155/64(95) {120/50(73) - 325/115(105)} mmHg\n RR: 25 (0 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 14 (9 - 14)mmHg\n Total In:\n 2,541 mL\n 257 mL\n PO:\n TF:\n IVF:\n 2,401 mL\n 257 mL\n Blood products:\n Total out:\n 1,563 mL\n 545 mL\n Urine:\n 1,473 mL\n 510 mL\n NG:\n 90 mL\n 35 mL\n Stool:\n Drains:\n Balance:\n 978 mL\n -288 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 452 (452 - 647) mL\n PS : 12 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 68\n RSBI Deferred: RR >35\n PIP: 18 cmH2O\n SpO2: 97%\n ABG: 7.36/34/126/18/-5\n Ve: 9.9 L/min\n PaO2 / FiO2: 315\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), Hard to\n assess heart sounds since patient tachypneic with loud noises.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present),\n Increased amplitude\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese,\n Normal intercostal reflexes\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Normal ROTs\n Skin: Not assessed\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Normal, Negative Babinsky; corneal reflex present,\n diminished gag reflex.\n Labs / Radiology\n 104 K/uL\n 8.7 g/dL\n 83 mg/dL\n 1.2 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 117 mEq/L\n 143 mEq/L\n 26.5 %\n 10.8 K/uL\n [image002.jpg]\n 04:52 PM\n 09:18 PM\n 09:30 PM\n 09:47 PM\n 05:00 AM\n 05:13 AM\n 12:00 PM\n 05:37 PM\n 04:45 AM\n 05:03 AM\n WBC\n 8.9\n 10.8\n Hct\n 28.2\n 28.3\n 25.6\n 27.6\n 26.5\n Plt\n 104\n Cr\n 1.6\n 1.6\n 1.5\n 1.2\n TropT\n 0.14\n 0.14\n TCO2\n 14\n 21\n 20\n 20\n Glucose\n 111\n 110\n 78\n 83\n Other labs: PT / PTT / INR:14.6/41.4/1.3, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.6\n mg/dL, Mg++:1.8 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2192-08-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342208, "text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n -Baseline status per nurse : Patient is minimally\n verbal at baseline. When you call her name she will look at you. If\n you ask her how she is she will reply \"fine\" but she can't carry on a\n conversation. She has a dense paralysis on the right side and does\n not spontaneously move unless stimulated by nursing staff.\n - RESPIRATORY CULTURE (Preliminary): No growth\n - Urine culture - E coli\n - Culture, Routine (Final ): E coli\n - Asked them to add on aztreonam sensitivities - if sensitive to\n aztreonam would consider d/c of gent\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 05:00 AM\n Vancomycin - 09:06 AM\n Gentamicin - 09:30 PM\n Aztreonam - 11:50 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydralazine - 01:26 PM\n Dextrose 50% - 03:27 PM\n Heparin Sodium - 08:00 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 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36.9\nC (98.5\n HR: 86 (73 - 92) bpm\n BP: 155/64(95) {120/50(73) - 325/115(105)} mmHg\n RR: 25 (0 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 14 (9 - 14)mmHg\n Total In:\n 2,541 mL\n 257 mL\n PO:\n TF:\n IVF:\n 2,401 mL\n 257 mL\n products:\n Total out:\n 1,563 mL\n 545 mL\n Urine:\n 1,473 mL\n 510 mL\n NG:\n 90 mL\n 35 mL\n Stool:\n Drains:\n Balance:\n 978 mL\n -288 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 452 (452 - 647) mL\n PS : 12 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 68\n RSBI Deferred: RR >35\n PIP: 18 cmH2O\n SpO2: 97%\n ABG: 7.36/34/126/18/-5\n Ve: 9.9 L/min\n PaO2 / FiO2: 315\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), Hard to\n assess heart sounds since patient tachypneic with loud noises.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present),\n Increased amplitude\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese,\n Normal intercostal reflexes\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Normal ROTs\n Skin: Not assessed\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Normal, Negative Babinsky; corneal reflex present,\n diminished gag reflex.\n Labs / Radiology\n 104 K/uL\n 8.7 g/dL\n 83 mg/dL\n 1.2 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 117 mEq/L\n 143 mEq/L\n 26.5 %\n 10.8 K/uL\n [image002.jpg]\n 04:52 PM\n 09:18 PM\n 09:30 PM\n 09:47 PM\n 05:00 AM\n 05:13 AM\n 12:00 PM\n 05:37 PM\n 04:45 AM\n 05:03 AM\n WBC\n 8.9\n 10.8\n Hct\n 28.2\n 28.3\n 25.6\n 27.6\n 26.5\n Plt\n 104\n Cr\n 1.6\n 1.6\n 1.5\n 1.2\n TropT\n 0.14\n 0.14\n TCO2\n 14\n 21\n 20\n 20\n Glucose\n 111\n 110\n 78\n 83\n Other labs: PT / PTT / INR:14.6/41.4/1.3, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.6\n mg/dL, Mg++:1.8 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia and septic physiology.\n Septic Shock: Current differential includes pneumonia vs. urosepsis\n vs. GI source. Cultures currently growing e. coli in the urine and the\n . Sputum cultures with polys and 4+ oropharyngeal flora. Patient\n was noted to have distended abdomen on presentation, CT abdomen shows\n distended bladder, b/l hydroureters and gas/stool in bowel with some\n mild bowel thickening. There is no indication of obstruction but\n patient has not passed gas/stool since admission (unclear if this is\n chronic diarrhea). This is likely ileus secondary to acute illness and\n less likely an infectious source. For hypotension the patient received\n large volume of IV NS, LR. Switched to D5 1/2NS w/bicarb d/t rising K\n and Na.\n - sputum cx/urine cx as above\n - currently on vancomycin, aztreonam, gentamycin, levofloxacin\n - would like to peel off an antibiotic given that now growing e. coli\n in the urine and in the , wait on speciation until this\n evening\n - currently off all pressors, off sedation\n - currently now hypertensive\n - lactate this AM 2.6 which is down from 3.4\n -monitor WBC, CBC, diff\n decreased hct this AM\n monitor fever curve- patient initially febrile but became hypothermic\n requiring bear hugger, now normothermic\n Respiratory Failure: Initially respiratory failure thought to be due to\n pneumonia. Patient on CPAP Vt 420, PEEP 8, FiO2 40%..\n -culture data from sputum thus far has grown orophyaryngeal flora only\n - patient would be candidate for extubation if mental status were\n better, currently no gag as per nursing, however unclear if at baseline\n patient has gag\n -off sedation\n Hematocrit drop\n -Patient guaic positive in the ED, have not sent stool studies as\n patient has had no stool, however suspect positive\n - Coffee ground emesis from NG tube\n - Ordered iron studies for AM tomorrow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n to 1.5. Likely prerenal in etiology secondary to volume depletion and\n septic shock\n likely ATN.\n - IVF boluses to maintain urine output\n - trend creatinine\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with upward trending CE. This is likely demand\n ischemia in setting of hypotension. Now that BP and tachycardia under\n control, warm and perfusing, can follow-up cardiac function with echo.\n - recheck EKG now that tachycardia has improved\n - ECHO ordered, not yet completed, unlikely to get done over the\n weekend\n - troponins on were 0.02, 0.03, 0.05\n - no troponins drawn yesterday\n - put in add on troponins for this AM\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension\n - gave 10 IV hydral in the setting now of hypertension to 200 may be in\n the setting of agitation\n - will hold on lisinopril in the setting of acute renal failure\n - written for metoprolol 25 mg PO BID, will continue to uptitrate as\n tolerated by heart rate and pressure and use hydral PRN as needed\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n - will call today to try to find out what baseline mental\n status is, question as to whether patient has gag at baseline, what her\n baseline orientation is etc\n FEN:\n - pt currently with high residuals so not getting tube feeds\n - will start IV maintenance fluids at 100 cc/ hr of normal saline as\n patient not eating\n - patient with evidence of stool in distal , give her fleets\n enema today, hope that that will improve residuals and allow for tube\n feedings\n -Monitor and replete electrolytes as needed.\n -Monitor K closely, add kayexelate if needed.\n -NGT in place with coffee ground emesis\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: DNR per nursing home record signed by patient's sister. Clarify\n goals of care with HCP.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2192-08-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342281, "text": "82 year old female with a history of breast CA (s/p XRT), CVA, baseline\n dementia, HTN, reflux, & recurrent UTI\ns, who presented on early\n am from after being found to be in respiratory distress\n with oxygen sats in 70s to 80\ns on r/a. Her EKG per report was within\n normal limits. Her exam was notable for audible rales and abdominal\n distension. Sent to EW, where she was emergently Intubated.\n T103. Code sepsis not initiated as BP >100/systolic. Peripheral BC\n from EW grew 4 out of 4 bottles positive for gram negative rods, E coli\n on C&S. Urine Cx () grew E coli. Sputum Cx shows many\n organisms consistent w/oropharyngeal flora. Became hypotensive in MICU\n on afternoon, received fluid boluses & levophed IV. Treated w/IV\n levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission. Off\n levophed since 0600. repeat sputum cx revealed gm + cocci.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Remains Intubated on psv: 12 ps, 5 peep on 40% fi02, maintaining 02\n sats in upper 90s to 100s. lungs with scattered rhonci in right lobe,\n left lung clear, diminished at bases. No gag, impaired weak cough.\n Continues with altered mental status (has baseline dementia) and\n sedated on fentanyl 50mcg/hr and versed 1mg/hr. opens eyes to voice or\n nsg intervention. Not following commands. R hemi. Moves l side\n occasionally but not on command. No agitation noted this shift.\n Action:\n Pt rested overnight per micu team and resp. therapist on 12 psv, 5 peep\n as pt having resp. distress yesterday with attempting to wean the psv,\n appeared r/t increased secretions and a sedation issue. Tube feeds shut\n off at 5am md request in possible event pt may get extubated later\n today.\n Response:\n Tolerating current vent settings well with fi02 40%, 12 psv, 5 peep.\n Adequately sedated on fentanyl 50mcg/hr and versed 1mg/hr.\n Plan:\n Attempt to wean psv in am and lighten sedation when psv decreases.\n .H/O hypertension, benign\n Assessment:\n Appears to be In\nwandering atrial pacemaker with 3 different p waves\n detected.continues with slightly high sbp. In the 160s.\n Action:\n Hyrdalaxiine given early at 11am d/t rising sbp in 160s. also receiving\n metoprolol via ogt.\n Response:\n Sbp dropping down to the 130s-140s with pt in WAP. Hr 60s-80s WAP.\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinine 1.2 on . urine output dropping to as low as 15cc/hr. pt\n receiving kvo, iv abx volume, tube feedings, 150cc free water boluses\n q6hr. potassium, magnesium, and phosphate levels low last am .\n Action:\n Ivf started: d5ns started, infusing at 100cc/hr. foley flushed without\n difficulty,\n Response:\n Creatinine stabilizing. Urine output increased up to 60cc/hr.\n Plan:\n Continue to monitor creatinine level daily, continue ivf. Monitor\n hourly urine ouput.\n i\n" }, { "category": "Respiratory ", "chartdate": "2192-08-22 00:00:00.000", "description": "Generic Note", "row_id": 342433, "text": "TITLE:\n Resp Care\n Remained Intubated and ventilated on cpap/psv . ABGs within\n normal limits. Suctioned for moderate amount of thick yellow\n secretions. RSBI= 56. Currently on %. Plan is for possible\n extubation this morning.\n" }, { "category": "Nursing", "chartdate": "2192-08-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342591, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology. Previous on pressors, sepsis resolving with normal\n lactate. New leukocytosis, WBC 22.6 ? new UTI vs c-diff ( loose stools\n x 1 day) ARF resolved, creatinine at baseline 0.8; previous hematocrit\n drop; normocytic normochromic with iron profile sugesting chornic\n disease or infection, Coffee ground emesis from NG tube; guaiac\n negative; hct stable at 27.1 as of yesterday. Slightly increased\n troponin with ST depressions from previous EKG mostly likely demand\n ischemia related to hypotension.\n .\n Respiratory Failure due to Pneumonia, bacterial, hospital acquired\n (non-VAP)\n Assessment:\n Patient on pressure support with 40% O2, sats 98-100%, moderate to\n large amount of thick yellow secretions, with moderate amount from\n oral; lung sounds rhonchorous, dim at bases. ETT 20 at the lip; repeat\n sputum culture with 3+ gram positive cocci in pairs and chains, with 2+\n oropharyngeal flora, speciation partial only with oral flora; vanc day\n 2, gentamicin day . afebrile, WBC 22.6 as of yesterday morning.\n Sedated with fentanyl 50 mcg/hr and versed 0.5 mg/hr\n Action:\n Suctioned secretions from ETT q2-3 hours, turn to sides q2-3 hours;\n continues on antibiotics ( Vanco and Gentamycin)\n Response:\n Sats > 95% at same settings, tachypneic 28-30\ns when awake Tolerated\n daily wake\nup for 30 mins BP 150\ns RSBI =94 minute volume 9.9-10L/min,\n ETT secretions decreased than what she had at the beginning of the\n shift. Still with poor cough and impaired gag\n Plan:\n Culture if temp spikes, continue pulmonary toilet and antibiotics;\n frequent pulmonary toilet\n Altered mental status (not Delirium)\n Assessment:\n History of CVA / dementia; ? if baseline aphasic, opens eye to\n stimulation ( turning and repositioning) but not tracking, impaired\n corneal, gag and very weak coughing reflexes. Pupils pinpoint but\n reactive. Slightly withdraws to pain\n nail bed. Noticed drooling when\n on her L side. 2mg/hr of versed at the beginning of the shift, not\n opening her eyes\n Action:\n Versed weaned down to 0.5 mg/hr, fentanyl resumed at 50 mcg/hr for\n pain. Patient BP 170\ns off pain med.\n Response:\n Awake with less benzos, BP better controlled with fentanyl on board.\n Not tracking\n Plan:\n Daily wake up this am; to start on namenda and aricept.\n Electrolyte & fluid disorder, other\n Assessment:\n Evening lytes K- 3.4, phos -2.0 and calcium- 7.4; soaked with loose\n stool at the beginning of the shift, FS 61 at 1800 received\n amp D50W\n at 1830 per day nurse, repeat FS 76\n Action:\n Repleted with 40 mEq KCl, 2 packets of neutraphos and 2 grams of\n calcium gluconate; tube feeds restarted @ 20cc/hr with 150cc water\n flushes q6hrs\n Response:\n - 1.5 L as MN still 15l positive fro the LOS; tolerating tube feeds\n with 0-5 cc residuals q4hrs; no further loose stools noted\n Plan:\n Repeat lytes in am; replete per sliding scale, increase tube feeds to\n goal 55/hr\n .H/O hypertension, benign\n Assessment:\n SBP 170\ns at start of shift, NSR with WAP, occasional\n frequent PVCs\n Action:\n Electrolytes repleted, fentanyl drip resumed, schedules 50 mgs\n lopressor PO given\n Response:\n BP well controlled with beta blocker and pain meds SBP 120-130\ns, PVC\n remains frequent intermittently\n Plan:\n Continue lopressor and lisinopril, pain meds\n" }, { "category": "Respiratory ", "chartdate": "2192-08-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 342277, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 59 None\n Ideal tidal volume: 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: 20 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: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / 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: RESPIRATORY CARE: PT BECAME ANXIOUS/ AGGITATED THIS AM\n REQUIRING MORE SEDATION AND PRESSURE SUPPORT TO 20. HAS SINCE IMPROVED\n AND PS TAPERED BACK TO 12. WILL C/W PS 12 AS TOLERATED.\n" }, { "category": "Nursing", "chartdate": "2192-08-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342522, "text": "Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Pt tolerated Psv 5/5 large amt of secretions\n Action:\n Suctioned q 2 hrs , aggressive pulm toileting\n Response:\n Unable to extubated at this time\n Plan:\n Contt pulm toileting and active weaning as tolerated\n Altered mental status (not Delirium)\n Assessment:\n Aphasic patient , non responsive\n Action:\n Shut fent and versed\n Response:\n No change in pt neuro status , pt became hypertensive into 200\n systolic\n Plan:\n Versed back on bolused w/ fentynal 50mg\n" }, { "category": "Physician ", "chartdate": "2192-08-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342646, "text": "Chief Complaint: 82 year old female with h/o breast cancer, cva, htn\n who presented from rehab with pneumonia, uti with sepsis physiology.\n s/p intubation.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:00 AM\n URINE CULTURE - At 12:23 AM\n -Yesterday per nursing thought that patient not be ready for extubation\n with lots of secretions.\n - restarted namenda and aricept\n - low potassium yesterday morning, got repletion with IV sliding scale\n - fingersticks was 37 yesterday morning, then subsequently 61 (got \n amp d50) - which was not written for by M.D.\n - tube feeds were not re-started yesterday morning, even though it was\n decided on rounds to restart b/c did not extubate patient\n - spoke with evening nurse, restarted tube feeds, sent stool for c.\n diff (nurse like c. diff) so placed patient on\n precautions\n - repeat ca and phos low, repleted, still low\n - repeat UA still with large LE, WBCs, RBcs, urine cx pending\n - got repleted but phos didn't change, off Versed overnight, had to go\n back on fentanyl, d/c fentayl drip 5 am will bolus as needed with goal\n to wean this morning\n - Gent level this morning 3.8\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Vancomycin - 08:12 AM\n Gentamicin - 11:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 PM\n Fentanyl - 05:57 PM\n Dextrose 50% - 06:53 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 83 (67 - 108) bpm\n BP: 143/52(80) {124/45(67) - 190/75(112)} mmHg\n RR: 29 (0 - 37) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 8 (6 - 9)mmHg\n Total In:\n 823 mL\n 765 mL\n PO:\n TF:\n 79 mL\n 140 mL\n IVF:\n 554 mL\n 125 mL\n Blood products:\n Total out:\n 2,500 mL\n 490 mL\n Urine:\n 2,500 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,677 mL\n 275 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 414 (305 - 473) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 94\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: ///21/\n Ve: 9.8 L/min\n Physical Examination\n General\n intubated, sedated, nad\n Cards\n RRR, nl s1/s2, no murmurs appreciated\n Pulm- bronchial breath sounds right side, left lung more clear\n Abdomen -soft, non-tender, non-distended\n Extremities\n warm and well perfused, 2+ radial pulses trace edema feet\n b/l\n Labs / Radiology\n 133 K/uL\n 8.8 g/dL\n 90 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 144 mEq/L\n 26.8 %\n 22.8 K/uL\n [image002.jpg]\n 07:34 AM\n 03:29 PM\n 03:16 AM\n 03:31 AM\n 07:50 PM\n 04:10 AM\n 05:33 AM\n 06:00 AM\n 07:59 PM\n 03:58 AM\n WBC\n 17.0\n 22.6\n 22.8\n Hct\n 28.6\n 27.1\n 26.8\n Plt\n 91\n 104\n 133\n Cr\n 1.0\n 0.8\n 0.7\n 0.7\n TCO2\n 19\n 22\n 20\n 22\n 24\n Glucose\n 95\n 37\n 40\n 145\n 61\n 90\n Other labs: PT / PTT / INR:15.1/26.8/1.3, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:92.1 %, Band:5.0 %, Lymph:4.4 %, Mono:3.0 %, Eos:0.4\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.6\n mg/dL, Mg++:1.7 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology.\n Septic Shock: Patient was with SIRS with E coli in blood and urine.\n CXR shows bibasilar consolidations as well concerning for possible\n pneumonia. Sputum culture with gram + cocci however this has not grown\n out so far in speciation. There is some mild enteritis as wel as CTl.\n Presentation lactate was 3.4, then trended down.\n- repeat sputum culture - GRAM STAIN (Final ): >25 PMNs and <10 epitheli\n cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CHAINS.\n2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\nRESPIRATORY CULTURE (Final ): SPARSE GROWTH OROPHARYNGEAL FLORA.\n Urine -urine cx - URINE CULTURE (Final ):\n ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..\n PRESUMPTIVE IDENTIFICATION.\n PROVIDENCIA STUARTII. 10,000-100,000 ORGANISMS/ML..\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n ESCHERICHIA COLI\n | PROVIDENCIA STUARTII\n | |\n AMIKACIN-------------- <=2 S\n AMPICILLIN------------ 16 I\n AMPICILLIN/SULBACTAM-- 4 S\n CEFAZOLIN------------- <=4 S\n CEFEPIME-------------- <=1 S <=1 S\n CEFTAZIDIME----------- <=1 S <=1 S\n CEFTRIAXONE----------- <=1 S <=1 S\n CEFUROXIME------------ 4 S\n CIPROFLOXACIN--------- =>4 R =>4 R\n GENTAMICIN------------ <=1 S 8 I\n MEROPENEM-------------<=0.25 S <=0.25 S\n NITROFURANTOIN-------- <=16 S 256 R\n PIPERACILLIN---------- <=4 S <=4 S\n PIPERACILLIN/TAZO----- <=4 S <=4 S\n TOBRAMYCIN------------ <=1 S 8 I\nTRIMETHOPRIM/SULFA---- <=1 S <=1 S\n - currently on gentamycin Day to cover for urosepsis as well as\n possible healthcare associated pneumonia, vancomycin for possible\n healthcare associated pnemonia\n - currently off all pressors, now hypertensive\n -monitor WBC, CBC, diff\n - wbc count continuese to trend up\n will send repeat ua and urine\n culture as well as stool culture and c. diff and follow-up\n -monitor fever curve- patient initially febrile but became hypothermic\n requiring bear hugger, now normothermic\n Respiratory Failure: Initially respiratory failure thought to be due\n to pneumonia. Patient on pressure support with 40% O2; with thick\n secretions. + Gag reflex prior although not too much with deep\n suctioning this morning. Patient squeezing hands this morning.\n -culture data and antibiotics as above\n - Suction PRN\n - attempt extubation this morning as almost no pressure support\n - will shut off sedation and see if mental status improves, stronger\n cough and stronger gag prior to extubation\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension\n - gave 10 IV hydral in the setting of hypertension to 200 may be in the\n setting of agitation, would like to get away from IV hydral and titrate\n up beta blocker as tolerated\n - lisinopril 2.5 mg daily, will titrate up today to 5 mg daily\n -metoprolol 50 mg TID, consider furthur uptitration as tolerated\n post-extubation\n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since blood is prokinetic.\n Will guaiac stool when available.\n - crit is stable\n -Patient guaic positive in the ED, have not sent stool studies as\n patient has had no stool, however suspect positive\n - Coffee ground emesis from NG tube; guaiac negative\n - continue to follow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n to 0.7. Likely prerenal in etiology secondary to volume depletion and\n septic shock\n likely ATN. No cast seen in UA, but it was not fresh.\n Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n - trend creatinine\n -Maintain adequate BP and hydration\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with multiple negative troponins. This is\n likely demand ischemia in setting of hypotension. Now that BP and\n tachycardia under control, warm and perfusing, can follow-up cardiac\n function with echo.\n - repeat EKG from EKG Sinus rhythm. Premature ventricular\n contractions. Poor R wave progression may be lead placement or possible\n old anterior myocardial infarction. Compared to\n the previous tracing of axis has shifted rightward. Ventricular\n ectopy is new.\n - ECHO from - IMPRESSION: Mild focal LV systolic dysfunction.\n Mildly dilated right ventricle. Mild to moderate aortic regurgitation.\n Moderately dilated ascending aorta.\n - troponins slighlty increased, but in settig of sepsis may represent\n myocardial stunning, also echo is reassuming that there is no regional\n wall motion abnormalities\n Dementia: Currently intubated to difficult to assess mental status.\n - restart namenda and aricept yesterday\n FEN:\n - tube feedings overnight, hold this AM for extubation\n -Monitor and replete electrolytes as needed.\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: Full Code.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2192-08-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343103, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology. Previous on pressors, sepsis resolving with normal\n lactate. New leukocytosis, WBC 22.6 ? new UTI vs c-diff ( loose stools\n x 1 day) ARF resolved, creatinine at baseline 0.8; previous hematocrit\n drop; normocytic normochromic with iron profile sugesting chornic\n disease or infection, Coffee ground emesis from NG tube; guaiac\n negative; hct stable at 27.1 as of yesterday. Slightly increased\n troponin with ST depressions from previous EKG mostly likely demand\n ischemia related to hypotension.\n .\n .H/O hypertension, benign\n Assessment:\n Very hypertensive at beginning of shift with sbp up to as high as 200.\n unable to tell if pt in pain most of shift although appearing\n uncomfortable d/t tachypneic up to high 40s ( see pneumonia).\n Action:\n Given 10mg iv hydralazine for htn and 12.5mcg fentanyl for pain. Ngt\n placed in l nare to give po meds and confirmed + placement via cxr.\n Response:\n Htn continues but down to 160s after pain med given and receives\n hydralazine. still tachypneic but now down to high 20s to low 30s.\n continues to have tachypnea with repositioning requiring 12.5mcg\n fentanyl iv with good effect. Rr down to high 20s and appears more\n comfortable. Sbp up to 180s again with each turn but down to 160s after\n fentanyl given for comfort. At 6am did moan with repositioning\n appearing very uncomfortable. Given an additional 12.5mcg fentanyl for\n pain. Also given another 10mg iv hydralazine for htn with sbp in 180s.\n Plan:\n Continue antihypertensives, iv hyralazine prn as ordered, fentanyl prn\n with turns if appears uncomfortable again with tachypnea.\n Altered mental status (not Delirium)\n Assessment:\n Lethargic, opens eyes to voice, not following commands, nonverbal,\n localizes pain. Very stiff and contracted. Very little upper extremity\n movement, no lower extremity movement noted. Pt has baseline dementia\n and is not far from her baseline although family states pt is usually\n verbal with one word. Pt appearing to have pain as stated above with\n tacypnea with repositioning. Unable to take pos.\n Action:\n Reoriented frequently. Medicated with 12.5mcg fentanyl with\n repositioning. Ngt placed and confirmed via cxr po meds given via ngt.\n Senna given to keep bowels moving.\n Response:\n Continues with baseline dementia requiring frequent reorienting.\n Discomfort with tachypnea relieved with iv fentanyl. Medium and large\n loose/liquid stool.\n Plan:\n Continue to reorient prn and medicate with 12.5mcg fentanyl prn with\n repositioning. Hold bowel meds today, resume if no further bm today.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Pt with audible rhonchi most prominent 1^st half of shift with copious\n clear secretions from back of throat pooling into her face tent. Also\n sounded so junky in upper airways as if she was drowning in secretions.\n Am k = 3.2. continues to have frequent pvcs, short 3 beat runs vtachy.\n Apcs.\n Action:\n Nts for moderate amts thick white frothy secretions. Given 20mg iv\n lasix and diuresing well. Receiving iv abx, amikacin trough and peak\n drawn, pending. Receiving 60 meq iv kcl via r ij tlcl.\n Response:\n 4.9 liters negative by midnight over last 24 hours. 700cc negative\n since midnight tonight. Much less rhonchi the 2^nd of the shift. Am\n Abg good: 7.43/39/99.\n Plan:\n Continue suctioin prn, assess fluid status. Abx, replete lytes prn.\n Head and chest ct without contrast today per team to r/o malignant\n cells in right middle lobe that were found to have multiple\n questionable lesions on cxr yesterday.\n" }, { "category": "Nursing", "chartdate": "2192-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342272, "text": "82 year old female with a history of breast CA (s/p XRT), CVA, baseline\n dementia, HTN, reflux, & recurrent UTI\ns, who presented on early\n am from after being found to be in respiratory distress\n with oxygen sats in 70s to 80\ns on r/a. Her EKG per report was within\n normal limits. Her exam was notable for audible rales and abdominal\n distension. Sent to EW, where she was emergently Intubated.\n T103. Code sepsis not initiated as BP >100/systolic. Peripheral BC\n from EW grew 4 out of 4 bottles positive for gram negative rods, E coli\n on C&S. Urine Cx () grew E coli. Sputum Cx shows many\n organisms consistent w/oropharyngeal flora. Became hypotensive in MICU\n on afternoon, received fluid boluses & levophed IV. Treated w/IV\n levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission. Off\n levophed since 0600.\n Nuero: Pt remains sedated on 50 mcg/hr of fentanyl and 1 mg/hr of\n versed. Left pupil 2 mm and reactive; left pupil 2 mm and nonreactive.\n Opens eyes when stimulated. Moves toes on bed nonpurposefully. Impaired\n cough and absent gag reflex.\n GI: Hypoactive BS. No residual from OGT. Abdomen soft and distended. TF\n started at 1300 with free water boluses. Small brown BM.\n Endo: Siding scale insulin. Blood sugars in 70\ns. Watched q1-2hours\n while on D51/2 NS at 100/hr.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Intubated on CPAP Fi02 40% with a tidal volume of 500-600 and a MV\n of . Sp02 100%, RR 13-25. Tmax 101, diaphoresis noted on face. Upper\n lung fields rhonchus; lower fields clear but diminished. Moderate thick\n tan/blood tinged secretions suctioned q1-2 hours.\n Action:\n Pt initially on CPAP but showed signs of resp distress, tachypnea\n in the high 30\ns, labored work of breathing, and SBP in 180-190. Drew\n ABG at 0730 7.40/30/74. Increased pressure support to 20 and boluses\n with fentanyl and versed in response to VS changes. Suctioned\n q1-2hours. Changed positions frequently. Abx administered. Discontinued\n Vanco and Levoflaxacin. Sputum culture sent. Tylenol given for temp.\n Another ABG drawn at 1530. 7.39/35/166\n Response:\n Pt settled down decreasing RR to and lowering SBP 120-130 after\n vent changes and fentanyl and versed boluses. Able to decrease pressure\n support again to 15 where the pt remains to look comfortable breathing\n 12-20 breaths/min, Sp02 100% and displaying nonlabored breathing.\n Secretions remain thick and lungs remain rhonchus. Gram positive grew\n out in sputum. Dropped pressure support again to 12 as VSS- (+)\n response, RR 15, tidal volume 500, MV 8.\n Plan:\n Decrease pressure support as tolerated. ? ability to r/t copious\n amounts of secretions. Collect ABG as needed. Suction as needed noting\n amount and consistency of secretions. Positions changes. Tylenol as\n needed. Abx.\n .H/O hypertension, benign\n Assessment:\n Currently-- ABP 110-130/50-60. NSR 70-80\ns with occasional PVC\ns. Trop\n level at 0.14 DP pulses weakly palpable, PT pulses Doppler. <3 cap\n refill.\n Action:\n This morning the pt\ns ABP began to rise to a SBP of 180-190 with a HR\n of 110-120 and increasing ectopy. A bolus of versed and fentanyl was\n administered along with an increase in pressure support and ETT suction\n as the pt\ns work of breathing was also noted to be labored. Kept room\n dark and quiet allowing pt to rest and settle. Standing PO lopressor\n and IV hydralazine administered at 1200. Echo done at 1000. Team aware\n of trop level.\n Response:\n Pt responded well to boluses, vent changes, and resp care as SBP\n decreased to 120-130 along with the HR to 70-80\ns. Ectopy still noted\n but decreasing in frequency.\n Plan:\n Continue to monitor ABP and correlation between work of breathing and\n BP changes. Monitor sedation and its role in controlling ABP as well.\n Monitor cardiac changes resulting from ischemia r/t hypertension\n specifically trop levels and EKG changes. Administer standing cardiac\n meds.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO adequate 50-200 cc/hr; urine light yellow and clear. (+) 18 Liters\n for LOS. BUN 25 CR 1.2. Weight at 1000 was 77.7 kg.\n Action:\n Hourly UO. Started high fiber tube feedings at 1300 at 20 ml/hr with\n 150 cc fluid bolus q6h.\n Response:\n Pt remains to autodiurese. Minimal residual increased TF to 40 ml/hr at\n 1830.\n Plan:\n Follow BUN and Cr in AM labs. ? renal baseline. Check TF residuals q4h\n holding for >150 and increase rate q6h as tolerated with goal of 55\n ml/hr.\n" }, { "category": "Nursing", "chartdate": "2192-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342273, "text": "82 year old female with a history of breast CA (s/p XRT), CVA, baseline\n dementia, HTN, reflux, & recurrent UTI\ns, who presented on early\n am from after being found to be in respiratory distress\n with oxygen sats in 70s to 80\ns on r/a. Her EKG per report was within\n normal limits. Her exam was notable for audible rales and abdominal\n distension. Sent to EW, where she was emergently Intubated.\n T103. Code sepsis not initiated as BP >100/systolic. Peripheral BC\n from EW grew 4 out of 4 bottles positive for gram negative rods, E coli\n on C&S. Urine Cx () grew E coli. Sputum Cx shows many\n organisms consistent w/oropharyngeal flora. Became hypotensive in MICU\n on afternoon, received fluid boluses & levophed IV. Treated w/IV\n levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission. Off\n levophed since 0600.\n Nuero: Pt remains sedated on 50 mcg/hr of fentanyl and 1 mg/hr of\n versed. Left pupil 2 mm and reactive; left pupil 2 mm and nonreactive.\n Opens eyes when stimulated. Moves toes on bed nonpurposefully. Impaired\n cough and absent gag reflex.\n GI: Hypoactive BS. No residual from OGT. Abdomen soft and distended. TF\n started at 1300 with free water boluses. Small brown BM.\n Endo: Siding scale insulin. Blood sugars in 70\ns. Watched q1-2hours\n while on D51/2 NS at 100/hr.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Intubated on CPAP Fi02 40% with a tidal volume of 500-600 and a MV\n of . Sp02 100%, RR 13-25. Tmax 101, diaphoresis noted on face. Upper\n lung fields rhonchus; lower fields clear but diminished. Moderate thick\n tan/blood tinged secretions suctioned q1-2 hours.\n Action:\n Pt initially on CPAP but showed signs of resp distress, tachypnea\n in the high 30\ns, labored work of breathing, and SBP in 180-190. Drew\n ABG at 0730 7.40/30/74. Increased pressure support to 20 and boluses\n with fentanyl and versed in response to VS changes. Suctioned\n q1-2hours. Changed positions frequently. Abx administered. Discontinued\n Vanco and Levoflaxacin. Sputum culture sent. Tylenol given for temp.\n Another ABG drawn at 1530. 7.39/35/166\n Response:\n Pt settled down decreasing RR to and lowering SBP 120-130 after\n vent changes and fentanyl and versed boluses. Able to decrease pressure\n support again to 15 where the pt remains to look comfortable breathing\n 12-20 breaths/min, Sp02 100% and displaying nonlabored breathing.\n Secretions remain thick and lungs remain rhonchus. Gram positive grew\n out in sputum. Dropped pressure support again to 12 as VSS- (+)\n response, RR 15, tidal volume 500, MV 8.\n Plan:\n Decrease pressure support as tolerated. ? ability to r/t copious\n amounts of secretions. Collect ABG as needed. Suction as needed noting\n amount and consistency of secretions. Positions changes. Tylenol as\n needed. Abx.\n .H/O hypertension, benign\n Assessment:\n Currently-- ABP 110-130/50-60. NSR 70-80\ns with occasional PVC\ns. Trop\n level at 0.14 DP pulses weakly palpable, PT pulses Doppler. <3 cap\n refill.\n Action:\n This morning the pt\ns ABP began to rise to a SBP of 180-190 with a HR\n of 110-120 and increasing ectopy. A bolus of versed and fentanyl was\n administered along with an increase in pressure support and ETT suction\n as the pt\ns work of breathing was also noted to be labored. Kept room\n dark and quiet allowing pt to rest and settle. Standing PO lopressor\n and IV hydralazine administered at 1200. Echo done at 1000. Team aware\n of trop level.\n Response:\n Pt responded well to boluses, vent changes, and resp care as SBP\n decreased to 120-130 along with the HR to 70-80\ns. Ectopy still noted\n but decreasing in frequency.\n Plan:\n Continue to monitor ABP and correlation between work of breathing and\n BP changes. Monitor sedation and its role in controlling ABP as well.\n Monitor cardiac changes resulting from ischemia r/t hypertension\n specifically trop levels and EKG changes. Administer standing cardiac\n meds.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO adequate 50-200 cc/hr; urine light yellow and clear. (+) 18 Liters\n for LOS. BUN 25 CR 1.2. Weight at 1000 was 77.7 kg.\n Action:\n Hourly UO. Started high fiber tube feedings at 1300 at 20 ml/hr with\n 150 cc fluid bolus q6h.\n Response:\n Pt remains to autodiurese. Minimal residual increased TF to 40 ml/hr at\n 1830.\n Plan:\n Follow BUN and Cr in AM labs. ? renal baseline. Check TF residuals q4h\n holding for >150 and increase rate q6h as tolerated with goal of 55\n ml/hr.\n" }, { "category": "Respiratory ", "chartdate": "2192-08-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 342196, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 59 None\n Ideal tidal volume: 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: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT and on mech vent as per Metavision.\n Lung sounds coarse after suct mod th tan sput. ABGs compensated\n metabolic acidosis with good oxygenation; no vent changes required\n overnoc. Cont PSV.\n" }, { "category": "Nursing", "chartdate": "2192-08-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342584, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology. Previous on pressors, sepsis resolving with normal\n lactate. New leukocytosis, WBC 22.6 ? new UTI vs c-diff ( loose stools\n x 1 day) ARF resolved, creatinine at baseline 0.8; previous hematocrit\n drop; normocytic normochromic with iron profile sugesting chornic\n disease or infection, Coffee ground emesis from NG tube; guaiac\n negative; hct stable at 27.1 as of yesterday. Slightly increased\n troponin with ST depressions from previous EKG mostly likely demand\n ischemia related to hypotension.\n .\n Respiratory Failure due to Pneumonia, bacterial, hospital acquired\n (non-VAP)\n Assessment:\n Patient on pressure support with 40% O2, sats 98-100%, moderate to\n large amount of thick yellow secretions, with moderate amount from\n oral; lung sounds rhonchorous, dim at bases. ETT 20 at the lip; repeat\n sputum culture with 3+ gram positive cocci in pairs and chains, with 2+\n oropharyngeal flora, speciation partial only with oral flora; vanc day\n 2, gentamicin day . afebrile, WBC 22.6 as of yesterday morning.\n Sedated with fentanyl 50 mcg/hr and versed 0.5 mg/hr\n Action:\n Suctioned secretions from ETT q2-3 hours, turn to sides q2-3 hours;\n continues on antibiotics ( Vanco and Gentamycin)\n Response:\n Sats > 95% at same settings, tachypneic 28-30\ns when awake; increasing\n secretions requiring suctioning q2 hrs.\n Plan:\n Culture if temp spikes, continue pulmonary toilet and antibiotics\n Altered mental status (not Delirium)\n Assessment:\n History of CVA / dementia; ? if baseline aphasic, opens eye to\n stimulation ( turning and repositioning) but not tracking, impaired\n corneal, gag and very weak coughing reflexes. Pupils pinpoint but\n reactive. Slightly withdraws to pain\n nail bed. Noticed drooling when\n on her L side. 2mg/hr of versed at the beginning of the shift, not\n opening her eyes\n Action:\n Versed weaned down to 0.5 mg/hr, fentanyl resumed at 50 mcg/hr for\n pain. Patient BP 170\ns off pain med.\n Response:\n Awake with less benzos, BP better controlled with fentanyl on board.\n Not tracking\n Plan:\n Daily wake up this am; to start on namenda and aricept.\n Electrolyte & fluid disorder, other\n Assessment:\n Evening lytes K- 3.4, phos -2.0 and calcium- 7.4; soaked with loose\n stool at the beginning of the shift, FS 61 at 1800 received\n amp D50W\n at 1830 per day nurse, repeat FS 76\n Action:\n Repleted with 40 mEq KCl, 2 packets of neutraphos and 2 grams of\n calcium gluconate; tube feeds restarted @ 20cc/hr with 150cc water\n flushes q6hrs\n Response:\n - 1.5 L as MN still 15l positive fro the LOS; tolerating tube feeds\n with 0-5 cc residuals q4hrs; no further loose stools noted\n Plan:\n Repeat lytes in am; replete per sliding scale, increase tube feeds to\n goal 55/hr\n .H/O hypertension, benign\n Assessment:\n SBP 170\ns at start of shift, NSR with WAP, occasional\n frequent PVCs\n Action:\n Electrolytes repleted, fentanyl drip resumed, schedules 50 mgs\n lopressor PO given\n Response:\n BP well controlled with beta blocker and pain meds, PVC\ns remains\n frequent intermittently\n Plan:\n Continue lopressor and lisinopril, pain meds\n" }, { "category": "Nursing", "chartdate": "2192-08-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342585, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology. Previous on pressors, sepsis resolving with normal\n lactate. New leukocytosis, WBC 22.6 ? new UTI vs c-diff ( loose stools\n x 1 day) ARF resolved, creatinine at baseline 0.8; previous hematocrit\n drop; normocytic normochromic with iron profile sugesting chornic\n disease or infection, Coffee ground emesis from NG tube; guaiac\n negative; hct stable at 27.1 as of yesterday. Slightly increased\n troponin with ST depressions from previous EKG mostly likely demand\n ischemia related to hypotension.\n .\n Respiratory Failure due to Pneumonia, bacterial, hospital acquired\n (non-VAP)\n Assessment:\n Patient on pressure support with 40% O2, sats 98-100%, moderate to\n large amount of thick yellow secretions, with moderate amount from\n oral; lung sounds rhonchorous, dim at bases. ETT 20 at the lip; repeat\n sputum culture with 3+ gram positive cocci in pairs and chains, with 2+\n oropharyngeal flora, speciation partial only with oral flora; vanc day\n 2, gentamicin day . afebrile, WBC 22.6 as of yesterday morning.\n Sedated with fentanyl 50 mcg/hr and versed 0.5 mg/hr\n Action:\n Suctioned secretions from ETT q2-3 hours, turn to sides q2-3 hours;\n continues on antibiotics ( Vanco and Gentamycin)\n Response:\n Sats > 95% at same settings, tachypneic 28-30\ns when awake; increasing\n secretions requiring suctioning q2 hrs.\n Plan:\n Culture if temp spikes, continue pulmonary toilet and antibiotics\n Altered mental status (not Delirium)\n Assessment:\n History of CVA / dementia; ? if baseline aphasic, opens eye to\n stimulation ( turning and repositioning) but not tracking, impaired\n corneal, gag and very weak coughing reflexes. Pupils pinpoint but\n reactive. Slightly withdraws to pain\n nail bed. Noticed drooling when\n on her L side. 2mg/hr of versed at the beginning of the shift, not\n opening her eyes\n Action:\n Versed weaned down to 0.5 mg/hr, fentanyl resumed at 50 mcg/hr for\n pain. Patient BP 170\ns off pain med.\n Response:\n Awake with less benzos, BP better controlled with fentanyl on board.\n Not tracking\n Plan:\n Daily wake up this am; to start on namenda and aricept.\n Electrolyte & fluid disorder, other\n Assessment:\n Evening lytes K- 3.4, phos -2.0 and calcium- 7.4; soaked with loose\n stool at the beginning of the shift, FS 61 at 1800 received\n amp D50W\n at 1830 per day nurse, repeat FS 76\n Action:\n Repleted with 40 mEq KCl, 2 packets of neutraphos and 2 grams of\n calcium gluconate; tube feeds restarted @ 20cc/hr with 150cc water\n flushes q6hrs\n Response:\n - 1.5 L as MN still 15l positive fro the LOS; tolerating tube feeds\n with 0-5 cc residuals q4hrs; no further loose stools noted\n Plan:\n Repeat lytes in am; replete per sliding scale, increase tube feeds to\n goal 55/hr\n .H/O hypertension, benign\n Assessment:\n SBP 170\ns at start of shift, NSR with WAP, occasional\n frequent PVCs\n Action:\n Electrolytes repleted, fentanyl drip resumed, schedules 50 mgs\n lopressor PO given\n Response:\n BP well controlled with beta blocker and pain meds SBP 120-130\ns, PVC\n remains frequent intermittently\n Plan:\n Continue lopressor and lisinopril, pain meds\n" }, { "category": "Physician ", "chartdate": "2192-08-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342655, "text": "Chief Complaint: 82 year old female with h/o breast cancer, cva, htn\n who presented from rehab with pneumonia, uti with sepsis physiology.\n s/p intubation.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:00 AM\n URINE CULTURE - At 12:23 AM\n -Yesterday per nursing thought that patient not be ready for extubation\n with lots of secretions.\n - restarted namenda and aricept\n - low potassium yesterday morning, got repletion with IV sliding scale\n - fingersticks was 37 yesterday morning, then subsequently 61 (got \n amp d50) - which was not written for by M.D.\n - tube feeds were not re-started yesterday morning, even though it was\n decided on rounds to restart b/c did not extubate patient\n - spoke with evening nurse, restarted tube feeds, sent stool for c.\n diff (nurse like c. diff) so placed patient on\n precautions\n - repeat ca and phos low, repleted, still low\n - repeat UA still with large LE, WBCs, RBcs, urine cx pending\n - got repleted but phos didn't change, off Versed overnight, had to go\n back on fentanyl, d/c fentayl drip 5 am will bolus as needed with goal\n to wean this morning\n - Gent level this morning 3.8\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Vancomycin - 08:12 AM\n Gentamicin - 11:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 PM\n Fentanyl - 05:57 PM\n Dextrose 50% - 06:53 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 83 (67 - 108) bpm\n BP: 143/52(80) {124/45(67) - 190/75(112)} mmHg\n RR: 29 (0 - 37) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 8 (6 - 9)mmHg\n Total In:\n 823 mL\n 765 mL\n PO:\n TF:\n 79 mL\n 140 mL\n IVF:\n 554 mL\n 125 mL\n Blood products:\n Total out:\n 2,500 mL\n 490 mL\n Urine:\n 2,500 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,677 mL\n 275 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 414 (305 - 473) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 94\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: ///21/\n Ve: 9.8 L/min\n Physical Examination\n General\n intubated, sedated, nad\n Cards\n RRR, nl s1/s2, no murmurs appreciated\n Pulm- bronchial breath sounds right side, left lung more clear\n Abdomen -soft, non-tender, non-distended\n Extremities\n warm and well perfused, 2+ radial pulses trace edema feet\n b/l\n Labs / Radiology\n 133 K/uL\n 8.8 g/dL\n 90 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 144 mEq/L\n 26.8 %\n 22.8 K/uL\n [image002.jpg]\n 07:34 AM\n 03:29 PM\n 03:16 AM\n 03:31 AM\n 07:50 PM\n 04:10 AM\n 05:33 AM\n 06:00 AM\n 07:59 PM\n 03:58 AM\n WBC\n 17.0\n 22.6\n 22.8\n Hct\n 28.6\n 27.1\n 26.8\n Plt\n 91\n 104\n 133\n Cr\n 1.0\n 0.8\n 0.7\n 0.7\n TCO2\n 19\n 22\n 20\n 22\n 24\n Glucose\n 95\n 37\n 40\n 145\n 61\n 90\n Other labs: PT / PTT / INR:15.1/26.8/1.3, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:92.1 %, Band:5.0 %, Lymph:4.4 %, Mono:3.0 %, Eos:0.4\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.6\n mg/dL, Mg++:1.7 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology.\n Septic Shock: Patient was with SIRS with E coli in blood and urine.\n CXR shows bibasilar consolidations as well concerning for possible\n pneumonia. Sputum culture with gram + cocci however this has not grown\n out so far in speciation. There is some mild enteritis as wel as CTl.\n Presentation lactate was 3.4, then trended down.\n- repeat sputum culture - GRAM STAIN (Final ): >25 PMNs and <10 epitheli\n cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CHAINS.\n2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\nRESPIRATORY CULTURE (Final ): SPARSE GROWTH OROPHARYNGEAL FLORA.\n Urine -urine cx - URINE CULTURE (Final ):\n ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..\n PRESUMPTIVE IDENTIFICATION.\n PROVIDENCIA STUARTII. 10,000-100,000 ORGANISMS/ML..\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n ESCHERICHIA COLI\n | PROVIDENCIA STUARTII\n | |\n AMIKACIN-------------- <=2 S\n AMPICILLIN------------ 16 I\n AMPICILLIN/SULBACTAM-- 4 S\n CEFAZOLIN------------- <=4 S\n CEFEPIME-------------- <=1 S <=1 S\n CEFTAZIDIME----------- <=1 S <=1 S\n CEFTRIAXONE----------- <=1 S <=1 S\n CEFUROXIME------------ 4 S\n CIPROFLOXACIN--------- =>4 R =>4 R\n GENTAMICIN------------ <=1 S 8 I\n MEROPENEM-------------<=0.25 S <=0.25 S\n NITROFURANTOIN-------- <=16 S 256 R\n PIPERACILLIN---------- <=4 S <=4 S\n PIPERACILLIN/TAZO----- <=4 S <=4 S\n TOBRAMYCIN------------ <=1 S 8 I\nTRIMETHOPRIM/SULFA---- <=1 S <=1 S\n - currently on gentamycin Day to cover for urosepsis as well as\n possible healthcare associated pneumonia, vancomycin for possible\n healthcare associated pneumonia, given sensitivities above will change\n to amikacin and keep vancomycin\n - currently off all pressors, now hypertensive\n -monitor WBC, CBC, diff\n - wbc count continuese to trend up\n will send repeat ua and urine\n culture as well as stool culture and c. diff and follow-up\n -monitor fever curve- patient initially febrile but became hypothermic\n requiring bear hugger, now normothermic\n Respiratory Failure: Initially respiratory failure thought to be due\n to pneumonia. Patient on pressure support with 40% O2; with thick\n secretions, however looks like working harder to breath with tachypnea.\n + Gag reflex prior although not too much with deep suctioning this\n morning. Patient squeezing hands this morning.\n -culture data and antibiotics as above\n - Suction PRN\n - will go up on pressure support today to 10 or 12 to improve breathing\n - continue sedation for now\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension\n - gave 10 IV hydral in the setting of hypertension to 200 may be in the\n setting of agitation, would like to get away from IV hydral and titrate\n up beta blocker as tolerated\n - lisinopril 2.5 mg daily\n -metoprolol 50 mg TID, consider furthur uptitration as tolerated\n post-extubation\n - lasix today for blood pressure control as well as fluid removal\n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since blood is prokinetic.\n Will guaiac stool when available.\n - crit is stable\n -Patient guaic positive in the ED, have not sent stool studies as\n patient has had no stool, however suspect positive\n - Coffee ground emesis from NG tube; guaiac negative\n - continue to follow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n to 0.7. Likely prerenal in etiology secondary to volume depletion and\n septic shock\n likely ATN. No cast seen in UA, but it was not fresh.\n Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n - trend creatinine\n -Maintain adequate BP and hydration\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with multiple negative troponins. This is\n likely demand ischemia in setting of hypotension. Now that BP and\n tachycardia under control, warm and perfusing, can follow-up cardiac\n function with echo.\n - repeat EKG from EKG Sinus rhythm. Premature ventricular\n contractions. Poor R wave progression may be lead placement or possible\n old anterior myocardial infarction. Compared to\n the previous tracing of axis has shifted rightward. Ventricular\n ectopy is new.\n - ECHO from - IMPRESSION: Mild focal LV systolic dysfunction.\n Mildly dilated right ventricle. Mild to moderate aortic regurgitation.\n Moderately dilated ascending aorta.\n - troponins slighlty increased, but in settig of sepsis may represent\n myocardial stunning, also echo is reassuming that there is no regional\n wall motion abnormalities\n Dementia: Currently intubated to difficult to assess mental status.\n - restart namenda and aricept yesterday\n FEN:\n - restart tube feeds\n -check pm lytes, replete electrolytes as needed.\n Prophylaxis: SC heparin, holding bowel regimen for diarrhea\n Access: RIJ\n Communcation: Sister \n Code: Full Code.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2192-08-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342656, "text": "Chief Complaint: 82 year old female with h/o breast cancer, cva, htn\n who presented from rehab with pneumonia, uti with sepsis physiology.\n s/p intubation.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:00 AM\n URINE CULTURE - At 12:23 AM\n -Yesterday per nursing thought that patient not be ready for extubation\n with lots of secretions.\n - restarted namenda and aricept\n - low potassium yesterday morning, got repletion with IV sliding scale\n - fingersticks was 37 yesterday morning, then subsequently 61 (got \n amp d50) - which was not written for by M.D.\n - tube feeds were not re-started yesterday morning, even though it was\n decided on rounds to restart b/c did not extubate patient\n - spoke with evening nurse, restarted tube feeds, sent stool for c.\n diff (nurse like c. diff) so placed patient on\n precautions\n - repeat ca and phos low, repleted, still low\n - repeat UA still with large LE, WBCs, RBcs, urine cx pending\n - got repleted but phos didn't change, off Versed overnight, had to go\n back on fentanyl, d/c fentayl drip 5 am will bolus as needed with goal\n to wean this morning\n - Gent level this morning 3.8\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Vancomycin - 08:12 AM\n Gentamicin - 11:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 PM\n Fentanyl - 05:57 PM\n Dextrose 50% - 06:53 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 83 (67 - 108) bpm\n BP: 143/52(80) {124/45(67) - 190/75(112)} mmHg\n RR: 29 (0 - 37) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 8 (6 - 9)mmHg\n Total In:\n 823 mL\n 765 mL\n PO:\n TF:\n 79 mL\n 140 mL\n IVF:\n 554 mL\n 125 mL\n Blood products:\n Total out:\n 2,500 mL\n 490 mL\n Urine:\n 2,500 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,677 mL\n 275 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 414 (305 - 473) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 94\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: ///21/\n Ve: 9.8 L/min\n Physical Examination\n General\n intubated, sedated, nad\n Cards\n RRR, nl s1/s2, no murmurs appreciated\n Pulm- bronchial breath sounds right side, left lung more clear\n Abdomen -soft, non-tender, non-distended\n Extremities\n warm and well perfused, 2+ radial pulses trace edema feet\n b/l\n Labs / Radiology\n 133 K/uL\n 8.8 g/dL\n 90 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 144 mEq/L\n 26.8 %\n 22.8 K/uL\n [image002.jpg]\n 07:34 AM\n 03:29 PM\n 03:16 AM\n 03:31 AM\n 07:50 PM\n 04:10 AM\n 05:33 AM\n 06:00 AM\n 07:59 PM\n 03:58 AM\n WBC\n 17.0\n 22.6\n 22.8\n Hct\n 28.6\n 27.1\n 26.8\n Plt\n 91\n 104\n 133\n Cr\n 1.0\n 0.8\n 0.7\n 0.7\n TCO2\n 19\n 22\n 20\n 22\n 24\n Glucose\n 95\n 37\n 40\n 145\n 61\n 90\n Other labs: PT / PTT / INR:15.1/26.8/1.3, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:92.1 %, Band:5.0 %, Lymph:4.4 %, Mono:3.0 %, Eos:0.4\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.6\n mg/dL, Mg++:1.7 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology.\n Septic Shock: Patient was with SIRS with E coli in blood and urine.\n CXR shows bibasilar consolidations as well concerning for possible\n pneumonia. Sputum culture with gram + cocci however this has not grown\n out so far in speciation. There is some mild enteritis as wel as CTl.\n Presentation lactate was 3.4, then trended down.\n- repeat sputum culture - GRAM STAIN (Final ): >25 PMNs and <10 epitheli\n cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CHAINS.\n2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\nRESPIRATORY CULTURE (Final ): SPARSE GROWTH OROPHARYNGEAL FLORA.\n Urine -urine cx - URINE CULTURE (Final ):\n ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..\n PRESUMPTIVE IDENTIFICATION.\n PROVIDENCIA STUARTII. 10,000-100,000 ORGANISMS/ML..\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n ESCHERICHIA COLI\n | PROVIDENCIA STUARTII\n | |\n AMIKACIN-------------- <=2 S\n AMPICILLIN------------ 16 I\n AMPICILLIN/SULBACTAM-- 4 S\n CEFAZOLIN------------- <=4 S\n CEFEPIME-------------- <=1 S <=1 S\n CEFTAZIDIME----------- <=1 S <=1 S\n CEFTRIAXONE----------- <=1 S <=1 S\n CEFUROXIME------------ 4 S\n CIPROFLOXACIN--------- =>4 R =>4 R\n GENTAMICIN------------ <=1 S 8 I\n MEROPENEM-------------<=0.25 S <=0.25 S\n NITROFURANTOIN-------- <=16 S 256 R\n PIPERACILLIN---------- <=4 S <=4 S\n PIPERACILLIN/TAZO----- <=4 S <=4 S\n TOBRAMYCIN------------ <=1 S 8 I\nTRIMETHOPRIM/SULFA---- <=1 S <=1 S\n - currently on gentamycin Day to cover for urosepsis as well as\n possible healthcare associated pneumonia, vancomycin for possible\n healthcare associated pneumonia, given sensitivities above will change\n to amikacin and keep vancomycin\n - currently off all pressors, now hypertensive\n -monitor WBC, CBC, diff\n - wbc count continuese to trend up\n will send repeat ua and urine\n culture as well as stool culture and c. diff and follow-up\n -monitor fever curve- patient initially febrile but became hypothermic\n requiring bear hugger, now normothermic\n Respiratory Failure: Initially respiratory failure thought to be due\n to pneumonia. Patient on pressure support with 40% O2; with thick\n secretions, however looks like working harder to breath with tachypnea.\n + Gag reflex prior although not too much with deep suctioning this\n morning. Patient squeezing hands this morning.\n -culture data and antibiotics as above\n - Suction PRN\n - will go up on pressure support today to 10 or 12 to improve breathing\n - continue sedation for now\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension\n - gave 10 IV hydral in the setting of hypertension to 200 may be in the\n setting of agitation, would like to get away from IV hydral and titrate\n up beta blocker as tolerated\n - lisinopril 2.5 mg daily\n -metoprolol 50 mg TID, consider furthur uptitration as tolerated\n post-extubation\n - lasix today for blood pressure control as well as fluid removal\n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since blood is prokinetic.\n Will guaiac stool when available.\n - crit is stable\n -Patient guaic positive in the ED, have not sent stool studies as\n patient has had no stool, however suspect positive\n - Coffee ground emesis from NG tube; guaiac negative\n - continue to follow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n to 0.7. Likely prerenal in etiology secondary to volume depletion and\n septic shock\n likely ATN. No cast seen in UA, but it was not fresh.\n Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n - trend creatinine\n -Maintain adequate BP and hydration\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with multiple negative troponins. This is\n likely demand ischemia in setting of hypotension. Now that BP and\n tachycardia under control, warm and perfusing, can follow-up cardiac\n function with echo.\n - repeat EKG from EKG Sinus rhythm. Premature ventricular\n contractions. Poor R wave progression may be lead placement or possible\n old anterior myocardial infarction. Compared to\n the previous tracing of axis has shifted rightward. Ventricular\n ectopy is new.\n - ECHO from - IMPRESSION: Mild focal LV systolic dysfunction.\n Mildly dilated right ventricle. Mild to moderate aortic regurgitation.\n Moderately dilated ascending aorta.\n - troponins slighlty increased, but in settig of sepsis may represent\n myocardial stunning, also echo is reassuming that there is no regional\n wall motion abnormalities\n Dementia: Currently intubated to difficult to assess mental status.\n - restart namenda and aricept yesterday\n FEN:\n - restart tube feeds\n -check pm lytes, replete electrolytes as needed.\n Prophylaxis: SC heparin, holding bowel regimen for diarrhea\n Access: RIJ\n Communcation: Sister \n Code: Full Code.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2192-08-23 00:00:00.000", "description": "Generic Note", "row_id": 342622, "text": "TITLE:\n RESPIRATORY CARE:\n Pt remains intubated, minimally vent supported on psv/cpap. No changes\n made overnight. BS\ns diminished, sxing thick yellow secretions. Pt\n has weak cough. RSBI=94 this am. See flowsheet for further pt data.\n Will follow.\n 06:40\n" }, { "category": "Physician ", "chartdate": "2192-08-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342631, "text": "Chief Complaint: 82 year old female with h/o breast cancer, cva, htn\n who presented from rehab with pneumonia, uti with sepsis physiology.\n s/p intubation.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:00 AM\n URINE CULTURE - At 12:23 AM\n -Yesterday per nursing thought that patient not be ready for extubation\n with lots of secretions.\n - restarted namenda and aricept\n - low potassium yesterday morning, got repletion with IV sliding scale\n - fingersticks was 37 yesterday morning, then subsequently 61 (got \n amp d50) - which was not written for by M.D.\n - tube feeds were not re-started yesterday morning, even though it was\n decided on rounds to restart b/c did not extubate patient\n - spoke with evening nurse, restarted tube feeds, sent stool for c.\n diff (nurse like c. diff) so placed patient on\n precautions\n - repeat ca and phos low, repleted, still low\n - repeat UA still with large LE, WBCs, RBcs, urine cx pending\n - got repleted but phos didn't change, off Versed overnight, had to go\n back on fentanyl, d/c fentayl drip 5 am will bolus as needed with goal\n to wean this morning\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Vancomycin - 08:12 AM\n Gentamicin - 11:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 PM\n Fentanyl - 05:57 PM\n Dextrose 50% - 06:53 PM\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 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 83 (67 - 108) bpm\n BP: 143/52(80) {124/45(67) - 190/75(112)} mmHg\n RR: 29 (0 - 37) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 8 (6 - 9)mmHg\n Total In:\n 823 mL\n 765 mL\n PO:\n TF:\n 79 mL\n 140 mL\n IVF:\n 554 mL\n 125 mL\n Blood products:\n Total out:\n 2,500 mL\n 490 mL\n Urine:\n 2,500 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,677 mL\n 275 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 414 (305 - 473) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 94\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: ///21/\n Ve: 9.8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 133 K/uL\n 8.8 g/dL\n 90 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 144 mEq/L\n 26.8 %\n 22.8 K/uL\n [image002.jpg]\n 07:34 AM\n 03:29 PM\n 03:16 AM\n 03:31 AM\n 07:50 PM\n 04:10 AM\n 05:33 AM\n 06:00 AM\n 07:59 PM\n 03:58 AM\n WBC\n 17.0\n 22.6\n 22.8\n Hct\n 28.6\n 27.1\n 26.8\n Plt\n 91\n 104\n 133\n Cr\n 1.0\n 0.8\n 0.7\n 0.7\n TCO2\n 19\n 22\n 20\n 22\n 24\n Glucose\n 95\n 37\n 40\n 145\n 61\n 90\n Other labs: PT / PTT / INR:15.1/26.8/1.3, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:92.1 %, Band:5.0 %, Lymph:4.4 %, Mono:3.0 %, Eos:0.4\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.6\n mg/dL, Mg++:1.7 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n urine cx - URINE CULTURE (Final ):\n ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..\n PRESUMPTIVE IDENTIFICATION.\n PROVIDENCIA STUARTII. 10,000-100,000 ORGANISMS/ML..\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n ESCHERICHIA COLI\n | PROVIDENCIA STUARTII\n | |\n AMIKACIN-------------- <=2 S\n AMPICILLIN------------ 16 I\n AMPICILLIN/SULBACTAM-- 4 S\n CEFAZOLIN------------- <=4 S\n CEFEPIME-------------- <=1 S <=1 S\n CEFTAZIDIME----------- <=1 S <=1 S\n CEFTRIAXONE----------- <=1 S <=1 S\n CEFUROXIME------------ 4 S\n CIPROFLOXACIN--------- =>4 R =>4 R\n GENTAMICIN------------ <=1 S 8 I\n MEROPENEM-------------<=0.25 S <=0.25 S\n NITROFURANTOIN-------- <=16 S 256 R\n PIPERACILLIN---------- <=4 S <=4 S\n PIPERACILLIN/TAZO----- <=4 S <=4 S\n TOBRAMYCIN------------ <=1 S 8 I\n TRIMETHOPRIM/SULFA---- <=1 S <=1 S\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2192-08-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342632, "text": "Chief Complaint: 82 year old female with h/o breast cancer, cva, htn\n who presented from rehab with pneumonia, uti with sepsis physiology.\n s/p intubation.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:00 AM\n URINE CULTURE - At 12:23 AM\n -Yesterday per nursing thought that patient not be ready for extubation\n with lots of secretions.\n - restarted namenda and aricept\n - low potassium yesterday morning, got repletion with IV sliding scale\n - fingersticks was 37 yesterday morning, then subsequently 61 (got \n amp d50) - which was not written for by M.D.\n - tube feeds were not re-started yesterday morning, even though it was\n decided on rounds to restart b/c did not extubate patient\n - spoke with evening nurse, restarted tube feeds, sent stool for c.\n diff (nurse like c. diff) so placed patient on\n precautions\n - repeat ca and phos low, repleted, still low\n - repeat UA still with large LE, WBCs, RBcs, urine cx pending\n - got repleted but phos didn't change, off Versed overnight, had to go\n back on fentanyl, d/c fentayl drip 5 am will bolus as needed with goal\n to wean this morning\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Vancomycin - 08:12 AM\n Gentamicin - 11:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 PM\n Fentanyl - 05:57 PM\n Dextrose 50% - 06:53 PM\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 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 83 (67 - 108) bpm\n BP: 143/52(80) {124/45(67) - 190/75(112)} mmHg\n RR: 29 (0 - 37) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 8 (6 - 9)mmHg\n Total In:\n 823 mL\n 765 mL\n PO:\n TF:\n 79 mL\n 140 mL\n IVF:\n 554 mL\n 125 mL\n Blood products:\n Total out:\n 2,500 mL\n 490 mL\n Urine:\n 2,500 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,677 mL\n 275 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 414 (305 - 473) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 94\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: ///21/\n Ve: 9.8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 133 K/uL\n 8.8 g/dL\n 90 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 144 mEq/L\n 26.8 %\n 22.8 K/uL\n [image002.jpg]\n 07:34 AM\n 03:29 PM\n 03:16 AM\n 03:31 AM\n 07:50 PM\n 04:10 AM\n 05:33 AM\n 06:00 AM\n 07:59 PM\n 03:58 AM\n WBC\n 17.0\n 22.6\n 22.8\n Hct\n 28.6\n 27.1\n 26.8\n Plt\n 91\n 104\n 133\n Cr\n 1.0\n 0.8\n 0.7\n 0.7\n TCO2\n 19\n 22\n 20\n 22\n 24\n Glucose\n 95\n 37\n 40\n 145\n 61\n 90\n Other labs: PT / PTT / INR:15.1/26.8/1.3, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:92.1 %, Band:5.0 %, Lymph:4.4 %, Mono:3.0 %, Eos:0.4\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.6\n mg/dL, Mg++:1.7 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology.\n Septic Shock: Patient was with SIRS with E coli in blood and urine.\n CXR shows bibasilar consolidations as well concerning for possible\n pneumonia. Sputum culture with gram + cocci however this has not grown\n out so far in speciation. There is some mild enteritis as wel as CTl.\n Presentation lactate was 3.4, then trended down.\n - repeat sputum culture wtih 3+ gram positive cocci in pairs and\n chains, with 2+ oropharyngeal flora, speciation partial only with oral\n flora currently\n - currently on gentamycin Day , yesterday restrated vancomycin\n - currently off all pressors, now hypertensive\n -monitor WBC, CBC, diff\n - wbc count continuese to trend up\n will send repeat ua and urine\n culture as well as stool culture and c. diff and follow-up\n -monitor fever curve- patient initially febrile but became hypothermic\n requiring bear hugger, now normothermic\n Respiratory Failure: Initially respiratory failure thought to be due\n to pneumonia. Patient on pressure support with 40% O2; with thick\n secretions. + Gag reflex prior although not too much with deep\n suctioning this morning. Patient squeezing hands this morning.\n -culture data from sputum thus far has grown orophyaryngeal flora only,\n now with 3+ gram positive cocci in pairs, awaiting speciation\n - vanc day 2, gentamicin day .\n - Suction PRN\n - will hold on extubation this morning despite excellent vent settings\n secondary to copious secretions\n - will shut off sedation and see if mental status improves, stronger\n cough and stronger gag prior to extubation\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension\n - gave 10 IV hydral in the setting of hypertension to 200 may be in the\n setting of agitation, would like to get away from IV hydral and titrate\n up beta blocker as tolerated\n - will restart lisinopril today now that acute renal failure has\n resolved, home dose 2.5\n -Increase metoprolol today (to 50 TID), holding parameters to HR < 60\n and SBP < 100\n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since blood is prokinetic.\n Will guaiac stool when available.\n - crit is stable\n -Patient guaic positive in the ED, have not sent stool studies as\n patient has had no stool, however suspect positive\n - Coffee ground emesis from NG tube; guaiac negative\n - continue to follow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n to 1.0. Likely prerenal in etiology secondary to volume depletion and\n septic shock\n likely ATN. No cast seen in UA, but it was not fresh.\n Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n - trend creatinine\n -Maintain adequate BP and hydration\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with multiple negative troponins. This is\n likely demand ischemia in setting of hypotension. Now that BP and\n tachycardia under control, warm and perfusing, can follow-up cardiac\n function with echo.\n - repeat EKG from EKG Sinus rhythm. Premature ventricular\n contractions. Poor R wave progression may be lead placement or possible\n old anterior myocardial infarction. Compared to\n the previous tracing of axis has shifted rightward. Ventricular\n ectopy is new.\n - ECHO from - IMPRESSION: Mild focal LV systolic dysfunction.\n Mildly dilated right ventricle. Mild to moderate aortic regurgitation.\n Moderately dilated ascending aorta.\n - troponins slighlty increased, but in settig of sepsis may represent\n myocardial stunning, also echo is reassuming that there is no regional\n wall motion abnormalities\n Dementia: Currently intubated to difficult to assess mental status.\n - restart namenda and aricept for now\n FEN:\n - residuals improve, re-start tube feedings in the setting of holding\n off on extubation today\n -Monitor and replete electrolytes as needed.\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: Full Code.\n urine cx - URINE CULTURE (Final ):\n ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..\n PRESUMPTIVE IDENTIFICATION.\n PROVIDENCIA STUARTII. 10,000-100,000 ORGANISMS/ML..\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n ESCHERICHIA COLI\n | PROVIDENCIA STUARTII\n | |\n AMIKACIN-------------- <=2 S\n AMPICILLIN------------ 16 I\n AMPICILLIN/SULBACTAM-- 4 S\n CEFAZOLIN------------- <=4 S\n CEFEPIME-------------- <=1 S <=1 S\n CEFTAZIDIME----------- <=1 S <=1 S\n CEFTRIAXONE----------- <=1 S <=1 S\n CEFUROXIME------------ 4 S\n CIPROFLOXACIN--------- =>4 R =>4 R\n GENTAMICIN------------ <=1 S 8 I\n MEROPENEM-------------<=0.25 S <=0.25 S\n NITROFURANTOIN-------- <=16 S 256 R\n PIPERACILLIN---------- <=4 S <=4 S\n PIPERACILLIN/TAZO----- <=4 S <=4 S\n TOBRAMYCIN------------ <=1 S 8 I\n TRIMETHOPRIM/SULFA---- <=1 S <=1 S\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2192-08-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342633, "text": "Chief Complaint: 82 year old female with h/o breast cancer, cva, htn\n who presented from rehab with pneumonia, uti with sepsis physiology.\n s/p intubation.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:00 AM\n URINE CULTURE - At 12:23 AM\n -Yesterday per nursing thought that patient not be ready for extubation\n with lots of secretions.\n - restarted namenda and aricept\n - low potassium yesterday morning, got repletion with IV sliding scale\n - fingersticks was 37 yesterday morning, then subsequently 61 (got \n amp d50) - which was not written for by M.D.\n - tube feeds were not re-started yesterday morning, even though it was\n decided on rounds to restart b/c did not extubate patient\n - spoke with evening nurse, restarted tube feeds, sent stool for c.\n diff (nurse like c. diff) so placed patient on\n precautions\n - repeat ca and phos low, repleted, still low\n - repeat UA still with large LE, WBCs, RBcs, urine cx pending\n - got repleted but phos didn't change, off Versed overnight, had to go\n back on fentanyl, d/c fentayl drip 5 am will bolus as needed with goal\n to wean this morning\n - Gent level this morning 3.8\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Vancomycin - 08:12 AM\n Gentamicin - 11:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 PM\n Fentanyl - 05:57 PM\n Dextrose 50% - 06:53 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 83 (67 - 108) bpm\n BP: 143/52(80) {124/45(67) - 190/75(112)} mmHg\n RR: 29 (0 - 37) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 8 (6 - 9)mmHg\n Total In:\n 823 mL\n 765 mL\n PO:\n TF:\n 79 mL\n 140 mL\n IVF:\n 554 mL\n 125 mL\n Blood products:\n Total out:\n 2,500 mL\n 490 mL\n Urine:\n 2,500 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,677 mL\n 275 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 414 (305 - 473) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 94\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: ///21/\n Ve: 9.8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 133 K/uL\n 8.8 g/dL\n 90 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 144 mEq/L\n 26.8 %\n 22.8 K/uL\n [image002.jpg]\n 07:34 AM\n 03:29 PM\n 03:16 AM\n 03:31 AM\n 07:50 PM\n 04:10 AM\n 05:33 AM\n 06:00 AM\n 07:59 PM\n 03:58 AM\n WBC\n 17.0\n 22.6\n 22.8\n Hct\n 28.6\n 27.1\n 26.8\n Plt\n 91\n 104\n 133\n Cr\n 1.0\n 0.8\n 0.7\n 0.7\n TCO2\n 19\n 22\n 20\n 22\n 24\n Glucose\n 95\n 37\n 40\n 145\n 61\n 90\n Other labs: PT / PTT / INR:15.1/26.8/1.3, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:92.1 %, Band:5.0 %, Lymph:4.4 %, Mono:3.0 %, Eos:0.4\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.6\n mg/dL, Mg++:1.7 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology.\n Septic Shock: Patient was with SIRS with E coli in blood and urine.\n CXR shows bibasilar consolidations as well concerning for possible\n pneumonia. Sputum culture with gram + cocci however this has not grown\n out so far in speciation. There is some mild enteritis as wel as CTl.\n Presentation lactate was 3.4, then trended down.\n- repeat sputum culture - GRAM STAIN (Final ): >25 PMNs and <10 epitheli\n cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CHAINS.\n2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\nRESPIRATORY CULTURE (Final ): SPARSE GROWTH OROPHARYNGEAL FLORA.\n Urine -urine cx - URINE CULTURE (Final ):\n ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..\n PRESUMPTIVE IDENTIFICATION.\n PROVIDENCIA STUARTII. 10,000-100,000 ORGANISMS/ML..\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n ESCHERICHIA COLI\n | PROVIDENCIA STUARTII\n | |\n AMIKACIN-------------- <=2 S\n AMPICILLIN------------ 16 I\n AMPICILLIN/SULBACTAM-- 4 S\n CEFAZOLIN------------- <=4 S\n CEFEPIME-------------- <=1 S <=1 S\n CEFTAZIDIME----------- <=1 S <=1 S\n CEFTRIAXONE----------- <=1 S <=1 S\n CEFUROXIME------------ 4 S\n CIPROFLOXACIN--------- =>4 R =>4 R\n GENTAMICIN------------ <=1 S 8 I\n MEROPENEM-------------<=0.25 S <=0.25 S\n NITROFURANTOIN-------- <=16 S 256 R\n PIPERACILLIN---------- <=4 S <=4 S\n PIPERACILLIN/TAZO----- <=4 S <=4 S\n TOBRAMYCIN------------ <=1 S 8 I\nTRIMETHOPRIM/SULFA---- <=1 S <=1 S\n - currently on gentamycin Day to cover for urosepsis as well as\n possible healthcare associated pneumonia, vancomycin for possible\n healthcare associated pnemonia\n - currently off all pressors, now hypertensive\n -monitor WBC, CBC, diff\n - wbc count continuese to trend up\n will send repeat ua and urine\n culture as well as stool culture and c. diff and follow-up\n -monitor fever curve- patient initially febrile but became hypothermic\n requiring bear hugger, now normothermic\n Respiratory Failure: Initially respiratory failure thought to be due\n to pneumonia. Patient on pressure support with 40% O2; with thick\n secretions. + Gag reflex prior although not too much with deep\n suctioning this morning. Patient squeezing hands this morning.\n -culture data and antibiotics as above\n - Suction PRN\n - attempt extubation this morning as almost no pressure support\n - will shut off sedation and see if mental status improves, stronger\n cough and stronger gag prior to extubation\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension\n - gave 10 IV hydral in the setting of hypertension to 200 may be in the\n setting of agitation, would like to get away from IV hydral and titrate\n up beta blocker as tolerated\n - lisinopril 2.5 mg daily, will titrate up today to 5 mg daily\n -metoprolol 50 mg TID, consider furthur uptitration as tolerated\n post-extubation\n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since blood is prokinetic.\n Will guaiac stool when available.\n - crit is stable\n -Patient guaic positive in the ED, have not sent stool studies as\n patient has had no stool, however suspect positive\n - Coffee ground emesis from NG tube; guaiac negative\n - continue to follow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n to 0.7. Likely prerenal in etiology secondary to volume depletion and\n septic shock\n likely ATN. No cast seen in UA, but it was not fresh.\n Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n - trend creatinine\n -Maintain adequate BP and hydration\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with multiple negative troponins. This is\n likely demand ischemia in setting of hypotension. Now that BP and\n tachycardia under control, warm and perfusing, can follow-up cardiac\n function with echo.\n - repeat EKG from EKG Sinus rhythm. Premature ventricular\n contractions. Poor R wave progression may be lead placement or possible\n old anterior myocardial infarction. Compared to\n the previous tracing of axis has shifted rightward. Ventricular\n ectopy is new.\n - ECHO from - IMPRESSION: Mild focal LV systolic dysfunction.\n Mildly dilated right ventricle. Mild to moderate aortic regurgitation.\n Moderately dilated ascending aorta.\n - troponins slighlty increased, but in settig of sepsis may represent\n myocardial stunning, also echo is reassuming that there is no regional\n wall motion abnormalities\n Dementia: Currently intubated to difficult to assess mental status.\n - restart namenda and aricept yesterday\n FEN:\n - tube feedings overnight, hold this AM for extubation\n -Monitor and replete electrolytes as needed.\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: Full Code.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2192-08-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 342358, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 59 None\n Ideal tidal volume: 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: 20 cm at teeth\n Route: Oral\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: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / 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 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 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": "2192-08-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342615, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology. Previous on pressors, sepsis resolving with normal\n lactate. New leukocytosis, WBC 22.6 ? new UTI vs c-diff ( loose stools\n x 1 day) ARF resolved, creatinine at baseline 0.8; previous hematocrit\n drop; normocytic normochromic with iron profile sugesting chornic\n disease or infection, Coffee ground emesis from NG tube; guaiac\n negative; hct stable at 27.1 as of yesterday. Slightly increased\n troponin with ST depressions from previous EKG mostly likely demand\n ischemia related to hypotension.\n .\n Respiratory Failure due to Pneumonia, bacterial, hospital acquired\n (non-VAP)\n Assessment:\n Patient on pressure support with 40% O2, sats 98-100%, moderate to\n large amount of thick yellow secretions, with moderate amount from\n oral; lung sounds rhonchorous, dim at bases. ETT 20 at the lip; repeat\n sputum culture with 3+ gram positive cocci in pairs and chains, with 2+\n oropharyngeal flora, speciation partial only with oral flora; vanc day\n 2, gentamicin day . afebrile, WBC 22.6 as of yesterday morning.\n Sedated with fentanyl 50 mcg/hr and versed 0.5 mg/hr\n Action:\n Suctioned secretions from ETT q2-3 hours and PRN, turn to sides q2-3\n hours; continues on antibiotics ( Vanco and Gentamycin) no vent setting\n change overnight.\n Response:\n Sats > 95% at same settings, tachypneic 28-30\ns when awake Tolerated\n daily wake\nup for 30 mins BP 150\ns RSBI =94 minute volume 9.9-10L/min,\n ETT secretions decreased than what she had at the beginning of the\n shift. Still with poor cough and impaired gag\n Plan:\n Culture if temp spikes, continue pulmonary toilet and antibiotics; plan\n to extubate patient today ? if she will be able to tolerate this,\n although secretions has decreased patient remains to have poor\n mechanics to clear secretions. Keep HOB > 30 degrees\n Altered mental status (not Delirium)\n Assessment:\n History of CVA / dementia; ? if baseline aphasic, opens eye to\n stimulation ( turning and repositioning) but not tracking, impaired\n corneal, gag and very weak coughing reflexes. Pupils pinpoint but\n reactive. Slightly withdraws to pain\n nail bed. Noticed drooling when\n on her L side. 2mg/hr of versed at the beginning of the shift, not\n opening her eyes\n Action:\n Versed weaned down to 0.5 mg/hr, fentanyl resumed at 50 mcg/hr for\n pain. Patient BP 170\ns off pain med.\n Response:\n Awake with less benzos, BP better controlled with fentanyl on board.\n Not tracking; sedation off by 0500\n Plan:\n Daily wake up this am; to start on namenda and aricept.\n Electrolyte & fluid disorder, other\n Assessment:\n Evening lytes K- 3.4, phos -2.0 and calcium- 7.4; soaked with loose\n stool guiac positive at the beginning of the shift, FS 61 at 1800\n received\n amp D50W at 1830 per day nurse, repeat FS 76\n Action:\n Repleted with 40 mEq KCl, 2 packets of neutraphos and 2 grams of\n calcium gluconate; tube feeds restarted @ 20cc/hr with 150cc water\n flushes q6hrs; specimen for c-diff sent, placed on contact precaution\n for ? c-diff until r/o\n Response:\n - 1.5 L as MN still 15L positive fro the LOS; tolerating tube feeds\n with 0-5 cc residuals q4hrs; no further loose stools noted; CVP 6-9;\n Plan:\n replete lytes per sliding scale; resume tube feeds if plan to unable to\n forego extubation, follow closely FS while on NPO episode of\n hypoglycemia\n 37 with yesterday am labs\n .H/O hypertension, benign\n Assessment:\n SBP 170\ns at start of shift, NSR with WAP, occasional\n frequent PVCs\n Action:\n Electrolytes repleted, fentanyl drip resumed, schedules 50 mgs\n lopressor PO given\n Response:\n BP well controlled with beta blocker and pain meds SBP 120-130\ns, mid\n 150\ns now that sedation is off. frequent PVC\ns remains intermittently\n Plan:\n Continue lopressor and lisinopril, pain meds\n Code status : full code as confirmed yesterday with HCP ( patient\n sister)\n" }, { "category": "Nursing", "chartdate": "2192-08-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342729, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology.\n Septic Shock: Patient was with SIRS with E coli in blood and urine.\n CXR shows bibasilar consolidations as well concerning for possible\n pneumonia. Sputum culture with gram + cocci however this has not grown\n out so far in speciation. . Presentation lactate was 3.4, then trended\n down.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Pt remains Intubated on 40% 5 peep, 5 pressure support. Suctioned\n for copious tan secretions. RSBI 86, rr~32-38 O2 sats 92-97%\n antibx changed Gent d\ncd, Amiikacin started . Vanco continues.\n Temp 99.2 po WBC 22.8\n Action:\n Decided pt not ready to be extubated, pressure support increased to\n 10.\n Response:\n RR down in the 20\ns on 10 pressure support , pt appears more\n comfortable\n Plan:\n continue antibx, follow temp, WBC continue vigorous pulmonary\n toilet\n Altered mental status (not Delirium)\n Assessment:\n Pt remains off sedation (Fentanyl/versed) opens eyes spont. At\n one point pt did move toes on command, unable to squeeze my hand. Pt\n very stiff\n Action:\n Pt remains lethargic\n Response:\n Off sedation\n Plan:\n Continue to follow.\n GI: tube feeds restarted after decision was made not to extubate.\n Fibersource HN FS at 30 cc/hr, goal is 55 cc/hr.\n CV/FLUIDS: bp stable 170-170/68 HR 80-100 SR occ PVC pt\n received 20 mg IVP lasix with good response. Pt negative 1 liter so\n far, (would like 2 liters neg) CVP 4-6\n" }, { "category": "Respiratory ", "chartdate": "2192-08-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 342730, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 6\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ED\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\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: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thin\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: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions\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": "2192-08-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342733, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology.\n Septic Shock: Patient was with SIRS with E coli in blood and urine.\n CXR shows bibasilar consolidations as well concerning for possible\n pneumonia. Sputum culture with gram + cocci however this has not grown\n out so far in speciation. . Presentation lactate was 3.4, then trended\n down.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Pt remains Intubated on 40% 5 peep, 5 pressure support. Suctioned\n for copious tan secretions. RSBI 86, rr~32-38 O2 sats\n 92-97% antibx changed Gent d\ncd, Amiikacin started . Vanco\n continues. Temp 99.2 po WBC 22.8\n Action:\n Decided pt not ready to be extubated, pressure support increased to\n 10.\n Response:\n RR down in the 20\ns on 10 pressure support , pt appears more\n comfortable\n Plan:\n continue antibx, follow temp, WBC continue vigorous pulmonary\n toilet\n Altered mental status (not Delirium)\n Assessment:\n Pt remains off sedation (Fentanyl/versed) opens eyes spont. At\n one point pt did move toes on command, unable to squeeze my hand. Pt\n very stiff\n Action:\n Pt remains lethargic\n Response:\n Off sedation\n Plan:\n Continue to follow. Pt remains a full code.\n GI: tube feeds restarted after decision was made not to extubate.\n Fibersource HN FS at 30 cc/hr, goal is 55 cc/hr. no water boluses.\n CV/FLUIDS: bp stable 170-170/68 HR 80-100 SR occ PVC pt\n received 20 mg IVP lasix with good response. Pt negative 1 liter so\n far, (would like 2 liters neg) CVP 4-6 on Lisinopril and\n Metoprolol .\n" }, { "category": "Nursing", "chartdate": "2192-08-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342562, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology.\n .\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Hypoglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2192-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342845, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology. Previous on pressors, sepsis resolving with normal\n lactate. New leukocytosis, WBC 22.6 ? new UTI vs c-diff ( loose stools\n x 1 day) ARF resolved, creatinine at baseline 0.8; previous hematocrit\n drop; normocytic normochromic with iron profile sugesting chornic\n disease or infection, Coffee ground emesis from NG tube; guaiac\n negative; hct stable at 27.1 as of yesterday. Slightly increased\n troponin with ST depressions from previous EKG mostly likely demand\n ischemia related to hypotension.\n .\n Respiratory Failure due to Pneumonia, bacterial, hospital acquired\n (non-VAP)\n Assessment:\n Patient on pressure support with 40% O2, sats 92-100%, moderate to\n large amount of thin clear secretions, with moderate amount from\n oral; drooling when turn on her L side, lung sounds clear, dim at\n bases. ETT 20 at the lip; repeat sputum culture with 3+ gram positive\n cocci in pairs and chains, with 2+ oropharyngeal flora, speciation\n partial only with oral flora; vanc day 2, gentamicin dc\nd yesterday,\n amikacin started.. afebrile, WBC 22 as of yesterday morning. Off\n sedation since for 24 hours now, fentanyl IV bolus for pain\n Action:\n Suctioned secretions from ETT q2-3 hours and PRN, turn to sides q2-3\n hours; continues on antibiotics ( Vanco and Amikacin) no vent setting\n change overnight.\n Response:\n Sats > 95% at same settings, sats dip down 88 % during turning; ETT\n secretions thinner and clearer than yesterday, patient now able to\n cough out secretions. ABG 7.49/31/121\n Plan:\n Culture if temp spikes, continue pulmonary toilet and antibiotics\n Altered mental status (not Delirium)\n Assessment:\n History of CVA / dementia; ? if baseline aphasic, opens eye to\n stimulation ( turning and repositioning) but not tracking, impaired\n corneal, gag and very weak coughing reflexes. Pupils pinpoint but\n reactive. Slightly withdraws to pain\n nail bed. Noticed drooling when\n on her L side.\n Action:\n Fentanyl IV push ( 12.5mcg and 25 mcg given fro ? pain) SBP 180\n Response:\n More awake, better cough reflex\n Plan:\n Continue to evaluate level of awakeness now off sedation drip ?\n extubation\n Electrolyte & fluid disorder, other\n Assessment:\n Evening lytes K- 3.5,\n Action:\n Repleted with 40 mEq KCl PO and 20 mEq IV\n Response:\n CVP 6-9; tolerating tube feeds\n Plan:\n replete lytes per sliding scale\n .H/O hypertension, benign\n Assessment:\n SBP 170\ns at start of shift, NSR occasional\n frequent PVCs\n Action:\n Electrolytes repleted, schedules 50 mgs lopressor PO given\n Response:\n BP well controlled with beta blocker and pain meds SBP 130-140\n otherwise 150-160\n Plan:\n Continue lopressor and lisinopril, pain meds\n Code status : full code as confirmed yesterday with HCP ( patient\n sister)\n" }, { "category": "Respiratory ", "chartdate": "2192-08-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 342852, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 59 None\n Ideal tidal volume: 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: 20 cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n :\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Copious\n Plan/Comments\n No changes overnight, remained stable on PSV/CPAP. RSBI=119. See\n flowsheet for further pt data. Will follow.\n 05:44\n" }, { "category": "Nursing", "chartdate": "2192-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342831, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology. Previous on pressors, sepsis resolving with normal\n lactate. New leukocytosis, WBC 22.6 ? new UTI vs c-diff ( loose stools\n x 1 day) ARF resolved, creatinine at baseline 0.8; previous hematocrit\n drop; normocytic normochromic with iron profile sugesting chornic\n disease or infection, Coffee ground emesis from NG tube; guaiac\n negative; hct stable at 27.1 as of yesterday. Slightly increased\n troponin with ST depressions from previous EKG mostly likely demand\n ischemia related to hypotension.\n .\n Respiratory Failure due to Pneumonia, bacterial, hospital acquired\n (non-VAP)\n Assessment:\n Patient on pressure support with 40% O2, sats 92-100%, moderate to\n large amount of thin clear secretions, with moderate amount from oral;\n drooling when turn on her L side, lung sounds clear, dim at bases. ETT\n 20 at the lip; repeat sputum culture with 3+ gram positive cocci in\n pairs and chains, with 2+ oropharyngeal flora, speciation partial only\n with oral flora; vanc day 2, gentamicin dc\nd yesterday, amikacin\n started.. afebrile, WBC 22 as of yesterday morning. Off sedation since\n for 24 hours now, fentanyl IV bolus for pain\n Action:\n Suctioned secretions from ETT q2-3 hours and PRN, turn to sides q2-3\n hours; continues on antibiotics ( Vanco and Amikacin) no vent setting\n change overnight.\n Response:\n Sats > 95% at same settings, sats dip down 88 % during turning; ETT\n secretions thinner and clearer than yesterday, patient now able to\n cough out secretions.\n Plan:\n Culture if temp spikes, continue pulmonary toilet and antibiotics; plan\n to extubate patient today ? if she will be able to tolerate this,\n although secretions has decreased patient remains to have poor\n mechanics to clear secretions. Keep HOB > 30 degrees\n Altered mental status (not Delirium)\n Assessment:\n History of CVA / dementia; ? if baseline aphasic, opens eye to\n stimulation ( turning and repositioning) but not tracking, impaired\n corneal, gag and very weak coughing reflexes. Pupils pinpoint but\n reactive. Slightly withdraws to pain\n nail bed. Noticed drooling when\n on her L side.\n Action:\n Fentanyl IV push ( 12.5mcg and 25 mcg given fro ? pain) SBP 180\n Response:\n More awake, better cough reflex\n Plan:\n Continue to evaluate level of awakeness now off sedation drip ?\n extubation\n Electrolyte & fluid disorder, other\n Assessment:\n Evening lytes K- 3.5,\n Action:\n Repleted with 40 mEq KCl PO and 20 mEq IV\n Response:\n CVP 6-9; tolerating tube feeds\n Plan:\n replete lytes per sliding scale\n .H/O hypertension, benign\n Assessment:\n SBP 170\ns at start of shift, NSR with WAP, occasional\n frequent PVCs\n Action:\n Electrolytes repleted, schedules 50 mgs lopressor PO given\n Response:\n BP well controlled with beta blocker and pain meds SBP 120-130\ns, mid\n 150\ns now that sedation is off. frequent PVC\ns remains intermittently\n Plan:\n Continue lopressor and lisinopril, pain meds\n Code status : full code as confirmed yesterday with HCP ( patient\n sister)\n" }, { "category": "Physician ", "chartdate": "2192-08-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342960, "text": "Chief Complaint: 82 year old female with history of breast cancer, CVA,\n htn, who presents from rehab with pneumonia and urosepsis.\n 24 Hour Events:\n EKG - At 12:30 AM\n Yesterday patient placed back on higher pressure support for tachypnea\n to . Per nursing patient with less yellow secretions, now more thin\n and watery. Started on amikacin with providencia stuartii and e. coli\n in urine. C. diff negative. Repeat urine culture now negative.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Gentamicin - 11:00 PM\n Vancomycin - 08:10 AM\n Amikacin - 05:04 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:07 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Pantoprazole (Protonix) - 12:31 AM\n Fentanyl - 04:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.4\nC (97.6\n HR: 75 (65 - 93) bpm\n BP: 170/53(89) {128/48(72) - 182/75(108)} mmHg\n RR: 27 (16 - 37) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 7 (-2 - 7)mmHg\n Total In:\n 1,851 mL\n 356 mL\n PO:\n TF:\n 586 mL\n 346 mL\n IVF:\n 475 mL\n 10 mL\n Blood products:\n Total out:\n 3,470 mL\n 700 mL\n Urine:\n 3,470 mL\n 640 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n -1,619 mL\n -344 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 316 (316 - 460) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 119\n PIP: 16 cmH2O\n SpO2: 97%\n ABG: 7.49/31/121/22/2\n Ve: 9.4 L/min\n PaO2 / FiO2: 303\n Physical Examination\n General\n intubated, not sedated, not responding to commands\n Cards\n RRR, nl s1/s2, no murmur appreciated\n Pulm\n decreased breath sounds right side compared to left, + rhonchi\n on right , left lung clear\n Abdomen - + BS, soft, non-tender\n Extremities\n 2+ radial pulses b/l, 1+ edema of arms, 2+ edema of feet\n b/l to mid calf, WWP, no clubbing or cyanosis\n Labs / Radiology\n 195 K/uL\n 8.7 g/dL\n 141 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 112 mEq/L\n 141 mEq/L\n 26.1 %\n 24.0 K/uL\n [image002.jpg]\n 03:31 AM\n 07:50 PM\n 04:10 AM\n 05:33 AM\n 06:00 AM\n 07:59 PM\n 03:58 AM\n 05:43 PM\n 08:36 PM\n 03:46 AM\n WBC\n 22.6\n 22.8\n 24.0\n Hct\n 27.1\n 26.8\n 26.1\n Plt\n 104\n 133\n 195\n Cr\n 0.8\n 0.7\n 0.7\n 0.8\n 0.9\n TCO2\n 20\n 22\n 24\n 24\n Glucose\n 37\n 40\n 145\n 61\n 90\n 104\n 141\n Other labs: PT / PTT / INR:13.9/26.8/1.2, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:92.1 %, Band:5.0 %, Lymph:4.4 %, Mono:3.0 %, Eos:0.4\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.3\n mg/dL, Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology.\n Septic Shock: Patient was with SIRS with E coli in blood and urine,\n as well as providencia stuartii in urine. CXR shows bibasilar\n consolidations as well concerning for possible pneumonia. Sputum\n culture with gram + cocci however this has not grown out so far in\n speciation. Presentation lactate was 3.4, then trended down. Repeat\n urine culture now negative.\n - repeat sputum culture - GRAM STAIN (Final ): >25 PMNs and <10\n epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM\n POSITIVE COCCI. IN PAIRS AND CHAINS.\n 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Final ): SPARSE GROWTH OROPHARYNGEAL\n FLORA.\n - urine culture 9./17\n no growth final\n - c. diff negative \n - Urine -urine cx - URINE CULTURE (Final ):\n ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..\n PROVIDENCIA STUARTII. 10,000-100,000 ORGANISMS/ML..\n - currently on amikacin and vancomycin, still with tachypneia,\n although secretions have improved\n - allergy to PCN\n - currently off all pressors, now hypertensive\n - wbc count continuese to trend up with bandemia\n repeat Ucx is clean,\n c diff negative, may suggest that pneumonia is not being adequately\n treated, however patient remains afebrile\n - chest x-ray from yesterday\n 1) No significant change since with right pleural\n effusion\n and basilar opacity, likely atelectasis.\n 2) Unchanged support lines and tubes.\n -continue to monitor fever curve, WBC\n Respiratory Failure: Initially respiratory failure likely due to\n pneumonia. Suspect that also be aspect of deconditioning. Patient on\n pressure support with 40% O2; with improved secretions, hoever\n patient remains tachypneic with significant work of breathing, patient\n with present but impaired gag reflex. Rsbi this morning 85.\n - trial of pressure support 8/0 then check after 30 minutes then\n consider vent liberation\n - iv lasx 20 daily as patient net > 10 liters positive, may be\n impairing ability to get off vent\n -culture data and antibiotics as above\n - Suction PRN\n - consider again increasing pressure support\n - off sedation\n Mental status\n - decreased mental status even when off the sedating medications, will\n check head CT to ensure that hasn\nt had new ischemic event\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension,\n now restarted\n - IV hydral PRN for elevated blood pressure, but trying to get on\n better beta blocker/ace regimen\n - increased lisinopril today to 5\n -increased metoprolol to 75 TID this morning\n - lasix today for blood pressure control as well as fluid removal\n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since blood is prokinetic.\n Will guaiac stool when available.\n - crit is stable\n -Patient guaic positive in the ED, guiac positive stool\n - Coffee ground emesis from NG tube; guaiac negative\n - likely requires outpatient colonscopy, which is non-emergent\n - continue to follow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n baseline. Likely prerenal in etiology secondary to volume depletion\n and septic shock\n likely ATN. No cast seen in UA, but it was not\n fresh. Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n - continue to follow\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with multiple negative troponins. This was\n likely demand ischemia in setting of hypotension. repeat EKG from \n EKG Sinus rhythm. Premature ventricular contractions. Poor R wave\n progression may be lead placement or possible old anterior myocardial\n infarction. Compared to\n the previous tracing of axis has shifted rightward. Ventricular\n ectopy is new. ECHO from - IMPRESSION: Mild focal LV systolic\n dysfunction. Mildly dilated right ventricle. Mild to moderate aortic\n regurgitation. Moderately dilated ascending aorta.\n Dementia: Currently intubated to difficult to assess mental status.\n - namenda and aricept yesterday\n FEN:\n - tube feeds\n -check pm lytes, replete electrolytes as needed.\n Prophylaxis: SC heparin, holding bowel regimen for diarrhea\n Access: RIJ\n Communcation: Sister \n Code: Full Code.\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 01:49 PM 55 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 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": "2192-08-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342321, "text": "Chief Complaint: 82 year old female with hx of breast cancer, CVa, htn\n who presetns from rehab with pneumonia and urosepsis growing E. coli in\n her blood and her urine.\n 24 Hour Events:\n SPUTUM CULTURE - At 08:16 AM\n TRANSTHORACIC ECHO - At 10:30 AM\n FEVER - 101.1\nF - 09:00 AM\n Yesterday, d/c vancomycin and levofloxacin as patient had e. coli in\n the urine and the blood. still with thick secretions. peep was weaned\n overnight. otherwise quiet night.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 05:00 AM\n Vancomycin - 09:06 AM\n Gentamicin - 10:00 PM\n Aztreonam - 11:53 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Fentanyl - 09:00 AM\n Midazolam (Versed) - 09:15 AM\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium - 04:00 AM\n Hydralazine - 05:35 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 07:34 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: 35.8\nC (96.5\n HR: 92 (68 - 117) bpm\n BP: 152/58(88) {111/53(71) - 201/73(112)} mmHg\n RR: 30 (12 - 32) insp/min\n SpO2: 100%\n Heart rhythm: WAP (Wandering atrial pacemaker)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 4 (3 - 12)mmHg\n Total In:\n 2,326 mL\n 952 mL\n PO:\n TF:\n 238 mL\n 140 mL\n IVF:\n 1,783 mL\n 542 mL\n Blood products:\n Total out:\n 2,193 mL\n 548 mL\n Urine:\n 2,158 mL\n 548 mL\n NG:\n 35 mL\n Stool:\n Drains:\n Balance:\n 133 mL\n 404 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 420 (420 - 420) mL\n Vt (Spontaneous): 535 (354 - 626) mL\n PS : 8 cmH2O\n RR (Set): 24\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 51\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.38/33/106/19/-4\n Ve: 10.5 L/min\n PaO2 / FiO2: 265\n Physical Examination\n General Appearance: sedated, intubated\n Head, Ears, Nose, Throat: Endotracheal tube, NG tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), no murmur\n appreciated\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:\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 91 K/uL\n 9.5 g/dL\n 95 mg/dL\n 1.0 mg/dL\n 19 mEq/L\n 3.1 mEq/L\n 24 mg/dL\n 116 mEq/L\n 143 mEq/L\n 28.6 %\n 17.0 K/uL\n [image002.jpg]\n 05:00 AM\n 05:13 AM\n 12:00 PM\n 05:37 PM\n 04:45 AM\n 05:03 AM\n 07:34 AM\n 03:29 PM\n 03:16 AM\n 03:31 AM\n WBC\n 8.9\n 10.8\n 17.0\n Hct\n 25.6\n 27.6\n 26.5\n 28.6\n Plt\n 104\n 84\n 91\n Cr\n 1.5\n 1.2\n 1.0\n TropT\n 0.14\n 0.14\n TCO2\n 21\n 20\n 20\n 19\n 22\n 20\n Glucose\n 78\n 83\n 95\n Other labs: PT / PTT / INR:16.2/31.9/1.4, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.5\n mg/dL, Mg++:1.7 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia and septic physiology.\n Septic Shock: Patient was with SIRS now with E coli in blood and\n urine. CXR shows bibasilar consolidations as well. Nothing has grown in\n the sputum culture. There is some mild enteritis as well. Patient\n received fluid resucitation; here presentation lactate was 3.4, then\n trended down yesterday.\n - repeat sputum culture wtih 3+ gram positive cocci in pairs and\n chains, with 2+ oropharyngeal flora, nothing speciated out yet\n - currently on aztreonam, gentamycin Day , yesterday vanco and levo\n were d/c\n - currently off all pressors, off sedation and now hypertensive\n -monitor WBC, CBC, diff\n -monitor fever curve- patient initially febrile but became hypothermic\n requiring bear hugger, now normothermic\n Respiratory Failure: Initially respiratory failure thought to be due to\n pneumonia. Patient on CPAP 20/5 with 40% O2; however is very\n tachypneic. O2 sats in monitor are ok. not be able to extubate in\n AM and require gas. Still requiring pressure support. Presence of gag\n reflex is unknown at baseline. Mental status is non-responsive. Patient\n without much secretions.\n -culture data from sputum thus far has grown orophyaryngeal flora only,\n now with 3+ gram positive cocci in pairs, awaiting speciation\n - would like to add back gram + coverage as was d/c yesterday given\n flora findings above\n - + gag reflex\n - increased secretions, likely not candidate for extubation today\n - Suction PRN\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension\n - gave 10 IV hydral in the setting now of hypertension to 200 may be in\n the setting of agitation\n - consider restarting lisinopril once acute renal failure improves\n -Increase metoprolol today (to 50 ), as per notes was suppose to be\n done yesterday but was not, decreased holding parameters to HR < 60 and\n SBP < 100\n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since blood is prokinetic.\n Will guaiac stool when available.\n -Patient guaic positive in the ED, have not sent stool studies as\n patient has had no stool, however suspect positive\n - Coffee ground emesis from NG tube; guaiac negative\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n to 1.0. Likely prerenal in etiology secondary to volume depletion and\n septic shock\n likely ATN. No cast seen in UA, but it was not fresh.\n Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n - trend creatinine\n -Maintain adequate BP and hydration\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with upward trending CE. This is likely demand\n ischemia in setting of hypotension. Now that BP and tachycardia under\n control, warm and perfusing, can follow-up cardiac function with echo.\n - recheck EKG now that tachycardia has improved\n - ECHO from - IMPRESSION: Mild focal LV systolic dysfunction.\n Mildly dilated right ventricle. Mild to moderate aortic regurgitation.\n Moderately dilated ascending aorta.\n - troponins slighlty increased, but in settig of sepsis may represent\n myocardial stunning\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n FEN:\n - residuals improve, restarted tube feedings, holding this AM in the\n setting of considering extubation\n -Monitor and replete electrolytes as needed.\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: DNR per nursing home record signed by patient's sister. Clarify\n goals of care with HCP.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2192-08-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342407, "text": "82 year old female with a history of breast CA (s/p XRT), CVA, baseline\n dementia, HTN, reflux, & recurrent UTI\ns, who presented on early\n am from after being found to be in respiratory distress\n with oxygen sats in 70s to 80\ns on r/a. Her EKG per report was within\n normal limits. Her exam was notable for audible rales and abdominal\n distension. Sent to EW, where she was emergently Intubated.\n T103. Code sepsis not initiated as BP >100/systolic. Peripheral BC\n from EW grew 4 out of 4 bottles positive for gram negative rods, E coli\n on C&S. Urine Cx () grew E coli. Sputum Cx shows many\n organisms consistent w/oropharyngeal flora. Became hypotensive in MICU\n on afternoon, received fluid boluses & levophed IV. Treated w/IV\n levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission. Off\n levophed since 0600. repeat sputum cx revealed gm + cocci.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Pt. remains intubated and on vent. PS 40%/5. Large amounts of thick\n yellow/tan secretions noted this shift. Breath sounds coarse with\n rhonchi bilat.\n Action:\n Aggressive pulm toileting suction q 3-4 hrs\n Response:\n Maint sats @ 100% tol PSV @ 40%\n Plan:\n Cont mech vent support. Cont to wean as tolerated. ? extubated this\n am. Suction prn.\n .H/O hypertension, benign\n Assessment:\n Pt hypertensive with SBP 150\ns to 170\ns. Does increase to 190\ns with\n nsg. Care.\n Action:\n Increased lopressor to 50 mg TID. Received 10mg IV hydralizine at\n 2200.\n Response:\n Pt bp now 150-160\ns w/ better rate control\n Plan:\n Cont to assess hemodynamics. PRN hydralizine as needed.\n" }, { "category": "Nutrition", "chartdate": "2192-08-24 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 342948, "text": "Subjective\n Patient intubated\n Objective\n Pertinent medications: RISS, lasix, 2gmMgsulf\n Labs:\n Value\n Date\n Glucose\n 141 mg/dL\n 03:46 AM\n Glucose Finger Stick\n 160\n 12:00 AM\n BUN\n 17 mg/dL\n 03:46 AM\n Creatinine\n 0.9 mg/dL\n 03:46 AM\n Sodium\n 141 mEq/L\n 03:46 AM\n Potassium\n 4.0 mEq/L\n 03:46 AM\n Chloride\n 112 mEq/L\n 03:46 AM\n TCO2\n 22 mEq/L\n 03:46 AM\n Albumin\n 2.2 g/dL\n 04:10 AM\n Calcium non-ionized\n 7.3 mg/dL\n 03:46 AM\n Phosphorus\n 2.5 mg/dL\n 03:46 AM\n Ionized Calcium\n 1.17 mmol/L\n 03:31 AM\n Magnesium\n 1.6 mg/dL\n 03:46 AM\n Current diet order / nutrition support: Fibersource HN at 55ml/hr x 24\n hours - provides 1584kcal and 73g protein\n GI: Abdomen soft with hypoactive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n 82 year old female with history of breast cancer, CVA presenting from\n rehab with pneumonia, UTI and sepsis. Patient was not able to be\n extubated yesterday d/t secretions. Tube feedings were restarted. If\n unable to extubate, would continue with tube feedings of Fibersource HN\n at 55ml/hr x 24 hours.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Continue with Fibersource HN at 55ml/hr x 24 hours\n 2. Monitor residuals q4H and hold tube feedings if >150ml\n 3. Will follow for extubation and plan for feeding\n 12:06\n" }, { "category": "Physician ", "chartdate": "2192-08-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 342949, "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 12:30 AM\n Increased levels of PSV rquired for treatment despite decresed\n secretions\n Amikacin started and Gent D/C'd\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Gentamicin - 11:00 PM\n Vancomycin - 08:03 AM\n Amikacin - 08:04 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:07 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Pantoprazole (Protonix) - 12:31 AM\n Fentanyl - 04:00 AM\n Hydralazine - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:49 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: 37.7\nC (99.8\n HR: 73 (65 - 96) bpm\n BP: 144/54(82) {128/48(72) - 182/75(108)} mmHg\n RR: 22 (16 - 35) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 5 (-2 - 7)mmHg\n Total In:\n 1,851 mL\n 649 mL\n PO:\n TF:\n 586 mL\n 339 mL\n IVF:\n 475 mL\n 310 mL\n Blood products:\n Total out:\n 3,470 mL\n 2,075 mL\n Urine:\n 3,470 mL\n 2,015 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n -1,619 mL\n -1,426 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 422 (316 - 460) mL\n PS : 12 cmH2O\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 119\n PIP: 18 cmH2O\n SpO2: 99%\n ABG: 7.49/31/121/22/2\n Ve: 8.5 L/min\n PaO2 / FiO2: 303\n Physical Examination\n General Appearance: Thin\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Distended\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Not assessed\n Neurologic: Responds to: Tactile stimuli, Movement: Not assessed, Tone:\n Not assessed-_She does respond to tactile stimulus and moves all\n extremities. Her pupils are equal, small and minimally reactive, She\n does have cough with suctioning\n Labs / Radiology\n 8.7 g/dL\n 195 K/uL\n 141 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 112 mEq/L\n 141 mEq/L\n 26.1 %\n 24.0 K/uL\n [image002.jpg]\n 03:31 AM\n 07:50 PM\n 04:10 AM\n 05:33 AM\n 06:00 AM\n 07:59 PM\n 03:58 AM\n 05:43 PM\n 08:36 PM\n 03:46 AM\n WBC\n 22.6\n 22.8\n 24.0\n Hct\n 27.1\n 26.8\n 26.1\n Plt\n 104\n 133\n 195\n Cr\n 0.8\n 0.7\n 0.7\n 0.8\n 0.9\n TCO2\n 20\n 22\n 24\n 24\n Glucose\n 37\n 40\n 145\n 61\n 90\n 104\n 141\n Other labs: PT / PTT / INR:13.9/26.8/1.2, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:92.1 %, Band:5.0 %, Lymph:4.4 %, Mono:3.0 %, Eos:0.4\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.3\n mg/dL, Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 82 yo female with respiratory failure and significant and prolonged\n intubation with altered mental status and prominent secretions limiting\n capacity to extubate. She has tolerated diuresis well with no evidence\n of hemodynamic impact from the diuresis.\n 1)Respiratory Failure\nPatient has decresed secreations, she has\n persistent altered mental status with decreased responsiveness but no\n localizing findings. She does cough with suctioning but does not\n follow commands. She has RSBI <105 with PSV-8/0. We have tried\n diuresis with some response.\n -Check NIF to evaluate for weakness is attractive but will not be able\n to comply\n -Trial 8/0 for SBT for 30 minutes\n -If favorable will move to extubation\n -If failure of extubation will have to consider tracheostomy\n 2)ID-Pneumonia-\n -Vanco/Amikacin\n 3)Altered Mental Status-\n Does have persistent and significant encephalopathy\n -Will Check head CT\n -Will continue Namenda/Aricept\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 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": "2192-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343034, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology. Previous on pressors, sepsis resolving with normal\n lactate. New leukocytosis, WBC 22.6 ? new UTI vs c-diff ( loose stools\n x 1 day) ARF resolved, creatinine at baseline 0.8; previous hematocrit\n drop; normocytic normochromic with iron profile sugesting chornic\n disease or infection, Coffee ground emesis from NG tube; guaiac\n negative; hct stable at 27.1 as of yesterday. Slightly increased\n troponin with ST depressions from previous EKG mostly likely demand\n ischemia related to hypotension.\n .\n .H/O hypertension, benign\n Assessment:\n Pt\ns BP this morning was 140-150s, after extubation her BP has\n increased to the 170s-180s\n the team is ok with this for now.\n Action:\n Hypertensive after extubation, she was given her lopressor dose and 20\n mg of IV lasix prior to extubation.\n Response:\n Hypertensive\n Plan:\n Cont to follow, her antihypertensives meds may need to be increased\n Altered mental status (not Delirium)\n Assessment:\n Pt is following commands through the day, she has not spoken so far\n her baseline is one word answers to questions\n Action:\n Pt is awake, following commands consistently\n squeezing hands, moving\n feet but not talking\n Response:\n She is awake but not at her baseline yet\n Plan:\n Cont to follow\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Pt with a pneumonia, T max 100.3, her most recent CXR shows an area of\n concern in her RLL, she was 14 liters pos this morning, given lasix in\n hopes of extubating her.\n Action:\n Given 20mg of IV lasix x2 today, able to extubat her at 3 pm, she is on\n 50% face tent\n Response:\n Good u/o\n she is ~ 12 liters pos for LOS now, tolerated extubation, 02\n SAT has been in the upper 90s on 50% cool face tent.\n Plan:\n She needs a chest CT to evaluate the area in her RLL, cont to follow\n I&Os, resp status\n" }, { "category": "Physician ", "chartdate": "2192-08-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 342337, "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 SPUTUM CULTURE - At 08:16 AM\n TRANSTHORACIC ECHO - At 10:30 AM\n FEVER - 101.1\nF - 09:00 AM\n Patient with continued PSV support\n Pulmonary secretions continue\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 05:00 AM\n Vancomycin - 09:06 AM\n Gentamicin - 10:00 PM\n Aztreonam - 08:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium - 04:00 AM\n Hydralazine - 05:35 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:47 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: 36.1\nC (97\n HR: 95 (68 - 95) bpm\n BP: 169/62(95) {111/53(71) - 170/72(106)} mmHg\n RR: 28 (12 - 30) insp/min\n SpO2: 100%\n Heart rhythm: WAP (Wandering atrial pacemaker)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 5 (3 - 12)mmHg\n Total In:\n 2,326 mL\n 1,074 mL\n PO:\n TF:\n 238 mL\n 140 mL\n IVF:\n 1,783 mL\n 664 mL\n Blood products:\n Total out:\n 2,193 mL\n 698 mL\n Urine:\n 2,158 mL\n 698 mL\n NG:\n 35 mL\n Stool:\n Drains:\n Balance:\n 133 mL\n 376 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 427 (427 - 626) mL\n PS : 8 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 51\n PIP: 14 cmH2O\n SpO2: 100%\n ABG: 7.38/33/106/19/-4\n Ve: 12 L/min\n PaO2 / FiO2: 265\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.5 g/dL\n 91 K/uL\n 95 mg/dL\n 1.0 mg/dL\n 19 mEq/L\n 3.1 mEq/L\n 24 mg/dL\n 116 mEq/L\n 143 mEq/L\n 28.6 %\n 17.0 K/uL\n [image002.jpg]\n 05:00 AM\n 05:13 AM\n 12:00 PM\n 05:37 PM\n 04:45 AM\n 05:03 AM\n 07:34 AM\n 03:29 PM\n 03:16 AM\n 03:31 AM\n WBC\n 8.9\n 10.8\n 17.0\n Hct\n 25.6\n 27.6\n 26.5\n 28.6\n Plt\n 104\n 84\n 91\n Cr\n 1.5\n 1.2\n 1.0\n TropT\n 0.14\n 0.14\n TCO2\n 21\n 20\n 20\n 19\n 22\n 20\n Glucose\n 78\n 83\n 95\n Other labs: PT / PTT / INR:16.2/31.9/1.4, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.5\n mg/dL, Mg++:1.7 mg/dL, PO4:1.9 mg/dL\n Fluid analysis / Other labs: 7.38/33/96\n Imaging: CXR-ETT and NGT in good position, poor technique for\n evaluation of lung fields.\n Assessment and Plan\n Patient with hypoxemic respiratory failure and now with imroved\n oxygenation and ventilation but with continued barriers to extubation\n primarily driven by persistent secretions and low grade fever. This,\n it must be noted, is in the setting of rising WBC count.\n 1)Respiratory Failure-\n -Patient with Rx ongoing for probable pulmonary infection.\n -She has had return of gag reflex\n -Her sputum volume had decreased to suctioning every 4 hours by nursing\n with perhaps some additional by respiratory\n -She has maintained reasonable support with PSV at 8/5 with Ve\n requirement of 10 lpm\n -Given fever and WBC increased to 17 will maintain Vanco/Gent\n -Goal is to D/C sedation and trial extubation today\n 2)Sepsis-\n -E.Coli seen in urine and blood\n -Sputum not revealing\n -Hemodynamics improved\n -Low grade fevers and rising WBC count are of concern and will maintain\n broad spectrum antibiotics\n -Vanco/Gent to continue\n 3)Dementia-\n -Patient described as verbal with one word answers at baseline\n -Will hope to see further improvement with discontinuation of sedating\n medications.\n gg\n ICU Care\n Nutrition: npo\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\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: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2192-08-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342340, "text": "Chief Complaint: 82 year old female with hx of breast cancer, CVa, htn\n who presetns from rehab with pneumonia and urosepsis growing E. coli in\n her blood and her urine.\n 24 Hour Events:\n SPUTUM CULTURE - At 08:16 AM\n TRANSTHORACIC ECHO - At 10:30 AM\n FEVER - 101.1\nF - 09:00 AM\n Yesterday, d/c vancomycin and levofloxacin as patient had e. coli in\n the urine and the blood. still with thick secretions. peep was weaned\n overnight. otherwise quiet night.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 05:00 AM\n Vancomycin - 09:06 AM\n Gentamicin - 10:00 PM\n Aztreonam - 11:53 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Fentanyl - 09:00 AM\n Midazolam (Versed) - 09:15 AM\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium - 04:00 AM\n Hydralazine - 05:35 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems:none\n Flowsheet Data as of 07:34 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: 35.8\nC (96.5\n HR: 92 (68 - 117) bpm\n BP: 152/58(88) {111/53(71) - 201/73(112)} mmHg\n RR: 30 (12 - 32) insp/min\n SpO2: 100%\n Heart rhythm: WAP (Wandering atrial pacemaker)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 4 (3 - 12)mmHg\n Total In:\n 2,326 mL\n 952 mL\n PO:\n TF:\n 238 mL\n 140 mL\n IVF:\n 1,783 mL\n 542 mL\n Blood products:\n Total out:\n 2,193 mL\n 548 mL\n Urine:\n 2,158 mL\n 548 mL\n NG:\n 35 mL\n Stool:\n Drains:\n Balance:\n 133 mL\n 404 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 420 (420 - 420) mL\n Vt (Spontaneous): 535 (354 - 626) mL\n PS : 8 cmH2O\n RR (Set): 24\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 51\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.38/33/106/19/-4\n Ve: 10.5 L/min\n PaO2 / FiO2: 265\n Physical Examination\n General Appearance: sedated, intubated\n Head, Ears, Nose, Throat: Endotracheal tube, NG tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), no murmur\n appreciated\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:\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 91 K/uL\n 9.5 g/dL\n 95 mg/dL\n 1.0 mg/dL\n 19 mEq/L\n 3.1 mEq/L\n 24 mg/dL\n 116 mEq/L\n 143 mEq/L\n 28.6 %\n 17.0 K/uL\n [image002.jpg]\n 05:00 AM\n 05:13 AM\n 12:00 PM\n 05:37 PM\n 04:45 AM\n 05:03 AM\n 07:34 AM\n 03:29 PM\n 03:16 AM\n 03:31 AM\n WBC\n 8.9\n 10.8\n 17.0\n Hct\n 25.6\n 27.6\n 26.5\n 28.6\n Plt\n 104\n 84\n 91\n Cr\n 1.5\n 1.2\n 1.0\n TropT\n 0.14\n 0.14\n TCO2\n 21\n 20\n 20\n 19\n 22\n 20\n Glucose\n 78\n 83\n 95\n Other labs: PT / PTT / INR:16.2/31.9/1.4, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.5\n mg/dL, Mg++:1.7 mg/dL, PO4:1.9 mg/dL\n Chest x-ray\n ET tube 4 cm above carina, R lung base with consolidation\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia and septic physiology.\n Septic Shock: Patient was with SIRS now with E coli in blood and\n urine. CXR shows bibasilar consolidations as well. Sputum culture with\n gram + cocci. There is some mild enteritis as well. Patient received\n fluid resucitation; here presentation lactate was 3.4, then trended\n down.\n - repeat sputum culture wtih 3+ gram positive cocci in pairs and\n chains, with 2+ oropharyngeal flora, nothing speciated out yet\n - currently on aztreonam, gentamycin Day , yesterday vanco and levo\n were d/c, spiked fever to 101\n - currently off all pressors, off sedation and now hypertensive\n -monitor WBC, CBC, diff\n -monitor fever curve- patient initially febrile but became hypothermic\n requiring bear hugger, now normothermic\n Respiratory Failure: Initially respiratory failure thought to be due to\n pneumonia. Patient on CPAP 8/5 with 40% O2; with thick secretions. O2\n sats in monitor are ok. + Gag reflex. Mental status is non-responsive.\n Patient without much secretions.\n -culture data from sputum thus far has grown orophyaryngeal flora only,\n now with 3+ gram positive cocci in pairs, awaiting speciation\n - start vanco back up, get ID approval\n - will decrease pressure support to and wean sedation, consider\n trial of extubation today\n - would like to add back gram + coverage as was d/c yesterday given\n flora findings above\n - + gag reflex\n - increased secretions, likely not candidate for extubation today\n - Suction PRN\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension\n - gave 10 IV hydral in the setting now of hypertension to 200 may be in\n the setting of agitation, would like to get away from IV hydral and\n titrate up beta blocker\n - consider restarting lisinopril once acute renal failure improves,\n home dose 2.5 ( would rather titrate up beta blocker at this time)\n -Increase metoprolol today (to 50 ), as per notes was suppose to be\n done yesterday but was not, decreased holding parameters to HR < 60 and\n SBP < 100\n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since blood is prokinetic.\n Will guaiac stool when available.\n - crit is stable\n -Patient guaic positive in the ED, have not sent stool studies as\n patient has had no stool, however suspect positive\n - Coffee ground emesis from NG tube; guaiac negative\n - continue to follow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n to 1.0. Likely prerenal in etiology secondary to volume depletion and\n septic shock\n likely ATN. No cast seen in UA, but it was not fresh.\n Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n - trend creatinine\n -Maintain adequate BP and hydration\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with upward trending CE. This is likely demand\n ischemia in setting of hypotension. Now that BP and tachycardia under\n control, warm and perfusing, can follow-up cardiac function with echo.\n - recheck EKG now that tachycardia has improved\n - ECHO from - IMPRESSION: Mild focal LV systolic dysfunction.\n Mildly dilated right ventricle. Mild to moderate aortic regurgitation.\n Moderately dilated ascending aorta.\n - troponins slighlty increased, but in settig of sepsis may represent\n myocardial stunning, also echo is reassuming that there is no regional\n wall motion abnormalities\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n FEN:\n - residuals improve, restarted tube feedings, holding this AM in the\n setting of considering extubation\n -Monitor and replete electrolytes as needed.\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: currently full code, as initial DNR was reversed by HCP. \n need to re-establish if patient would be re-intubated pending failure\n of extubation.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2192-08-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342406, "text": "82 year old female with a history of breast CA (s/p XRT), CVA, baseline\n dementia, HTN, reflux, & recurrent UTI\ns, who presented on early\n am from after being found to be in respiratory distress\n with oxygen sats in 70s to 80\ns on r/a. Her EKG per report was within\n normal limits. Her exam was notable for audible rales and abdominal\n distension. Sent to EW, where she was emergently Intubated.\n T103. Code sepsis not initiated as BP >100/systolic. Peripheral BC\n from EW grew 4 out of 4 bottles positive for gram negative rods, E coli\n on C&S. Urine Cx () grew E coli. Sputum Cx shows many\n organisms consistent w/oropharyngeal flora. Became hypotensive in MICU\n on afternoon, received fluid boluses & levophed IV. Treated w/IV\n levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission. Off\n levophed since 0600. repeat sputum cx revealed gm + cocci.\n" }, { "category": "Nutrition", "chartdate": "2192-08-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 342494, "text": "Subjective\n Patient intubated\n Objective\n Pertinent medications: RISS, 40meqKCl\n Labs:\n Value\n Date\n Glucose\n 145\n 06:00 AM\n Glucose Finger Stick\n 88\n 12:00 PM\n BUN\n 18 mg/dL\n 04:10 AM\n Creatinine\n 0.8 mg/dL\n 04:10 AM\n Sodium\n 142 mEq/L\n 04:10 AM\n Potassium\n 2.7 mEq/L\n 04:10 AM\n Chloride\n 113 mEq/L\n 04:10 AM\n TCO2\n 21 mEq/L\n 04:10 AM\n Albumin\n 2.2 g/dL\n 04:10 AM\n Calcium non-ionized\n 7.3 mg/dL\n 04:10 AM\n Phosphorus\n 2.3 mg/dL\n 04:10 AM\n Ionized Calcium\n 1.17 mmol/L\n 03:31 AM\n Magnesium\n 1.8 mg/dL\n 04:10 AM\n Current diet order / nutrition support: NPO\n Fibersource HN at 55ml/hr x 24 hours - currently on hold\n GI: Abdomen soft/distended with positive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n 82 year old female wit history of breast cancer, CVA presenting from\n rehab with respiratory failure, UTI, PNA, sepsis. Patient was NPO for\n possible extubation today. Tube feedings were also held d/t elevated\n residuals yesterday. Would trial restarting tube feeding if no plan for\n extubation. Goal Fibersource HN at 55ml/hr x 24 hours.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Restart Fibersource HN at 20ml/hr, advance by 20ml q6H to goal\n rate of 55ml/hr x 24 hours\n 2. Monitor residuals q4H and hold tube feeding if >150ml\n 3. If extubated, will follow for plan of care.\n 14:28\n" }, { "category": "Nursing", "chartdate": "2192-08-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343078, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology. Previous on pressors, sepsis resolving with normal\n lactate. New leukocytosis, WBC 22.6 ? new UTI vs c-diff ( loose stools\n x 1 day) ARF resolved, creatinine at baseline 0.8; previous hematocrit\n drop; normocytic normochromic with iron profile sugesting chornic\n disease or infection, Coffee ground emesis from NG tube; guaiac\n negative; hct stable at 27.1 as of yesterday. Slightly increased\n troponin with ST depressions from previous EKG mostly likely demand\n ischemia related to hypotension.\n .\n .H/O hypertension, benign\n Assessment:\n Very hypertensive at beginning of shift with sbp up to as high as 200.\n unable to tell if pt in pain although appearing uncomfortable d/t\n tachypneic up to high 40s ( see pneumonia).\n Action:\n Given 10mg iv hydralazine for htn and 12.5mcg fentanyl for pain. Ngt\n placed in l nare to give po meds and confirmed + placement via cxr.\n Response:\n Htn continues but down to 160s. still tachypneic but now down to high\n 20s to low 30s. continues to have tachypnea with repositioning\n requiring 12.5mcg fentanyl iv with good effect. Rr down to high 20s and\n appears more comfortable. Sbp up to 180s again with each turn but down\n to 160s after fentanyl given for comfort.\n Plan:\n Continue antihypertensives, iv hyralazine prn as ordered, fentanyl prn\n with turns if appears uncomfortable again with tachypnea.\n Altered mental status (not Delirium)\n Assessment:\n Lethargic, opens eyes to voice, not following commands, nonverbal,\n localizes pain. Very stiff and contracted. Very little upper extremity\n movement, no lower extremity movement noted. Pt has baseline dementia\n and is not far from her baseline although family states pt is usually\n verbal with one word. Pt appearing to have pain as stated above with\n tacypnea with repositioning. Unable to take pos.\n Action:\n Reoriented frequently. Medicated with 12.5mcg fentanyl with\n repositioning. Ngt placed and confirmed via cxr po meds given via ngt.\n Senna given to keep bowels moving.\n Response:\n Continues with baseline dementia requiring frequent reorienting.\n Discomfort with tachypnea relieved with iv fentanyl. Medium and large\n loose/liquid stool.\n Plan:\n Continue to reorient prn and medicate with 12.5mcg fentanyl prn with\n repositioning. Hold bowel meds today, resume if no further bm today.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Pt with audible rhonchi most prominent 1^st half of shift with copious\n clear secretions from back of throat pooling into her face tent. Also\n sounded so junky in upper airways as if she was drowning in secretions.\n Am k = 3.2. continues to have frequent pvcs, short 3 beat runs vtachy.\n Apcs.\n Action:\n Nts for moderate amts thick white frothy secretions. Given 20mg iv\n lasix and diuresing well. Receiving iv abx, amikacin trough and peak\n drawn, pending. Receiving 60 meq iv kcl via r ij tlcl.\n Response:\n 4.9 liters negative by midnight over last 24 hours. 700cc negative\n since midnight tonight. Much less rhonchi the 2^nd of the shift. Am\n Abg good: 7.43/39/99.\n Plan:\n Continue suctioin prn, assess fluid status. Abx, replete lytes prn.\n" }, { "category": "Nursing", "chartdate": "2192-08-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 343176, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology. Previous on pressors, sepsis resolving with normal\n lactate. New leukocytosis, WBC 22.6 ? new UTI vs c-diff ( loose stools\n x 1 day) ARF resolved, creatinine at baseline 0.8; previous hematocrit\n drop; normocytic normochromic with iron profile sugesting chornic\n disease or infection, Coffee ground emesis from NG tube; guaiac\n negative; hct stable at 27.1 as of yesterday. Slightly increased\n troponin with ST depressions from previous EKG mostly likely demand\n ischemia related to hypotension.\n .\n .H/O hypertension, benign\n Assessment:\n Pts BP has been 160-170s, occationally decreased to the 140s, HR 80s SR\n with occational PVCs\n Action:\n Her lisinopril was increased to 10mg from 5mg, her lopressor was not\n increased. She has not required any hydralazine this shift.\n Response:\n Still hypertensive with the increase in her ace\n Plan:\n Cont to follow her BP, HR\n Altered mental status (not Delirium)\n Assessment:\n Pt is awake, not speaking, she is following commands, she does not nod\n yes or no to questions\n Action:\n Response:\n Plan:\n Cont to follow\n Electrolyte & fluid disorder, other\n Assessment:\n Pt had been receiving lasix and this has caused her potassium to be low\n and she has had frequent PVCs with low potassium levels\n Action:\n Potassium per sliding scale\n Response:\n Less ectopy with improved K levels\n Plan:\n Cont to follow electrolytes with lasix use\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Pt extubated yesterday, now on 2 L NC with 02 SATs in the mid to upper\n 90s, still with a large amount of oral secreations and has needed nasal\n tracheal suctioning fof mod to lg amount of thick secreations. She has\n been afebrile today\n Action:\n She had a CT pf her chest for a ? mass seen on her chest xray\n Response:\n Requiring NT suctioning\n Plan:\n Follow 02 SATs, RR, temp, cont on abx, NT suctioning prn\n" }, { "category": "Nursing", "chartdate": "2192-08-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343074, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology. Previous on pressors, sepsis resolving with normal\n lactate. New leukocytosis, WBC 22.6 ? new UTI vs c-diff ( loose stools\n x 1 day) ARF resolved, creatinine at baseline 0.8; previous hematocrit\n drop; normocytic normochromic with iron profile sugesting chornic\n disease or infection, Coffee ground emesis from NG tube; guaiac\n negative; hct stable at 27.1 as of yesterday. Slightly increased\n troponin with ST depressions from previous EKG mostly likely demand\n ischemia related to hypotension.\n .\n .H/O hypertension, benign\n Assessment:\n Very hypertensive at beginning of shift with sbp up to as high as 200.\n unable to tell if pt in pain although appearing uncomfortable d/t\n tachypneic up to high 40s ( see pneumonia).\n Action:\n Given 10mg iv hydralazine for htn and 12.5mcg fentanyl for pain. Ngt\n placed in l nare to give po meds and confirmed + placement via cxr.\n Response:\n Htn continues but down to 160s. still tachypneic but now down to 30s.\n Plan:\n Continue antihypertensives, iv hyralazine prn as ordered, may need more\n fentanyl if appears uncomfortable again with tachypnea.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2192-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342258, "text": "82 year old female with a history of breast CA (s/p XRT), CVA, baseline\n dementia, HTN, reflux, & recurrent UTI\ns, who presented on early\n am from after being found to be in respiratory distress\n with oxygen sats in 70s to 80\ns on r/a. Her EKG per report was within\n normal limits. Her exam was notable for audible rales and abdominal\n distension. Sent to EW, where she was emergently Intubated.\n T103. Code sepsis not initiated as BP >100/systolic. Peripheral BC\n from EW grew 4 out of 4 bottles positive for gram negative rods, E coli\n on C&S. Urine Cx () grew E coli. Sputum Cx shows many\n organisms consistent w/oropharyngeal flora. Became hypotensive in MICU\n on afternoon, received fluid boluses & levophed IV. Treated w/IV\n levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission. Off\n levophed since 0600.\n Nuero: Pt remains sedated on 50 mcg/hr of fentanyl and 1 mg/hr of\n versed. Left pupil 2 mm and reactive; left pupil 2 mm and nonreactive.\n Opens eyes when stimulated. Moves toes on bed nonpurposefully. Impaired\n cough and absent gag reflex.\n GI: Hypoactive BS. No residual from OGT. Abdomen soft and distended. TF\n started at 1300 with free water boluses. Small brown BM.\n Endo: Siding scale insulin. Blood sugars in 70\ns. Watched q1-2hours\n while on D51/2 NS at 100/hr.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Intubated on CPAP Fi02 40% with a tidal volume of 500-600 and a MV\n of . Sp02 100%, RR 13-25. Tmax 101, diaphoresis noted on face. Upper\n lung fields rhonchus; lower fields clear but diminished. Moderate thick\n tan/blood tinged secretions suctioned q1-2 hours.\n Action:\n Pt initially on CPAP but showed signs of resp distress, tachypnea\n in the high 30\ns, labored work of breathing, and SBP in 180-190. Drew\n ABG at 0730 7.40/30/74. Increased pressure support to 20 and boluses\n with fentanyl and versed in response to VS changes. Suctioned\n q1-2hours. Changed positions frequently. Abx administered. Discontinued\n Vanco and Levoflaxacin. Sputum culture sent. Tylenol given for temp.\n Another ABG drawn at 1530.\n Response:\n Pt settled down decreasing RR to and lowering SBP 120-130 after\n vent changes and fentanyl and versed boluses. Able to decrease pressure\n support again to 15 where the pt remains to look comfortable breathing\n 12-20 breaths/min, Sp02 100% and displaying nonlabored breathing.\n Secretions remain thick and lungs remain rhonchus. Gram positive grew\n out in sputum. Latest ABG at 1530 was 7.39/35/166\n Plan:\n Decrease pressure support as tolerated. ? ability to r/t copious\n amounts of secretions. Collect ABG as needed. Suction as needed noting\n amount and consistency of secretions. Positions changes. Tylenol as\n needed. Abx.\n .H/O hypertension, benign\n Assessment:\n Currently-- ABP 110-130/50-60. NSR 70-80\ns with occasional PVC\ns. Trop\n level at 0.14 DP pulses weakly palpable, PT pulses Doppler. <3 cap\n refill.\n Action:\n This morning the pt\ns ABP began to rise to a SBP of 180-190 with a HR\n of 110-120 and increasing ectopy. A bolus of versed and fentanyl was\n administered along with an increase in pressure support and ETT suction\n as the pt\ns work of breathing was also noted to be labored. Kept room\n dark and quiet allowing pt to rest and settle. Standing PO lopressor\n and IV hydralazine administered at 1200. Echo done at 1000. Team aware\n of trop level.\n Response:\n Pt responded well to boluses, vent changes, and resp care as SBP\n decreased to 120-130 along with the HR to 70-80\ns. Ectopy still noted\n but decreasing in frequency.\n Plan:\n Continue to monitor ABP and correlation between work of breathing and\n BP changes. Monitor sedation and its role in controlling ABP as well.\n Monitor cardiac changes resulting from ischemia r/t hypertension\n specifically trop levels and EKG changes. Administer standing cardiac\n meds.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO adequate 50-200 cc/hr; urine light yellow and clear. (+) 18 Liters\n for LOS. BUN 25 CR 1.2. Weight at 1000 was 77.7 kg.\n Action:\n Hourly UO. Started high fiber tube feedings at 1300 at 20 ml/hr with\n 150 cc fluid bolus q6h.\n Response:\n Pt remains to autodiurese.\n Plan:\n Follow BUN and Cr in AM labs. ? renal baseline. Check TF residuals q4h\n holding for >150 and increase rate q6h as tolerated with goal of 55\n ml/hr.\n" }, { "category": "Physician ", "chartdate": "2192-08-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 342480, "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 PSV wean to with FIO2=0.4 and ABG normalized\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Gentamicin - 09:24 PM\n Vancomycin - 08:12 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydralazine - 10:54 PM\n Heparin Sodium (Prophylaxis) - 03:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:05 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 67 (67 - 98) bpm\n BP: 165/67(99) {142/57(85) - 181/72(106)} mmHg\n RR: 22 (21 - 29) insp/min\n SpO2: 100%\n Heart rhythm: WAP (Wandering atrial pacemaker)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 8 (2 - 10)mmHg\n Total In:\n 1,615 mL\n 445 mL\n PO:\n TF:\n 140 mL\n IVF:\n 1,155 mL\n 405 mL\n Blood products:\n Total out:\n 2,018 mL\n 1,380 mL\n Urine:\n 2,018 mL\n 1,380 mL\n NG:\n Stool:\n Drains:\n Balance:\n -403 mL\n -935 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 354 (354 - 447) mL\n PS : 5 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.41/37/107/21/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 268\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\nshe does follow commands.\n Labs / Radiology\n 9.0 g/dL\n 104 K/uL\n 145\n 0.8 mg/dL\n 21 mEq/L\n 2.7 mEq/L\n 18 mg/dL\n 113 mEq/L\n 142 mEq/L\n 27.1 %\n 22.6 K/uL\n [image002.jpg]\n 04:45 AM\n 05:03 AM\n 07:34 AM\n 03:29 PM\n 03:16 AM\n 03:31 AM\n 07:50 PM\n 04:10 AM\n 05:33 AM\n 06:00 AM\n WBC\n 10.8\n 17.0\n 22.6\n Hct\n 26.5\n 28.6\n 27.1\n Plt\n 84\n 91\n 104\n Cr\n 1.2\n 1.0\n 0.8\n TropT\n 0.14\n TCO2\n 20\n 19\n 22\n 20\n 22\n 24\n Glucose\n 83\n 95\n 37\n 40\n 145\n Other labs: PT / PTT / INR:14.8/26.7/1.3, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.3\n mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Imaging: No new CXR\n Microbiology: No new results\n E.Coli from previous results\n Assessment and Plan\n 82 yo female with respiratory failure and persistent pulmonary\n secretions. Mental status has been impaired but it is likely near her\n baseline function. There were extensive discussions with the patient's\n sister and daughter to clarify current clinical course. They would\n endorse full code status and re-intubation if patient were to fail\n trial of extubation.\n With that clarified patient has had good tolerance of PSV and retains\n altered mental status and pulmonary secretions as the primary barriers\n to extubation.\n 1)Respiratory Failure-Has good tolerance of PSV wean but persistent and\n signficiant secreations remain at issue. She has had improved\n responsiveness. With suctioning there are fairly high volume of\n secreations noted and suctioning has been every 1-2 hours. This in\n combination with impaired gag reflex does raise concerns for successful\n extubation.\n -Continue with PSV today\n -Continue with Vanco/Gent\n -Will wake up and re-trial SBT in am\n 2)Sepsis-\n -Check C. Diff\n -Check differential\n -Reculture if fever seen\n -This leukocytsis will have to be explained but does not appear to be\n recurrence of sepsis at this time.\n Vanco/Gent\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2192-08-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342482, "text": "Chief Complaint: 82 year old female with history fo breast cancer, CVA,\n HTN who presents from rehab with likely pneumonia and UTI leading to\n sepsis.\n 24 Hour Events:\n Yesterday, decreased pressure supports. this morning on % and\n RSBI of 56. still with moderate thick yellow secretions.\n Hemodynamically stable. Family meeting yesterday confirmed tha tpatient\n is indeed full code. Vancomycin was restarted yesterday with concern\n for increased sputum and in the setting of sputum with gram positive\n cocci in pairs. Patient was ordered for potassium scale given low K.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Vancomycin - 03:00 PM\n Gentamicin - 09:24 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydralazine - 10:54 PM\n Heparin Sodium (Prophylaxis) - 03:30 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.4\nC (99.3\n HR: 79 (79 - 98) bpm\n BP: 142/62(86) {142/57(85) - 181/72(106)} mmHg\n RR: 22 (21 - 29) insp/min\n SpO2: 100%\n Heart rhythm: WAP (Wandering atrial pacemaker)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 8 (2 - 10)mmHg\n Total In:\n 1,615 mL\n 192 mL\n PO:\n TF:\n 140 mL\n IVF:\n 1,155 mL\n 152 mL\n Blood products:\n Total out:\n 2,018 mL\n 1,080 mL\n Urine:\n 2,018 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n -403 mL\n -888 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 447 (423 - 464) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 13 cmH2O\n SpO2: 100%\n ABG: 7.41/37/107/21/0\n Ve: 11.3 L/min\n PaO2 / FiO2: 268\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 104 K/uL\n 9.0 g/dL\n 145\n 0.8 mg/dL\n 21 mEq/L\n 2.7 mEq/L\n 18 mg/dL\n 113 mEq/L\n 142 mEq/L\n 27.1 %\n 22.6 K/uL\n [image002.jpg]\n 04:45 AM\n 05:03 AM\n 07:34 AM\n 03:29 PM\n 03:16 AM\n 03:31 AM\n 07:50 PM\n 04:10 AM\n 05:33 AM\n 06:00 AM\n WBC\n 10.8\n 17.0\n 22.6\n Hct\n 26.5\n 28.6\n 27.1\n Plt\n 84\n 91\n 104\n Cr\n 1.2\n 1.0\n 0.8\n TropT\n 0.14\n TCO2\n 20\n 19\n 22\n 20\n 22\n 24\n Glucose\n 83\n 95\n 37\n 40\n 145\n Other labs: PT / PTT / INR:14.8/26.7/1.3, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.3\n mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology.\n Septic Shock: Patient was with SIRS with E coli in blood and urine.\n CXR shows bibasilar consolidations as well concerning for possible\n pneumonia. Sputum culture with gram + cocci however this has not grown\n out so far in speciation. There is some mild enteritis as wel as CTl.\n Presentation lactate was 3.4, then trended down.\n - repeat sputum culture wtih 3+ gram positive cocci in pairs and\n chains, with 2+ oropharyngeal flora, speciation partial only with oral\n flora currently\n - currently on gentamycin Day , yesterday restrated vancomycin\n - currently off all pressors, now hypertensive\n -monitor WBC, CBC, diff\n - wbc count continuese to trend up\n will send repeat ua and urine\n culture as well as stool culture and c. diff and follow-up\n -monitor fever curve- patient initially febrile but became hypothermic\n requiring bear hugger, now normothermic\n Respiratory Failure: Initially respiratory failure thought to be due\n to pneumonia. Patient on pressure support with 40% O2; with thick\n secretions. + Gag reflex prior although not too much with deep\n suctioning this morning. Patient squeezing hands this morning.\n -culture data from sputum thus far has grown orophyaryngeal flora only,\n now with 3+ gram positive cocci in pairs, awaiting speciation\n - vanc day 2, gentamicin day .\n - Suction PRN\n - will hold on extubation this morning despite excellent vent settings\n secondary to copious secretions\n - will shut off sedation and see if mental status improves, stronger\n cough and stronger gag prior to extubation\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension\n - gave 10 IV hydral in the setting of hypertension to 200 may be in the\n setting of agitation, would like to get away from IV hydral and titrate\n up beta blocker as tolerated\n - will restart lisinopril today now that acute renal failure has\n resolved, home dose 2.5\n -Increase metoprolol today (to 50 TID), holding parameters to HR < 60\n and SBP < 100\n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since blood is prokinetic.\n Will guaiac stool when available.\n - crit is stable\n -Patient guaic positive in the ED, have not sent stool studies as\n patient has had no stool, however suspect positive\n - Coffee ground emesis from NG tube; guaiac negative\n - continue to follow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n to 1.0. Likely prerenal in etiology secondary to volume depletion and\n septic shock\n likely ATN. No cast seen in UA, but it was not fresh.\n Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n - trend creatinine\n -Maintain adequate BP and hydration\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with multiple negative troponins. This is\n likely demand ischemia in setting of hypotension. Now that BP and\n tachycardia under control, warm and perfusing, can follow-up cardiac\n function with echo.\n - repeat EKG from EKG Sinus rhythm. Premature ventricular\n contractions. Poor R wave progression may be lead placement or possible\n old anterior myocardial infarction. Compared to\n the previous tracing of axis has shifted rightward. Ventricular\n ectopy is new.\n - ECHO from - IMPRESSION: Mild focal LV systolic dysfunction.\n Mildly dilated right ventricle. Mild to moderate aortic regurgitation.\n Moderately dilated ascending aorta.\n - troponins slighlty increased, but in settig of sepsis may represent\n myocardial stunning, also echo is reassuming that there is no regional\n wall motion abnormalities\n Dementia: Currently intubated to difficult to assess mental status.\n - restart namenda and aricept for now\n FEN:\n - residuals improve, re-start tube feedings in the setting of holding\n off on extubation today\n -Monitor and replete electrolytes as needed.\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: Full Code.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2192-08-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 343178, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology. Previous on pressors, sepsis resolving with normal\n lactate. New leukocytosis, WBC 22.6 ? new UTI vs c-diff ( loose stools\n x 1 day) ARF resolved, creatinine at baseline 0.8; previous hematocrit\n drop; normocytic normochromic with iron profile sugesting chornic\n disease or infection, Coffee ground emesis from NG tube; guaiac\n negative; hct stable at 27.1 as of yesterday. Slightly increased\n troponin with ST depressions from previous EKG mostly likely demand\n ischemia related to hypotension.\n .\n .H/O hypertension, benign\n Assessment:\n Pts BP has been 160-170s, occationally decreased to the 140s, HR 80s SR\n with occational PVCs\n Action:\n Her lisinopril was increased to 10mg from 5mg, her lopressor was not\n increased. She has not required any hydralazine this shift.\n Response:\n Still hypertensive with the increase in her ace\n Plan:\n Cont to follow her BP, HR\n Altered mental status (not Delirium)\n Assessment:\n Pt is awake, not speaking, she is following commands, she does not nod\n yes or no to questions\n Action:\n Response:\n Plan:\n Cont to follow\n Electrolyte & fluid disorder, other\n Assessment:\n Pt had been receiving lasix and this has caused her potassium to be low\n and she has had frequent PVCs with low potassium levels\n Action:\n Potassium per sliding scale\n Response:\n Less ectopy with improved K levels\n Plan:\n Cont to follow electrolytes with lasix use\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Pt extubated yesterday, now on 2 L NC with 02 SATs in the mid to upper\n 90s, still with a large amount of oral secreations and has needed nasal\n tracheal suctioning fof mod to lg amount of thick secreations. She has\n been afebrile today\n Action:\n She had a CT pf her chest for a ? mass seen on her chest xray\n Response:\n Requiring NT suctioning\n Plan:\n Follow 02 SATs, RR, temp, cont on abx, NT suctioning prn\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 64.8 kg\n Daily weight:\n 77 kg\n Allergies/Reactions:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Precautions:\n PMH:\n CV-PMH: CVA, Hypertension\n Additional history: dementia, Hypokalemia, breast cancer s/p XRT with\n lumpectomy , hx of falls, arthritis, s/p hysterectomy, recurrent\n UTI's, cardiomegaly seen on CXR, osteoporosis, esophageal reflux\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:144\n D:65\n Temperature:\n 98\n Arterial BP:\n S:169\n D:58\n Respiratory rate:\n 32 insp/min\n Heart Rate:\n 84 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Face tent\n O2 saturation:\n 96% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 658 mL\n 24h total out:\n 2,185 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 01:47 AM\n Potassium:\n 3.8 mEq/L\n 01:07 PM\n Chloride:\n 106 mEq/L\n 01:47 AM\n CO2:\n 26 mEq/L\n 01:47 AM\n BUN:\n 15 mg/dL\n 01:47 AM\n Creatinine:\n 0.9 mg/dL\n 01:47 AM\n Glucose:\n 69 mg/dL\n 01:47 AM\n Hematocrit:\n 28.7 %\n 01:47 AM\n Finger Stick Glucose:\n 123\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": "Physician ", "chartdate": "2192-08-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342151, "text": "Chief Complaint: 82 year old female with a history of breast cancer,\n CVA, HTN, who presents from rehab with pneumonia and sepsis with gram\n negative rods in the non-speciated.\n 24 Hour Events:\n CULTURED - At 09:46 AM\n EKG - At 12:00 PM\n CULTURED - At 03:00 PM\n Attempted to wean patient off pressors yesterday. was off for about\n 1-1.5 hours and then patient had to go back on for low \n pressures. At 5 am levofed off. Fentanyl off, versed off. Urine\n culture growing back e. coli. 2 cultures now positive for e. coli\n as well.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Gentamicin - 10:47 PM\n Aztreonam - 10:00 PM\n Levofloxacin - 05:00 AM\n Vancomycin 1 gram IV q 48\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:38 PM\n Heparin Sodium - 04:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.3\nC (97.3\n HR: 77 (68 - 77) bpm\n BP: 121/55(77) {100/45(61) - 145/58(84)} mmHg\n RR: 16 (4 - 24) insp/\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 12 (9 - 17)mmHg\n Total In:\n 6,088 mL\n 560 mL\n PO:\n TF:\n IVF:\n 5,893 mL\n 560 mL\n products:\n Total out:\n 1,430 mL\n 333 mL\n Urine:\n 685 mL\n 263 mL\n NG:\n 745 mL\n 70 mL\n Stool:\n Drains:\n Balance:\n 4,658 mL\n 227 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 420 (420 - 500) mL\n Vt (Spontaneous): 501 (410 - 640) mL\n PS : 12 cmH2O\n RR (Set): 24\n RR (Spontaneous): 17\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 26 cmH2O\n Plateau: 17 cmH2O\n Compliance: 46.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.32/39/117/18/-5\n Ve: 8.8 L/\n PaO2 / FiO2: 293\n Physical Examination\n General\n intubated, sedated\n HEENT:NCAT mucus membranes dry pale conjunctiva\n CV: RRR S1S2 no m/r/g\n PULM: rales, crackles at RLL, scant crackles at LLL\n ABD: distended, soft +bs throughout\n EXT: WWP 1+dp pulses\n Labs / Radiology\n 104 K/uL\n 8.5 g/dL\n 78 mg/dL\n 1.5 mg/dL\n 18 mEq/L\n 4.8 mEq/L\n 28 mg/dL\n 116 mEq/L\n 142 mEq/L\n 25.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:19 AM\n 09:45 AM\n 10:39 AM\n 03:39 PM\n 04:52 PM\n 09:18 PM\n 09:30 PM\n 09:47 PM\n 05:00 AM\n 05:13 AM\n WBC\n 8.9\n Hct\n 28.2\n 28.3\n 25.6\n Plt\n 104\n Cr\n 1.7\n 1.6\n 1.6\n 1.5\n TCO2\n 18\n 17\n 18\n 14\n 21\n Glucose\n 72\n 111\n 110\n 78\n Other labs: PT / PTT / INR:15.2/41.4/1.3, CK / CKMB /\n Troponin-T:69/4/0.05, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.1\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia and septic physiology.\n Septic Shock: Current differential includes pneumonia vs. urosepsis\n vs. GI source. Cultures currently growing e. coli in the urine and the\n . Sputum cultures with polys and 4+ oropharyngeal flora. Patient\n was noted to have distended abdomen on presentation, CT abdomen shows\n distended bladder, b/l hydroureters and gas/stool in bowel with some\n mild bowel thickening. There is no indication of obstruction but\n patient has not passed gas/stool since admission (unclear if this is\n chronic diarrhea). This is likely ileus secondary to acute illness and\n less likely an infectious source. For hypotension the patient received\n large volume of IV NS, LR. Switched to D5 1/2NS w/bicarb d/t rising K\n and Na.\n - sputum cx/urine cx as above\n - currently on vancomycin, aztreonam, gentamycin, levofloxacin\n - would like to peel off an antibiotic given that now growing e. coli\n in the urine and in the , wait on speciation until this\n evening\n - currently off all pressors, off sedation\n - currently now hypertensive\n - lactate this AM 2.6 which is down from 3.4\n -monitor WBC, CBC, diff\n decreased hct this AM\n monitor fever curve- patient initially febrile but became hypothermic\n requiring bear hugger, now normothermic\n Respiratory Failure: Initially respiratory failure thought to be due to\n pneumonia. Patient on CPAP Vt 420, PEEP 8, FiO2 40%..\n -culture data from sputum thus far has grown orophyaryngeal flora only\n - patient would be candidate for extubation if mental status were\n better, currently no gag as per nursing, however unclear if at baseline\n patient has gag\n -off sedation\n Hematocrit drop\n -Patient guaic positive in the ED, have not sent stool studies as\n patient has had no stool, however suspect positive\n - Coffee ground emesis from NG tube\n - Ordered iron studies for AM tomorrow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n to 1.5. Likely prerenal in etiology secondary to volume depletion and\n septic shock\n likely ATN.\n - IVF boluses to maintain urine output\n - trend creatinine\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with upward trending CE. This is likely demand\n ischemia in setting of hypotension. Now that BP and tachycardia under\n control, warm and perfusing, can follow-up cardiac function with echo.\n - recheck EKG now that tachycardia has improved\n - ECHO ordered, not yet completed, unlikely to get done over the\n weekend\n - troponins on were 0.02, 0.03, 0.05\n - no troponins drawn yesterday\n - put in add on troponins for this AM\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension\n - gave 10 IV hydral in the setting now of hypertension to 200 may be in\n the setting of agitation\n - will hold on lisinopril in the setting of acute renal failure\n - written for metoprolol 25 mg PO BID, will continue to uptitrate as\n tolerated by heart rate and pressure and use hydral PRN as needed\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n - will call today to try to find out what baseline mental\n status is, question as to whether patient has gag at baseline, what her\n baseline orientation is etc\n FEN:\n - pt currently with high residuals so not getting tube feeds\n - will start IV maintenance fluids at 100 cc/ hr of normal saline as\n patient not eating\n - patient with evidence of stool in distal , give her fleets\n enema today, hope that that will improve residuals and allow for tube\n feedings\n -Monitor and replete electrolytes as needed.\n -Monitor K closely, add kayexelate if needed.\n -NGT in place with coffee ground emesis\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: DNR per nursing home record signed by patient's sister. Clarify\n goals of care with HCP.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I examined the patient and reviewed the history and relevant labs. I\n was also physically present with the MICU team during the key portions\n of the services provided. I agree with the note above and its\n assessment and plan. I would add and emphasize the following:\n Overnight pt required levophed for short while but back off it. Now off\n Fentanyl and Versed to better assess mental status. She is still on 4\n abx.\n On exam: afeb, BP= 121/55, p= 77, I/O= 4 L positive On PSV 12, PEEP 8,\n 40%, and VT = 500cc\n Pt grimaces to tactile rub, but no response to auditory. Lungs clear,\n abd soft, Cor RRR\n Lab: urine Cx and Cx positive for E Coli Lactate down to\n 2.4. ABG: 7.32/39/117\n Impression:\n 1. E Coli Sepsis with septic shock, now much improved\n Hemodynamically. Etiology of sepsis is either GU or resp\n 2. Pneumonia, HCAP vs aspiration\n Ecoli or other/anaerobe\n 3. Resp Failure due to #1 and #2\n 4. Pen Allergy\n 5. Obtundation/Dementia\n what is her baseline? How much due to\n hypotension and/or fentanyl/versed residual effect?\n 6. Demand ischemia\n 7. Drop in Hct\n 8. ARF, due to hypotension, improving\n 9. Prior DNR/DNI\n reversed by sister\n :\n 1. antibiotics\n 2. Call Nursing home to assess her baseline mental status\n 3. Decrease PeeP\n 4. Keep I=O\n 5. Now that hypotension better, if her HTN recurs retitrate her\n HTN meds\n 6. Follow residuals as fentanyl off and enemas tried\n 7. Try to re initiate end of life wishes discussion with pt\n sister\n is critically ill. Total time spent = 45 \n , \n ------ Protected Section Addendum Entered By: , MD\n on: 17:34 ------\n" }, { "category": "Nursing", "chartdate": "2192-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342156, "text": "Mrs. is an 82 year old female with a history of breast CA (s/p\n XRT), CVA, baseline dementia, HTN, reflux, & recurrent UTI\ns, who\n presented on early am from after being found to be\n in respiratory distress with oxygen sats in 70s to 80\ns on r/a. Her\n EKG per report was within normal limits. Her exam was notable for\n audible rales and abdominal distension. Foley catheter was placed with\n 100 cc dark urine. Sent to EW, where she was emergently\n Intubated. T103. Code sepsis not initiated as BP >100/systolic.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Urine Cx () grew nothing yet. UA from EW shows\n many bacti but UA from later in the day shows few. Sputum Cx shows\n many organisms consistent w/oropharyngeal flora. Became hypotensive in\n MICU on afternoon, received fluid boluses & levophed IV. Treated\n w/IV levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission.\n Significant Events:\n Trop level is 0.14 which is up from 0.5. Dr aware and goal is to\n keep BP below 140\ns. No other action at this time.\n HCT pending coffee ground emesis noted in ngt. Pt is recieveing\n protonix . TF held at this time d51/2ns running at 100cc/hr.\n Minimal residual but still absent/hypoactive bs noted.\n Fleets enema given times one with positive effect. Stool positive for\n occult blood.\n Pt restarted on some of her antihypertensive BPin the 190\ns-300\n IV hydrlazine q 6 hours, metoprolol and sedation restarted for\n comfort. Pt BP now 140\ns-150\n Sepsis without organ dysfunction\n Assessment:\n Lactate down to low of 2.6 on . MAP 64-78. Systolic BP\n 120-300/80-90\ns. HR: 70\ns-80\ns SR no ectopy. TMAX 100.3.\n Action:\n 60-180\nS. ABX GENT, VANCO, ATREZONAM, AND LEVOFLOX, HYDRLYAZINE Q\n 6, METOPROLOL \n Response:\n MAP maintained >65, ADEQUATE, PT HAS IN BLOOD/URINE, ??\n UROSPESIS\n Plan:\n MONITOR TEMPS, CONT ABX, WAITING TO SEE IT AZTREONAM IS SENITIVE TO\n .\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs: clear, diminished @ bases. Sx\ned scant to moderate thick tan\n secretions q 2-3 hrs. On CPAP 40%/ 8 PEEP/ 12 PS since 2130 .\n Continued on fentanyl 50mcg/hr & versed 1mg/HR NO EXTUBATION TODAY\n AND WITH CRITICALLY HIGH BP\n Action:\n CONTS ON PS PT HAD AFTERNOON RSBI OF 66, PT STILL HAS WEAK COUGH AND NO\n GAG\n Response:\n ABG IMPROVING ON PS, NO COUGH/GAG\n Plan:\n Cont to wean. Assess for readiness for extubation. Continue to assess\n gag & cough off sedation. WEAN SEDATION IN AM\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 60-180cc/hr cloudy yellow urine w/sediment. BUN 28 (no\n change) Cr 1.5 (1.6) ?? ATN FROM HYPOTENSION. RF IS IMPROVING\n Action:\n Received D5\n NS @ 100cc/hr TIMES TWO LITERS, FIRST LITER UP. LEVOPHED\n OFF, HYPOCALCEMIA.\n Response:\n Patient is beginning to turn corner w/sepsis, thereby perfusing kidneys\n more efficiently. REPLETED CALIUM WITH 4GM.\n Plan:\n Continue to follow electrolytes & BUN/Cr. Continue to monitor u/o.\n Hypoglycemia\n Assessment:\n Bs 50 at 1400\n Action:\n AMP d50 given\n Response:\n 1730 bs was 79\n Plan:\n D51/2ns at 100cc/hr, monitor bs q 6 hours,\n Altered mental status (not Delirium)\n Assessment:\n Pt keeps left eye open and right eye appears lazy, pt will open\n occasionally. Pt pupils fully dilated bilaterally and NR. Md\ns aware ??\n from previous stroke. Pt did move left hands fingers but not\n purposefully. No movement noted on the right. Pt did wiggle bilateral\n toes with babinski test. Pt would not grimace/withdraw to strenal rub\n or nail bed pressure but would localize with mouth care. unclear of pt\n baseline. No gag noted, weak cough.\n Action:\n Call to get a mental status baseline, pt would\n occasionally say the word fine but was bed bound and contracted. Still\n not an accurate assessment of pt baseline.\n Response:\n Pt resting in bed, restarted fent/versed change in vitals and no\n plans for extubation.\n Plan:\n Cont to assess for gag/cough, wean sedation as needed\n" }, { "category": "Nursing", "chartdate": "2192-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342172, "text": "Mrs. is an 82 year old female with a history of breast CA (s/p\n XRT), CVA, baseline dementia, HTN, reflux, & recurrent UTI\ns, who\n presented on early am from after being found to be\n in respiratory distress with oxygen sats in 70s to 80\ns on r/a. Her\n EKG per report was within normal limits. Her exam was notable for\n audible rales and abdominal distension. Sent to EW, where she\n was emergently Intubated. T103. Code sepsis not initiated as BP\n >100/systolic. Peripheral BC from EW grew 4 out of 4 bottles positive\n for gram negative rods, E coli on C&S. Urine Cx () grew E\n coli. Sputum Cx shows many organisms consistent w/oropharyngeal\n flora. Became hypotensive in MICU on afternoon, received fluid\n boluses & levophed IV. Treated w/IV levofloxacin, vanco aztreonam\n &genta. Lactate 9.0 on admission. Off levophed since 0600. On\n CPAP @ 40% FiO2 since 2100. Absent to hypoactive bowel sounds\n w/large residuals - . Kept NPO. Bowel sounds still hypoactive\n but residuals improved. Emesis guiac + . On protonix. Now\n emesis guiac -. 1^st BM since admission after fleets enema. CT\n abdomen showed stool .\n Renal failure, acute (Acute renal failure, ARF)\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": "2192-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342173, "text": "Mrs. is an 82 year old female with a history of breast CA (s/p\n XRT), CVA, baseline dementia, HTN, reflux, & recurrent UTI\ns, who\n presented on early am from after being found to be\n in respiratory distress with oxygen sats in 70s to 80\ns on r/a. Her\n EKG per report was within normal limits. Her exam was notable for\n audible rales and abdominal distension. Sent to EW, where she\n was emergently Intubated. T103. Code sepsis not initiated as BP\n >100/systolic. Peripheral BC from EW grew 4 out of 4 bottles positive\n for gram negative rods, E coli on C&S. Urine Cx () grew E\n coli. Sputum Cx shows many organisms consistent w/oropharyngeal\n flora. Became hypotensive in MICU on afternoon, received fluid\n boluses & levophed IV. Treated w/IV levofloxacin, vanco aztreonam\n &genta. Lactate 9.0 on admission. Off levophed since 0600. On\n CPAP @ 40% FiO2 since 2100. Absent to hypoactive bowel sounds\n w/large residuals - . Kept NPO. Bowel sounds still hypoactive\n but residuals improved. Emesis guiac + . On protonix. Now\n emesis guiac -. 1^st BM since admission after fleets enema. CT\n abdomen showed stool .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 30- 130cc/hr clear light yellow urine. BUN Cr\n Action:\n IV: D5\n NS @ 100cc/hr for 2L (2^nd L hanging)\n Response:\n Plan:\n Continue to monitor u/o & electrolytes, BUN & Cr.\n Altered mental status (not Delirium)\n Assessment:\n Patient made sound in back of throat during mouth care. Moved L hand &\n forearm slightly. Unrestrained all day until 2200 when movement\n observed. Pupils dilated & not responsive bilaterally.\n Action:\n Restrained L hand only (& loosely) @ 2200.\n Response:\n No further movement noted.\n Plan:\n Continue to assess for MS.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Patient remains on CPAP 40%/ 12 PS/ 8 PEEP. Lungs are clear\n w/diminished BS @ bases. Did not need Sx\ning most of night. RSBI\n <100 on . Has impaired gag & weak cough. Remained on fentanyl\n 50mcg/hr & versed 1 mg/hr.\n Action:\n ABG\n Response:\n Gag improved from absent earlier.\n Plan:\n Continue to wean.\n" }, { "category": "Nursing", "chartdate": "2192-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342174, "text": "Mrs. is an 82 year old female with a history of breast CA (s/p\n XRT), CVA, baseline dementia, HTN, reflux, & recurrent UTI\ns, who\n presented on early am from after being found to be\n in respiratory distress with oxygen sats in 70s to 80\ns on r/a. Her\n EKG per report was within normal limits. Her exam was notable for\n audible rales and abdominal distension. Sent to EW, where she\n was emergently Intubated. T103. Code sepsis not initiated as BP\n >100/systolic. Peripheral BC from EW grew 4 out of 4 bottles positive\n for gram negative rods, E coli on C&S. Urine Cx () grew E\n coli. Sputum Cx shows many organisms consistent w/oropharyngeal\n flora. Became hypotensive in MICU on afternoon, received fluid\n boluses & levophed IV. Treated w/IV levofloxacin, vanco aztreonam\n &genta. Lactate 9.0 on admission. Off levophed since 0600. On\n CPAP @ 40% FiO2 since 2100. Absent to hypoactive bowel sounds\n w/large residuals - . Kept NPO. Bowel sounds still hypoactive\n but residuals improved. Emesis guiac + . On protonix. Now\n emesis guiac -. 1^st BM since admission after fleets enema. CT\n abdomen showed stool .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 30- 130cc/hr clear light yellow urine. BUN Cr\n Action:\n IV: D5\n NS @ 100cc/hr for 2L (2^nd L hanging)\n Response:\n Plan:\n Continue to monitor u/o & electrolytes, BUN & Cr.\n Altered mental status (not Delirium)\n Assessment:\n Patient made sound in back of throat during mouth care. Moved L hand &\n forearm slightly. Unrestrained all day until 2200 when movement\n observed. Pupils dilated & not responsive bilaterally.\n Action:\n Restrained L hand only (& loosely) @ 2200.\n Response:\n No further movement noted.\n Plan:\n Continue to assess for MS.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Patient remains on CPAP 40%/ 12 PS/ 8 PEEP. Lungs are clear\n w/diminished BS @ bases. Did not need Sx\ning most of night. RSBI\n <100 on . Has impaired gag & weak cough. Remained on fentanyl\n 50mcg/hr & versed 1 mg/hr.\n Action:\n ABG\n Response:\n Gag improved from absent earlier.\n Plan:\n Continue to wean.\n .H/O hypertension, benign\n Assessment:\n Patient\ns BP increased significantly after being off sedation for 6\n hours .\n Action:\n Started antihypertensives, lopressor per OGT for sBP>120/ &\n hydralazine IV for sBP >140/\n Response:\n BP remained 120\ns-150\ns/sys overnight\n Plan:\n Continue to assess for pain/ anxiety. Medicate for pain. Medicate for\n hypertension.\n" }, { "category": "Nursing", "chartdate": "2192-08-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342309, "text": "82 year old female with a history of breast CA (s/p XRT), CVA, baseline\n dementia, HTN, reflux, & recurrent UTI\ns, who presented on early\n am from after being found to be in respiratory distress\n with oxygen sats in 70s to 80\ns on r/a. Her EKG per report was within\n normal limits. Her exam was notable for audible rales and abdominal\n distension. Sent to EW, where she was emergently Intubated.\n T103. Code sepsis not initiated as BP >100/systolic. Peripheral BC\n from EW grew 4 out of 4 bottles positive for gram negative rods, E coli\n on C&S. Urine Cx () grew E coli. Sputum Cx shows many\n organisms consistent w/oropharyngeal flora. Became hypotensive in MICU\n on afternoon, received fluid boluses & levophed IV. Treated w/IV\n levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission. Off\n levophed since 0600. repeat sputum cx revealed gm + cocci.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Remains Intubated on psv: 12 ps, 5 peep on 40% fi02, maintaining 02\n sats in upper 90s to 100s. lungs with scattered rhonci in right lobe,\n left lung clear, diminished at bases. No gag, impaired weak cough.\n Continues with altered mental status (has baseline dementia) and\n sedated on fentanyl 50mcg/hr and versed 1mg/hr. opens eyes to voice or\n nsg intervention. Not following commands. R hemi. Moves l side\n occasionally but not on command. No agitation noted this shift.\n Action:\n Pt rested overnight per micu team and resp. therapist on 12 psv, 5 peep\n as pt having resp. distress yesterday with attempting to wean the psv,\n appeared r/t increased secretions and a sedation issue. Tube feeds shut\n off at 5am md request in possible event pt may get extubated later\n today.\n Response:\n Tolerating current vent settings well with fi02 40%, 12 psv, 5 peep.\n Adequately sedated on fentanyl 50mcg/hr and versed 1mg/hr. psv repeat\n abg on above settings: 7.38/33/106. pt weaned to 8 psv and tolerating\n well.\n Plan:\n Attempt to wean psv further in am and lighten sedation when psv\n decreases further if pt tolerates.\n .H/O hypertension, benign\n Assessment:\n Appears to be In\nwandering atrial pacemaker with 3 different p waves\n detected.continues with slightly high sbp. In the 160s. frequent pvcs.\n Am k 3.1. md notified. Mag 1.7, phosphate 1.9.\n Action:\n Hyrdalaxiine given early at 11am d/t rising sbp in 160s. also receiving\n metoprolol via ogt. K being repleted with 60 meq iv kcl total.\n Phosphate repleted with 1 packet neutraphos.\n Response:\n Sbp dropping down to the 130s-140s with pt in WAP. Hr 60s-80s WAP.\n Plan:\n Monitor bp, keep sbp >120, less than 160. replete with the rest of the\n iv potassium (pt receiving 2^nd bag of 20 meq iv kcl out of 3 bags\n ordered). Replete with 2 gm magnesium after potassium finished.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinine 1.2 on . urine output dropping to as low as 15cc/hr. pt\n receiving kvo, iv abx volume, tube feedings, 150cc free water boluses\n q6hr. potassium, magnesium, and phosphate levels low last am .\n Action:\n Ivf started: d5ns started, infusing at 100cc/hr. foley flushed without\n difficulty,\n Response:\n Creatinine stabilizing. Urine output increased up to 60cc/hr.\n Plan:\n Continue to monitor creatinine level daily, continue ivf. Monitor\n hourly urine ouput.\n i\n" }, { "category": "Physician ", "chartdate": "2192-08-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 342680, "text": "Chief Complaint: sepsis and 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 82 yo women with h/o breast CA, admitted with urosepsis, respiratory\n failure. Has improved. Ventilator weaned down, and having ++\n secretions. Off versed overnight. Having diarrhea.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:00 AM\n URINE CULTURE - At 12:23 AM\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Gentamicin - 11:00 PM\n Vancomycin - 08:10 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 PM\n Fentanyl - 05:57 PM\n Dextrose 50% - 06:53 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n SSI\n lopressor\n lisinopril\n donepezil\n nimenda\n tylenol\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 09:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36\nC (96.8\n HR: 90 (67 - 108) bpm\n BP: 162/61(95) {124/45(67) - 190/75(112)} mmHg\n RR: 36 (0 - 37) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 4 (4 - 9)mmHg\n Total In:\n 823 mL\n 1,045 mL\n PO:\n TF:\n 79 mL\n 140 mL\n IVF:\n 554 mL\n 325 mL\n Blood products:\n Total out:\n 2,500 mL\n 650 mL\n Urine:\n 2,500 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,677 mL\n 395 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 414 (305 - 473) mL\n PS : 5 cmH2O\n RR (Spontaneous): 33\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 94\n PIP: 11 cmH2O\n SpO2: 92%\n ABG: ///21/\n Ve: 14 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 : , Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Unable to stand\n Skin: Warm, Rash:\n Neurologic: No(t) Follows simple commands, Responds to: Tactile\n stimuli, Movement: Not assessed, Tone: Not assessed, no left leg\n movements\n Labs / Radiology\n 8.8 g/dL\n 133 K/uL\n 90 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 144 mEq/L\n 26.8 %\n 22.8 K/uL\n [image002.jpg]\n 07:34 AM\n 03:29 PM\n 03:16 AM\n 03:31 AM\n 07:50 PM\n 04:10 AM\n 05:33 AM\n 06:00 AM\n 07:59 PM\n 03:58 AM\n WBC\n 17.0\n 22.6\n 22.8\n Hct\n 28.6\n 27.1\n 26.8\n Plt\n 91\n 104\n 133\n Cr\n 1.0\n 0.8\n 0.7\n 0.7\n TCO2\n 19\n 22\n 20\n 22\n 24\n Glucose\n 95\n 37\n 40\n 145\n 61\n 90\n Other labs: PT / PTT / INR:15.1/26.8/1.3, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:92.1 %, Band:5.0 %, Lymph:4.4 %, Mono:3.0 %, Eos:0.4\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.6\n mg/dL, Mg++:1.7 mg/dL, PO4:2.0 mg/dL\n Microbiology: Urine cx. with E. coli and Providencia\n Assessment and Plan\n Respiratory failure: Seems grossly fluid overloaded. Will diurese.\n Does not seem ready to extubate given tachypnea and poor cough.\n Pulmonary Edema: IV diuresis.\n UTI: Change gentamicin to amikacin as providentia has intermediate\n resistence to tobra.\n HTN:\n Anemia: Stable\n ARF: improved\n Diarrhea: Follow up C. diff\n ICU Care\n Nutrition:\n Comments: restart TFs\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 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: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2192-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 343014, "text": "82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology. Previous on pressors, sepsis resolving with normal\n lactate. New leukocytosis, WBC 22.6 ? new UTI vs c-diff ( loose stools\n x 1 day) ARF resolved, creatinine at baseline 0.8; previous hematocrit\n drop; normocytic normochromic with iron profile sugesting chornic\n disease or infection, Coffee ground emesis from NG tube; guaiac\n negative; hct stable at 27.1 as of yesterday. Slightly increased\n troponin with ST depressions from previous EKG mostly likely demand\n ischemia related to hypotension.\n .\n .H/O hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342018, "text": "Sepsis without organ dysfunction\n Assessment:\n Tmax 99.5 oral; ABP 110-120/60-70 MAP >65; NSR with rare PVC\ns; HR\n 60-70; CVP 9-12; CO 3.2-3.8; Doppler pedal pulses, left DP easily\n palpable; cap refill <3; intubated and sedated on A/C, Fi02 40%, Peep\n 8, RR 24. Last ABG @ 1600 7.32/34/106. Lungs clear, diminished at\n bases. Moderate tan, thick secretions. Abdomen soft and distended;\n hypoactive BS; suctioned 325 cc of brown coffee ground gastric\n secretions from OGT- occult (+), hct drop to 28.2 at 1700 from 30.2.\n UO 20-30 cc/hr, urine yellow with sediment. Latest labs- BUN 27, CR\n 1.7, Lactate 3.4\n Action:\n Blood cultures x2 sent; Weaned levophed, was off levo for about 2 hours\n at 1530 but dropped MAP to low 60\ns, UO decreased a few points/hr,\n restarted levo at 1715 at 0.066 mcg/kg/min and gave a 500 cc bolus of\n NS at 1820. Versed and Fentanyl weaned; vent changes- dropped Fi02 to\n 40% from 60%, changed TV to 7L from 8L; Decompressed abdomen with\n intermittent low wall suction, informed team of (+) occultl; Followed\n ABG and blood chemistry; last CBC at 1700.\n Response:\n ABP currently 120\ns/50\ns with MAP >65 on 0.066 mcg/kg/min of levo.\n Versed at 1 mcg/kg/min. Fentanyl at 50 mcg/kg/min. CVP showing a\n downward trend now at 9-10; CO 3.4-3.8 Maintains intubated on A/C with\n Fi02 40%, Peep 8, RR 24. UO currently 18-20 ml/hr.\n Plan:\n Monitor ABP and need for pressors. Monitor CVP and Monitor vent\n status, making adjustments as needed. Monitor abdomen for bowel sounds\n and distention. Monitor UO, BUN, CR, and lactate.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 27, CR 1.7 UO 20-30 cc/hr. Urine clear with sediment.\n Action:\n UO qhour. D51/2 NS @ 125 ml/hr. Labs drawn.\n Response:\n BUN 28 and CR 1.6 UO currently 18-20 cc/hr.\n Plan:\n Follow BUN and CR. Assess hourly urine outputs and need for fluid\n boluses.\n Electrolyte & fluid disorder, other\n Assessment:\n Currently 16.5 L positive for LOS. Positive 4 L for the day. Labs at\n 0900 NA 144 K 5.9 Mg 2.1 Ph 2.6. Ionized calcium at 1000 was 0.82.\n Action:\n Changed NS at 150 cc/hr to D51/2NS @125 cc/hr for 2 Liters. Treated\n calcium with 2 gram of calcium gluconate. Labs drawn.\n Response:\n Ionized calcium at 1600 was 1.07. Latest chem s of 1800 NA 143 K 5.2\n Mg 2.1 Ph 2.5.\n Plan:\n Monitor fluid balance and UO. Monitor labs, drawing again at 2200.\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342019, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n Sepsis without organ dysfunction\n Assessment:\n Tmax 99.5 oral; ABP 110-120/60-70 MAP >65; NSR with rare PVC\ns; HR\n 60-70; CVP 9-12; CO 3.2-3.8; Doppler pedal pulses, left DP easily\n palpable; cap refill <3; intubated and sedated on A/C, Fi02 40%, Peep\n 8, RR 24. Last ABG @ 1600 7.32/34/106. Lungs clear, diminished at\n bases. Moderate tan, thick secretions. Abdomen soft and distended;\n hypoactive BS; suctioned 325 cc of brown coffee ground gastric\n secretions from OGT- occult (+), hct drop to 28.2 at 1700 from 30.2.\n UO 20-30 cc/hr, urine yellow with sediment. Latest labs- BUN 27, CR\n 1.7, Lactate 3.4\n Action:\n Blood cultures x2 sent; Weaned levophed, was off levo for about 2 hours\n at 1530 but dropped MAP to low 60\ns, UO decreased a few points/hr,\n restarted levo at 1715 at 0.066 mcg/kg/min and gave a 500 cc bolus of\n NS at 1820. Versed and Fentanyl weaned; vent changes- dropped Fi02 to\n 40% from 60%, changed TV to 7L from 8L; Decompressed abdomen with\n intermittent low wall suction, informed team of (+) occultl; Followed\n ABG and blood chemistry; last CBC at 1700.\n Response:\n ABP currently 120\ns/50\ns with MAP >65 on 0.066 mcg/kg/min of levo.\n Versed at 1 mcg/kg/min. Fentanyl at 50 mcg/kg/min. CVP showing a\n downward trend now at 9-10; CO 3.4-3.8 Maintains intubated on A/C with\n Fi02 40%, Peep 8, RR 24. UO currently 18-20 ml/hr.\n Plan:\n Monitor ABP and need for pressors. Monitor CVP and Monitor vent\n status, making adjustments as needed. Monitor abdomen for bowel sounds\n and distention. Monitor UO, BUN, CR, and lactate.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 27, CR 1.7 UO 20-30 cc/hr. Urine clear with sediment.\n Action:\n UO qhour. D51/2 NS @ 125 ml/hr. Labs drawn.\n Response:\n BUN 28 and CR 1.6 UO currently 18-20 cc/hr.\n Plan:\n Follow BUN and CR. Assess hourly urine outputs and need for fluid\n boluses.\n Electrolyte & fluid disorder, other\n Assessment:\n Currently 16.5 L positive for LOS. Positive 4 L for the day. Labs at\n 0900 NA 144 K 5.9 Mg 2.1 Ph 2.6. Ionized calcium at 1000 was 0.82.\n Action:\n Changed NS at 150 cc/hr to D51/2NS @125 cc/hr for 2 Liters. Treated\n calcium with 2 gram of calcium gluconate. Labs drawn.\n Response:\n Ionized calcium at 1600 was 1.07. Latest chem s of 1800 NA 143 K 5.2\n Mg 2.1 Ph 2.5.\n Plan:\n Monitor fluid balance and UO. Monitor labs, drawing again at 2200.\n" }, { "category": "Respiratory ", "chartdate": "2192-08-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 342020, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 59 None\n Ideal tidal volume: 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: Tan / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: RESPIRATORY CARE: PT REMAINS INTUBATED AND SEDATED ON\n VENTILATORY SUPPORT. AC MODE AS PER METAVISION. FIO2 TAPERED TO .40\n TODAY. VT DECREASED TO 420 CC AND RR INCREASED TO 24 AS WELL. 420 CC\n ABOUT 7 ML/KG AND CLOSER TO GOAL OF 6 ML/KG. ABG'S C/W A PART. COMP.\n METABOLIC ACIDOSIS AND IMPROVED OXYGENATION. SXING SMALL AMTS OF THICK\n TAN SPUTUM. 3-4 CM H2O OF AUTOPEEP NOTED. DOING A BIT BETTER OVERALL\n AND OFF LEVOPHED AND ON LESS SEDATION. WILL C/W THE AC MODE AS\n TOLERATED.\n" }, { "category": "Respiratory ", "chartdate": "2192-08-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 342023, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 59 None\n Ideal tidal volume: 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: Tan / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: RESPIRATORY CARE: PT REMAINS W/ AN 8.0 PORTEX TRACH IN PLACE.\n TRACH COLLAR .50 THIS AM CURTAILED AFTER 1 HOUR DUE TO TACHYPNEA ...\n PULMONARY EDEMA DEVELOPED AND WORSENED REQUIRING SEDATION AND RETURN TO\n THE AC MODE AS PER CV. WILL C/W AC MODE AS TOLERATED.\n" }, { "category": "Nursing", "chartdate": "2192-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342170, "text": "Mrs. is an 82 year old female with a history of breast CA (s/p\n XRT), CVA, baseline dementia, HTN, reflux, & recurrent UTI\ns, who\n presented on early am from after being found to be\n in respiratory distress with oxygen sats in 70s to 80\ns on r/a. Her\n EKG per report was within normal limits. Her exam was notable for\n audible rales and abdominal distension. Sent to EW, where she\n was emergently Intubated. T103. Code sepsis not initiated as BP\n >100/systolic. Peripheral BC from EW grew 4 out of 4 bottles positive\n for gram negative rods, E coli on C&S. Urine Cx () grew E\n coli. Sputum Cx shows many organisms consistent w/oropharyngeal\n flora. Became hypotensive in MICU on afternoon, received fluid\n boluses & levophed IV. Treated w/IV levofloxacin, vanco aztreonam\n &genta. Lactate 9.0 on admission. Off levophed since 0600. On\n CPAP @ 40% FiO2 since 2100. Absent to hypoactive bowel sounds\n w/large residuals - . Kept NPO. Bowel sounds still hypoactive\n but residuals improved. Emesis guiac + . On protonix. Now\n emesis guiac -. 1^st BM since admission after fleets enema. CT\n abdomen showed stool .\n" }, { "category": "Physician ", "chartdate": "2192-08-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342211, "text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n -Baseline status per nurse : Patient is minimally\n verbal at baseline. When you call her name she will look at you. If\n you ask her how she is she will reply \"fine\" but she can't carry on a\n conversation. She has a dense paralysis on the right side and does\n not spontaneously move unless stimulated by nursing staff.\n - RESPIRATORY CULTURE (Preliminary): No growth\n - Urine culture - E coli\n - Culture, Routine (Final ): E coli\n - Asked them to add on aztreonam sensitivities - if sensitive to\n aztreonam would consider d/c of gent\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 05:00 AM\n Vancomycin - 09:06 AM\n Gentamicin - 09:30 PM\n Aztreonam - 11:50 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydralazine - 01:26 PM\n Dextrose 50% - 03:27 PM\n Heparin Sodium - 08:00 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 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36.9\nC (98.5\n HR: 86 (73 - 92) bpm\n BP: 155/64(95) {120/50(73) - 325/115(105)} mmHg\n RR: 25 (0 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 14 (9 - 14)mmHg\n Total In:\n 2,541 mL\n 257 mL\n PO:\n TF:\n IVF:\n 2,401 mL\n 257 mL\n products:\n Total out:\n 1,563 mL\n 545 mL\n Urine:\n 1,473 mL\n 510 mL\n NG:\n 90 mL\n 35 mL\n Stool:\n Drains:\n Balance:\n 978 mL\n -288 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 452 (452 - 647) mL\n PS : 12 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 68\n RSBI Deferred: RR >35\n PIP: 18 cmH2O\n SpO2: 97%\n ABG: 7.36/34/126/18/-5\n Ve: 9.9 L/min\n PaO2 / FiO2: 315\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), Hard to\n assess heart sounds since patient tachypneic with loud noises.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present),\n Increased amplitude\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese,\n Normal intercostal reflexes\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Normal ROTs\n Skin: Not assessed\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Normal, Negative Babinsky; corneal reflex present,\n diminished gag reflex.\n Labs / Radiology\n 104 K/uL\n 8.7 g/dL\n 83 mg/dL\n 1.2 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 117 mEq/L\n 143 mEq/L\n 26.5 %\n 10.8 K/uL\n [image002.jpg]\n 04:52 PM\n 09:18 PM\n 09:30 PM\n 09:47 PM\n 05:00 AM\n 05:13 AM\n 12:00 PM\n 05:37 PM\n 04:45 AM\n 05:03 AM\n WBC\n 8.9\n 10.8\n Hct\n 28.2\n 28.3\n 25.6\n 27.6\n 26.5\n Plt\n 104\n Cr\n 1.6\n 1.6\n 1.5\n 1.2\n TropT\n 0.14\n 0.14\n TCO2\n 14\n 21\n 20\n 20\n Glucose\n 111\n 110\n 78\n 83\n Other labs: PT / PTT / INR:14.6/41.4/1.3, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.6\n mg/dL, Mg++:1.8 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia and septic physiology.\n Septic Shock: Patient was with SIRS now with E coli in and\n urine. CXR shows bibasilar consolidations as well. Nothing has grown in\n the sputum culture. There is some mild enteritis as well. Patient\n received fluid resucitation; here presentation lactate was 3.4, then\n trended down yesterday.\n - sputum cx/urine cx as above\n - currently on vancomycin, aztreonam, gentamycin, levofloxacin Day \n - would like to peel off an antibiotic given that now growing e. coli\n in the urine and in the , wait on speciation until this\n evening\n - currently off all pressors, off sedation\n - currently now hypertensive\n -monitor WBC, CBC, diff\n -monitor fever curve- patient initially febrile but became hypothermic\n requiring bear hugger, now normothermic\n Respiratory Failure: Initially respiratory failure thought to be due to\n pneumonia. Patient on CPAP 20/5 with 40% O2; however is very\n tachypneic. O2 sats in monitor are ok. not be able to extubate in\n AM and require gas. Still requiring pressure support. Presence of gag\n reflex is unknown at baseline. Mental status is non-responsive. Patient\n without much secretions.\n -culture data from sputum thus far has grown orophyaryngeal flora only\n - patient may not have gag reflex at baseline\n - ABG now and change vent settings accordingly\n - Suction PRN\n -Reposition patient\n -off sedation\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension\n - gave 10 IV hydral in the setting now of hypertension to 200 may be in\n the setting of agitation\n - restart lisinopril today\n -Increase metoprolol to 50 \n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since is prokinetic.\n Will guaiac stool when available.\n -Patient guaic positive in the ED, have not sent stool studies as\n patient has had no stool, however suspect positive\n - Coffee ground emesis from NG tube; guaiac negative\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n to 1.2. Likely prerenal in etiology secondary to volume depletion and\n septic shock\n likely ATN. No cast seen in UA, but it was not fresh.\n Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n - trend creatinine\n -Maintain adequate BP and hydration\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with upward trending CE. This is likely demand\n ischemia in setting of hypotension. Now that BP and tachycardia under\n control, warm and perfusing, can follow-up cardiac function with echo.\n - recheck EKG now that tachycardia has improved\n - ECHO ordered, not yet completed\n - troponins slighlty increased, but in settig of sepsis may represent\n myocardial stunning\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n FEN:\n - residuals improve, so if not extubated may re-start feeding\n - will continue IV maintenance fluids at 100 cc/ hr of normal saline as\n patient not eating\n - patient with evidence of stool in distal , give her fleets\n enema today, hope that that will improve residuals and allow for tube\n feedings\n -Monitor and replete electrolytes as needed.\n -Monitor K closely, add kayexelate if needed.\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: DNR per nursing home record signed by patient's sister. Clarify\n goals of care with HCP.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2192-08-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 342231, "text": "Chief Complaint: Sepsis\n Acute 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 tachycardia and hypotension in the setting of wean of\n sedation\n increased pulmonary secreations noted across the morning\n History obtained from Medical records\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 05:00 AM\n Vancomycin - 09:06 AM\n Gentamicin - 09:30 PM\n Aztreonam - 08:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydralazine - 01:26 PM\n Dextrose 50% - 03:27 PM\n Heparin Sodium - 08:00 PM\n Fentanyl - 09:00 AM\n Midazolam (Versed) - 09:15 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:53 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: 38.4\nC (101.1\n HR: 100 (73 - 117) bpm\n BP: 153/63(93) {120/50(73) - 325/115(112)} mmHg\n RR: 28 (12 - 34) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 9 (7 - 14)mmHg\n Total In:\n 2,541 mL\n 1,452 mL\n PO:\n TF:\n IVF:\n 2,401 mL\n 1,367 mL\n Blood products:\n Total out:\n 1,563 mL\n 1,705 mL\n Urine:\n 1,473 mL\n 1,670 mL\n NG:\n 90 mL\n 35 mL\n Stool:\n Drains:\n Balance:\n 978 mL\n -253 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 420 (420 - 420) mL\n Vt (Spontaneous): 354 (354 - 610) mL\n PS : 15 cmH2O\n RR (Set): 24\n RR (Spontaneous): 27\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 20 cmH2O\n SpO2: 97%\n ABG: 7.40/30/74/18/-4\n Ve: 9 L/min\n PaO2 / FiO2: 185\n Physical Examination\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Unable to stand\n Skin: Not assessed\n Neurologic: Responds to: Noxious stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.7 g/dL\n 84 K/uL\n 83 mg/dL\n 1.2 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 117 mEq/L\n 143 mEq/L\n 26.5 %\n 10.8 K/uL\n [image002.jpg]\n 09:18 PM\n 09:30 PM\n 09:47 PM\n 05:00 AM\n 05:13 AM\n 12:00 PM\n 05:37 PM\n 04:45 AM\n 05:03 AM\n 07:34 AM\n WBC\n 8.9\n 10.8\n Hct\n 28.3\n 25.6\n 27.6\n 26.5\n Plt\n 104\n 84\n Cr\n 1.6\n 1.5\n 1.2\n TropT\n 0.14\n 0.14\n TCO2\n 14\n 21\n 20\n 20\n 19\n Glucose\n 110\n 78\n 83\n Other labs: PT / PTT / INR:14.6/41.4/1.3, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.6\n mg/dL, Mg++:1.8 mg/dL, PO4:2.1 mg/dL\n Imaging: CXR-Suggestion of hyperinflation on the CXR. ETT at 5cm above\n carina, left sided consolidation persists.\n Assessment and Plan\n 82 yo female with admission with pneumonia and sepsis complicated by\n acute respiratory failure. She now has difficulty with wean of\n ventilator support largely driven by the increase in secretions this\n morning. In addition the marked changes in hemodynamics at the time of\n decrease in sedation may be related to anxiety/background HTN but more\n likely and more important would be evidence that patient is not ready\n to accept extubation successfully.\n Sepsis\nShe has multiple organisms identified and it may well be primary\n pulmonary insult with sepsis as result and aspiration pneumonia is\n perhaps most likely.\n -Levo/Vanco/Aztreonam/Gent\n -Aztreonam-For coverage of aspiration related organisms\n -Gent-For expanded gram negative converage\n Acute Respiratory Failure\nHypoxemic respiratory failure. She has\n improved hemodynamics at this time. She, however, has continued\n significant secretions and limited mental status to allow safe attempt\n at extubation\n -Continue with pneumonia Rx\n -PSV at 15/5\n -Will continue with PEEP increase if hypoxemia continuting.\n Hypertension-\n -Hydralazine and will up titrate B-blocker as stability of hemodynamics\n around extubation is essential.\n Dementia\nnear baseline status per family\n ICU Care\n Nutrition: Tube Feeds to resume\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: Bundle in place\n Comments:\n Communication: Comments:\n Code status: Full code\nwill need to clarify goals fo care prior to move\n to extubation.\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2192-08-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342242, "text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n -Baseline status per nurse : Patient is minimally\n verbal at baseline. When you call her name she will look at you. If\n you ask her how she is she will reply \"fine\" but she can't carry on a\n conversation. She has a dense paralysis on the right side and does\n not spontaneously move unless stimulated by nursing staff.\n - RESPIRATORY CULTURE (Preliminary): No growth\n - Urine culture - E coli\n - Culture, Routine (Final ): E coli\n - Asked them to add on aztreonam sensitivities - if sensitive to\n aztreonam would consider d/c of gent\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 05:00 AM\n Vancomycin - 09:06 AM\n Gentamicin - 09:30 PM\n Aztreonam - 11:50 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydralazine - 01:26 PM\n Dextrose 50% - 03:27 PM\n Heparin Sodium - 08:00 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 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36.9\nC (98.5\n HR: 86 (73 - 92) bpm\n BP: 155/64(95) {120/50(73) - 325/115(105)} mmHg\n RR: 25 (0 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 14 (9 - 14)mmHg\n Total In:\n 2,541 mL\n 257 mL\n PO:\n TF:\n IVF:\n 2,401 mL\n 257 mL\n products:\n Total out:\n 1,563 mL\n 545 mL\n Urine:\n 1,473 mL\n 510 mL\n NG:\n 90 mL\n 35 mL\n Stool:\n Drains:\n Balance:\n 978 mL\n -288 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 452 (452 - 647) mL\n PS : 12 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 68\n RSBI Deferred: RR >35\n PIP: 18 cmH2O\n SpO2: 97%\n ABG: 7.36/34/126/18/-5\n Ve: 9.9 L/min\n PaO2 / FiO2: 315\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), Hard to\n assess heart sounds since patient tachypneic with loud noises.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present),\n Increased amplitude\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese,\n Normal intercostal reflexes\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Normal ROTs\n Skin: Not assessed\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Normal, Negative Babinsky; corneal reflex present,\n diminished gag reflex.\n Labs / Radiology\n 104 K/uL\n 8.7 g/dL\n 83 mg/dL\n 1.2 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 117 mEq/L\n 143 mEq/L\n 26.5 %\n 10.8 K/uL\n [image002.jpg]\n 04:52 PM\n 09:18 PM\n 09:30 PM\n 09:47 PM\n 05:00 AM\n 05:13 AM\n 12:00 PM\n 05:37 PM\n 04:45 AM\n 05:03 AM\n WBC\n 8.9\n 10.8\n Hct\n 28.2\n 28.3\n 25.6\n 27.6\n 26.5\n Plt\n 104\n Cr\n 1.6\n 1.6\n 1.5\n 1.2\n TropT\n 0.14\n 0.14\n TCO2\n 14\n 21\n 20\n 20\n Glucose\n 111\n 110\n 78\n 83\n Other labs: PT / PTT / INR:14.6/41.4/1.3, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.6\n mg/dL, Mg++:1.8 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia and septic physiology.\n Septic Shock: Patient was with SIRS now with E coli in and\n urine. CXR shows bibasilar consolidations as well. Nothing has grown in\n the sputum culture. There is some mild enteritis as well. Patient\n received fluid resucitation; here presentation lactate was 3.4, then\n trended down yesterday.\n - sputum cx/urine cx as above\n - currently on vancomycin, aztreonam, gentamycin, levofloxacin Day \n - would like to peel off an antibiotic given that now growing e. coli\n in the urine and in the , wait on speciation until this\n evening\n - currently off all pressors, off sedation\n - currently now hypertensive\n -monitor WBC, CBC, diff\n -monitor fever curve- patient initially febrile but became hypothermic\n requiring bear hugger, now normothermic\n Respiratory Failure: Initially respiratory failure thought to be due to\n pneumonia. Patient on CPAP 20/5 with 40% O2; however is very\n tachypneic. O2 sats in monitor are ok. not be able to extubate in\n AM and require gas. Still requiring pressure support. Presence of gag\n reflex is unknown at baseline. Mental status is non-responsive. Patient\n without much secretions.\n -culture data from sputum thus far has grown orophyaryngeal flora only\n - patient may not have gag reflex at baseline\n - ABG now and change vent settings accordingly\n - Suction PRN\n -Reposition patient\n -off sedation\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension\n - gave 10 IV hydral in the setting now of hypertension to 200 may be in\n the setting of agitation\n - restart lisinopril today\n -Increase metoprolol to 50 \n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since is prokinetic.\n Will guaiac stool when available.\n -Patient guaic positive in the ED, have not sent stool studies as\n patient has had no stool, however suspect positive\n - Coffee ground emesis from NG tube; guaiac negative\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n to 1.2. Likely prerenal in etiology secondary to volume depletion and\n septic shock\n likely ATN. No cast seen in UA, but it was not fresh.\n Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n - trend creatinine\n -Maintain adequate BP and hydration\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with upward trending CE. This is likely demand\n ischemia in setting of hypotension. Now that BP and tachycardia under\n control, warm and perfusing, can follow-up cardiac function with echo.\n - recheck EKG now that tachycardia has improved\n - ECHO ordered, not yet completed\n - troponins slighlty increased, but in settig of sepsis may represent\n myocardial stunning\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n FEN:\n - residuals improve, so if not extubated may re-start feeding\n - will continue IV maintenance fluids at 100 cc/ hr of normal saline as\n patient not eating\n - patient with evidence of stool in distal , give her fleets\n enema today, hope that that will improve residuals and allow for tube\n feedings\n -Monitor and replete electrolytes as needed.\n -Monitor K closely, add kayexelate if needed.\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: DNR per nursing home record signed by patient's sister. Clarify\n goals of care with HCP.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2192-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342243, "text": "Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Intubated on CPAP Fi02 40% with a tidal volume of 500-600 and a MV\n of . Sp02 100%, RR 13-25. Tmax 101, diaphoresis noted on face. Upper\n lung fields rhonchus; lower fields clear but diminished. Moderate thick\n tan/ tinged secretions suctioned q1-2 hours.\n Action:\n Pt initially on CPAP but showed signs of resp distress, tachypnea\n in the high 30\ns, labored work of breathing, and SBP in 180-190. Drew\n ABG at 0730 7.40/30/74. Increased pressure support to 20 and boluses\n with fentanyl and versed in response to VS changes. Suctioned\n q1-2hours. Changed positions frequently. Abx administered. Sputum\n culture sent. Tylenol given for temp.\n Response:\n Pt settled down decreasing RR to and lowering SBP 120-130 after\n vent changes and fentanyl and versed boluses. Able to decrease pressure\n support again to 15 where the pt remains to look comfortable breathing\n 12-20 breaths/min, Sp02 100% and displaying nonlabored breathing.\n Secretions remain thick and lungs remain rhonchus.\n Plan:\n Decrease pressure support as tolerated. ? ability to r/t copious\n amounts of secretions. Collect ABG as needed. Suction as needed noting\n amount and consistency of secretions. Positions changes. Tylenol as\n needed. Abx. Follow sputum culture results.\n .H/O hypertension, benign\n Assessment:\n Currently-- ABP 110-130/50-60. NSR 70-80\ns with occasional PVC\ns. Trop\n level at 0.14 DP pulses weakly palpable, PT pulses Doppler. <3 cap\n refill.\n Action:\n This morning the pt\ns ABP began to rise to a SBP of 180-190 with a HR\n of 110-120 and increasing ectopy. A bolus of versed and fentanyl was\n administered along with an increase in pressure support and ETT suction\n as the pt\ns work of breathing was also noted to be labored. Kept room\n dark and quiet allowing pt to rest and settle. Standing PO lopressor\n and IV hydralazine administered at 1200. Echo done at 1000. Team aware\n of trop level.\n Response:\n Pt responded well to boluses, vent changes, and resp care as SBP\n decreased to 120-130 along with the HR to 70-80\ns. Ectopy still noted\n but decreasing in frequency.\n Plan:\n Continue to monitor ABP and correlation between work of breathing and\n BP changes. Monitor sedation and its role in controlling ABP as well.\n Monitor cardiac changes resulting from ischemia r/t hypertension\n specifically trop levels and EKG changes. Administer standing cardiac\n meds.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO adequate 50-200 cc/hr; urine light yellow and clear. (+) 18 Liters\n for LOS. BUN 25 CR 1.2. Weight at 1000 was 77.7 kg.\n Action:\n Hourly UO. Started high fiber tube feedings at 20 ml/hr with 150 cc\n fluid bolus q6h.\n Response:\n Pt remains to autodiurese.\n Plan:\n Follow BUN and Cr in AM labs. ? renal baseline. Check TF residuals and\n increase as tolerated.\n" }, { "category": "Nursing", "chartdate": "2192-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342244, "text": "Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Intubated on CPAP Fi02 40% with a tidal volume of 500-600 and a MV\n of . Sp02 100%, RR 13-25. Tmax 101, diaphoresis noted on face. Upper\n lung fields rhonchus; lower fields clear but diminished. Moderate thick\n tan/ tinged secretions suctioned q1-2 hours.\n Action:\n Pt initially on CPAP but showed signs of resp distress, tachypnea\n in the high 30\ns, labored work of breathing, and SBP in 180-190. Drew\n ABG at 0730 7.40/30/74. Increased pressure support to 20 and boluses\n with fentanyl and versed in response to VS changes. Suctioned\n q1-2hours. Changed positions frequently. Abx administered. Discontinued\n Vanco and Levoflaxacin. Sputum culture sent. Tylenol given for temp.\n Response:\n Pt settled down decreasing RR to and lowering SBP 120-130 after\n vent changes and fentanyl and versed boluses. Able to decrease pressure\n support again to 15 where the pt remains to look comfortable breathing\n 12-20 breaths/min, Sp02 100% and displaying nonlabored breathing.\n Secretions remain thick and lungs remain rhonchus. Gram positive grew\n out in sputum.\n Plan:\n Decrease pressure support as tolerated. ? ability to r/t copious\n amounts of secretions. Collect ABG as needed. Suction as needed noting\n amount and consistency of secretions. Positions changes. Tylenol as\n needed. Abx.\n .H/O hypertension, benign\n Assessment:\n Currently-- ABP 110-130/50-60. NSR 70-80\ns with occasional PVC\ns. Trop\n level at 0.14 DP pulses weakly palpable, PT pulses Doppler. <3 cap\n refill.\n Action:\n This morning the pt\ns ABP began to rise to a SBP of 180-190 with a HR\n of 110-120 and increasing ectopy. A bolus of versed and fentanyl was\n administered along with an increase in pressure support and ETT suction\n as the pt\ns work of breathing was also noted to be labored. Kept room\n dark and quiet allowing pt to rest and settle. Standing PO lopressor\n and IV hydralazine administered at 1200. Echo done at 1000. Team aware\n of trop level.\n Response:\n Pt responded well to boluses, vent changes, and resp care as SBP\n decreased to 120-130 along with the HR to 70-80\ns. Ectopy still noted\n but decreasing in frequency.\n Plan:\n Continue to monitor ABP and correlation between work of breathing and\n BP changes. Monitor sedation and its role in controlling ABP as well.\n Monitor cardiac changes resulting from ischemia r/t hypertension\n specifically trop levels and EKG changes. Administer standing cardiac\n meds.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO adequate 50-200 cc/hr; urine light yellow and clear. (+) 18 Liters\n for LOS. BUN 25 CR 1.2. Weight at 1000 was 77.7 kg.\n Action:\n Hourly UO. Started high fiber tube feedings at 20 ml/hr with 150 cc\n fluid bolus q6h.\n Response:\n Pt remains to autodiurese.\n Plan:\n Follow BUN and Cr in AM labs. ? renal baseline. Check TF residuals q4h\n holding for >150 and increase rate q6h as tolerated with goal of 55\n ml/hr.\n" }, { "category": "Nursing", "chartdate": "2192-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342245, "text": "82 year old female with a history of breast CA (s/p XRT), CVA, baseline\n dementia, HTN, reflux, & recurrent UTI\ns, who presented on early\n am from after being found to be in respiratory distress\n with oxygen sats in 70s to 80\ns on r/a. Her EKG per report was within\n normal limits. Her exam was notable for audible rales and abdominal\n distension. Sent to EW, where she was emergently Intubated.\n T103. Code sepsis not initiated as BP >100/systolic. Peripheral BC\n from EW grew 4 out of 4 bottles positive for gram negative rods, E coli\n on C&S. Urine Cx () grew E coli. Sputum Cx shows many\n organisms consistent w/oropharyngeal flora. Became hypotensive in MICU\n on afternoon, received fluid boluses & levophed IV. Treated w/IV\n levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission. Off\n levophed since 0600.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Intubated on CPAP Fi02 40% with a tidal volume of 500-600 and a MV\n of . Sp02 100%, RR 13-25. Tmax 101, diaphoresis noted on face. Upper\n lung fields rhonchus; lower fields clear but diminished. Moderate thick\n tan/ tinged secretions suctioned q1-2 hours.\n Action:\n Pt initially on CPAP but showed signs of resp distress, tachypnea\n in the high 30\ns, labored work of breathing, and SBP in 180-190. Drew\n ABG at 0730 7.40/30/74. Increased pressure support to 20 and boluses\n with fentanyl and versed in response to VS changes. Suctioned\n q1-2hours. Changed positions frequently. Abx administered. Discontinued\n Vanco and Levoflaxacin. Sputum culture sent. Tylenol given for temp.\n Response:\n Pt settled down decreasing RR to and lowering SBP 120-130 after\n vent changes and fentanyl and versed boluses. Able to decrease pressure\n support again to 15 where the pt remains to look comfortable breathing\n 12-20 breaths/min, Sp02 100% and displaying nonlabored breathing.\n Secretions remain thick and lungs remain rhonchus. Gram positive grew\n out in sputum.\n Plan:\n Decrease pressure support as tolerated. ? ability to r/t copious\n amounts of secretions. Collect ABG as needed. Suction as needed noting\n amount and consistency of secretions. Positions changes. Tylenol as\n needed. Abx.\n .H/O hypertension, benign\n Assessment:\n Currently-- ABP 110-130/50-60. NSR 70-80\ns with occasional PVC\ns. Trop\n level at 0.14 DP pulses weakly palpable, PT pulses Doppler. <3 cap\n refill.\n Action:\n This morning the pt\ns ABP began to rise to a SBP of 180-190 with a HR\n of 110-120 and increasing ectopy. A bolus of versed and fentanyl was\n administered along with an increase in pressure support and ETT suction\n as the pt\ns work of breathing was also noted to be labored. Kept room\n dark and quiet allowing pt to rest and settle. Standing PO lopressor\n and IV hydralazine administered at 1200. Echo done at 1000. Team aware\n of trop level.\n Response:\n Pt responded well to boluses, vent changes, and resp care as SBP\n decreased to 120-130 along with the HR to 70-80\ns. Ectopy still noted\n but decreasing in frequency.\n Plan:\n Continue to monitor ABP and correlation between work of breathing and\n BP changes. Monitor sedation and its role in controlling ABP as well.\n Monitor cardiac changes resulting from ischemia r/t hypertension\n specifically trop levels and EKG changes. Administer standing cardiac\n meds.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO adequate 50-200 cc/hr; urine light yellow and clear. (+) 18 Liters\n for LOS. BUN 25 CR 1.2. Weight at 1000 was 77.7 kg.\n Action:\n Hourly UO. Started high fiber tube feedings at 20 ml/hr with 150 cc\n fluid bolus q6h.\n Response:\n Pt remains to autodiurese.\n Plan:\n Follow BUN and Cr in AM labs. ? renal baseline. Check TF residuals q4h\n holding for >150 and increase rate q6h as tolerated with goal of 55\n ml/hr.\n" }, { "category": "Nursing", "chartdate": "2192-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342250, "text": "82 year old female with a history of breast CA (s/p XRT), CVA, baseline\n dementia, HTN, reflux, & recurrent UTI\ns, who presented on early\n am from after being found to be in respiratory distress\n with oxygen sats in 70s to 80\ns on r/a. Her EKG per report was within\n normal limits. Her exam was notable for audible rales and abdominal\n distension. Sent to EW, where she was emergently Intubated.\n T103. Code sepsis not initiated as BP >100/systolic. Peripheral BC\n from EW grew 4 out of 4 bottles positive for gram negative rods, E coli\n on C&S. Urine Cx () grew E coli. Sputum Cx shows many\n organisms consistent w/oropharyngeal flora. Became hypotensive in MICU\n on afternoon, received fluid boluses & levophed IV. Treated w/IV\n levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission. Off\n levophed since 0600.\n Nuero: Pt remains sedated on 50 mcg/hr of fentanyl and 1 mg/hr of\n versed. Left pupil 2 mm and reactive; left pupil 2 mm and nonreactive.\n Opens eyes when stimulated. Moves toes on bed nonpurposefully. Impaired\n cough and absent gag reflex.\n GI: Hypoactive BS. No residual from OGT. Abdomen soft and distended. TF\n started at 1300 with free water boluses. Small brown BM.\n Endo: Siding scale insulin. Blood sugars in 70\ns. Watched q1-2hours\n while on D51/2 NS at 100/hr.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Intubated on CPAP Fi02 40% with a tidal volume of 500-600 and a MV\n of . Sp02 100%, RR 13-25. Tmax 101, diaphoresis noted on face. Upper\n lung fields rhonchus; lower fields clear but diminished. Moderate thick\n tan/blood tinged secretions suctioned q1-2 hours.\n Action:\n Pt initially on CPAP but showed signs of resp distress, tachypnea\n in the high 30\ns, labored work of breathing, and SBP in 180-190. Drew\n ABG at 0730 7.40/30/74. Increased pressure support to 20 and boluses\n with fentanyl and versed in response to VS changes. Suctioned\n q1-2hours. Changed positions frequently. Abx administered. Discontinued\n Vanco and Levoflaxacin. Sputum culture sent. Tylenol given for temp.\n Another ABG drawn at 1530.\n Response:\n Pt settled down decreasing RR to and lowering SBP 120-130 after\n vent changes and fentanyl and versed boluses. Able to decrease pressure\n support again to 15 where the pt remains to look comfortable breathing\n 12-20 breaths/min, Sp02 100% and displaying nonlabored breathing.\n Secretions remain thick and lungs remain rhonchus. Gram positive grew\n out in sputum.\n Plan:\n Decrease pressure support as tolerated. ? ability to r/t copious\n amounts of secretions. Collect ABG as needed. Suction as needed noting\n amount and consistency of secretions. Positions changes. Tylenol as\n needed. Abx.\n .H/O hypertension, benign\n Assessment:\n Currently-- ABP 110-130/50-60. NSR 70-80\ns with occasional PVC\ns. Trop\n level at 0.14 DP pulses weakly palpable, PT pulses Doppler. <3 cap\n refill.\n Action:\n This morning the pt\ns ABP began to rise to a SBP of 180-190 with a HR\n of 110-120 and increasing ectopy. A bolus of versed and fentanyl was\n administered along with an increase in pressure support and ETT suction\n as the pt\ns work of breathing was also noted to be labored. Kept room\n dark and quiet allowing pt to rest and settle. Standing PO lopressor\n and IV hydralazine administered at 1200. Echo done at 1000. Team aware\n of trop level.\n Response:\n Pt responded well to boluses, vent changes, and resp care as SBP\n decreased to 120-130 along with the HR to 70-80\ns. Ectopy still noted\n but decreasing in frequency.\n Plan:\n Continue to monitor ABP and correlation between work of breathing and\n BP changes. Monitor sedation and its role in controlling ABP as well.\n Monitor cardiac changes resulting from ischemia r/t hypertension\n specifically trop levels and EKG changes. Administer standing cardiac\n meds.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO adequate 50-200 cc/hr; urine light yellow and clear. (+) 18 Liters\n for LOS. BUN 25 CR 1.2. Weight at 1000 was 77.7 kg.\n Action:\n Hourly UO. Started high fiber tube feedings at 1300 at 20 ml/hr with\n 150 cc fluid bolus q6h.\n Response:\n Pt remains to autodiurese.\n Plan:\n Follow BUN and Cr in AM labs. ? renal baseline. Check TF residuals q4h\n holding for >150 and increase rate q6h as tolerated with goal of 55\n ml/hr.\n" }, { "category": "Physician ", "chartdate": "2192-08-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342457, "text": "Chief Complaint: 82 year old female with history fo breast cancer, CVA,\n HTN who presents from rehab with likely pneumonia and UTI leading to\n sepsis.\n 24 Hour Events:\n Yesterday, decreased pressure supports. this morning on % and\n RSBI of 56. still with moderate thick yellow secretions.\n Hemodynamically stable. Family meeting yesterday confirmed tha tpatient\n is indeed full code. Vancomycin was restarted yesterday with concern\n for increased sputum and in the setting of sputum with gram positive\n cocci in pairs. Patient was ordered for potassium scale given low K.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Vancomycin - 03:00 PM\n Gentamicin - 09:24 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydralazine - 10:54 PM\n Heparin Sodium (Prophylaxis) - 03:30 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 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.4\nC (99.3\n HR: 79 (79 - 98) bpm\n BP: 142/62(86) {142/57(85) - 181/72(106)} mmHg\n RR: 22 (21 - 29) insp/min\n SpO2: 100%\n Heart rhythm: WAP (Wandering atrial pacemaker)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 8 (2 - 10)mmHg\n Total In:\n 1,615 mL\n 192 mL\n PO:\n TF:\n 140 mL\n IVF:\n 1,155 mL\n 152 mL\n Blood products:\n Total out:\n 2,018 mL\n 1,080 mL\n Urine:\n 2,018 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n -403 mL\n -888 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 447 (423 - 464) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 13 cmH2O\n SpO2: 100%\n ABG: 7.41/37/107/21/0\n Ve: 11.3 L/min\n PaO2 / FiO2: 268\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 104 K/uL\n 9.0 g/dL\n 145\n 0.8 mg/dL\n 21 mEq/L\n 2.7 mEq/L\n 18 mg/dL\n 113 mEq/L\n 142 mEq/L\n 27.1 %\n 22.6 K/uL\n [image002.jpg]\n 04:45 AM\n 05:03 AM\n 07:34 AM\n 03:29 PM\n 03:16 AM\n 03:31 AM\n 07:50 PM\n 04:10 AM\n 05:33 AM\n 06:00 AM\n WBC\n 10.8\n 17.0\n 22.6\n Hct\n 26.5\n 28.6\n 27.1\n Plt\n 84\n 91\n 104\n Cr\n 1.2\n 1.0\n 0.8\n TropT\n 0.14\n TCO2\n 20\n 19\n 22\n 20\n 22\n 24\n Glucose\n 83\n 95\n 37\n 40\n 145\n Other labs: PT / PTT / INR:14.8/26.7/1.3, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.3\n mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology.\n Septic Shock: Patient was with SIRS with E coli in blood and urine.\n CXR shows bibasilar consolidations as well concerning for possible\n pneumonia. Sputum culture with gram + cocci. There is some mild\n enteritis as wel as CTl. Presentation lactate was 3.4, then trended\n down.\n - repeat sputum culture wtih 3+ gram positive cocci in pairs and\n chains, with 2+ oropharyngeal flora, speciation partial only with oral\n flora currently\n - currently on gentamycin Day , yesterday restrated vancomycin\n - currently off all pressors, now hypertensive\n -monitor WBC, CBC, diff\n -monitor fever curve- patient initially febrile but became hypothermic\n requiring bear hugger, now normothermic\n Respiratory Failure: Initially respiratory failure thought to be due to\n pneumonia. Patient on CPAP 8/5 with 40% O2; with thick secretions. O2\n sats in monitor are ok. + Gag reflex. Mental status is non-responsive.\n Patient without much secretions.\n -culture data from sputum thus far has grown orophyaryngeal flora only,\n now with 3+ gram positive cocci in pairs, awaiting speciation\n - start vanco back up\n - will decrease pressure support to and wean sedation, consider\n trial of extubation today\n - + gag reflex, still with thick yellow secretions\n - Suction PRN\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension\n - gave 10 IV hydral in the setting of hypertension to 200 may be in the\n setting of agitation, would like to get away from IV hydral and titrate\n up beta blocker as tolerated\n - will restart lisinopril today now that acute renal failure has\n resolved, home dose 2.5\n -Increase metoprolol today (to 50 TID), holding parameters to HR < 60\n and SBP < 100\n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since blood is prokinetic.\n Will guaiac stool when available.\n - crit is stable\n -Patient guaic positive in the ED, have not sent stool studies as\n patient has had no stool, however suspect positive\n - Coffee ground emesis from NG tube; guaiac negative\n - continue to follow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n to 1.0. Likely prerenal in etiology secondary to volume depletion and\n septic shock\n likely ATN. No cast seen in UA, but it was not fresh.\n Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n - trend creatinine\n -Maintain adequate BP and hydration\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with upward trending CE. This is likely demand\n ischemia in setting of hypotension. Now that BP and tachycardia under\n control, warm and perfusing, can follow-up cardiac function with echo.\n - repeat EKG from EKG Sinus rhythm. Premature ventricular\n contractions. Poor R wave progression may be lead placement or possible\n old anterior myocardial infarction. Compared to\n the previous tracing of axis has shifted rightward. Ventricular\n ectopy is new.\n - ECHO from - IMPRESSION: Mild focal LV systolic dysfunction.\n Mildly dilated right ventricle. Mild to moderate aortic regurgitation.\n Moderately dilated ascending aorta.\n - troponins slighlty increased, but in settig of sepsis may represent\n myocardial stunning, also echo is reassuming that there is no regional\n wall motion abnormalities\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n FEN:\n - residuals improve, restarted tube feedings, holding this AM in the\n setting of considering extubation\n -Monitor and replete electrolytes as needed.\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: currently full code, as initial DNR was reversed by HCP. \n need to re-establish if patient would be re-intubated pending failure\n of extubation.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nutrition", "chartdate": "2192-08-17 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 341825, "text": "Subjective\n Patient intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 64.8 kg\n 23\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 59 kg\n 110\n Diagnosis: Pneumonia\n PMH : breast cancer s/p XRT and lumpectomy, CVA, hypertension,\n recurrent UTIs, dementia\n Food allergies and intolerances: none noted\n Pertinent medications: fentanyl, versed, others noted\n Labs:\n Value\n Date\n PO2 (arterial)\n 139 mm Hg\n 11:01 AM\n PCO2 (arterial)\n 43 mm Hg\n 11:01 AM\n pH (arterial)\n 7.25 units\n 11:01 AM\n CO2 (Calc) arterial\n 20 mEq/L\n 11:01 AM\n Current diet order / nutrition support: NPO\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1600- (BEE x or / 25-30 cal/kg)\n Protein: 75-100 (1.2-1.5 g/kg)\n Fluid: per team\n Specifics:\n 82 year old female presenting from Nursing Home with respiratory\n distress d/t ?pneumonia now intubated and sedated. Consult received for\n tube feeding recommendations. For now, would suggest\n Probalance/Fibersource HN to goal rate of 55ml/hr x 24 hours to provide\n 1584kcal and 73g protein. Will adjust as more information and labs are\n available if necessary.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Start Probalance/Fibersource HN at 20ml/hr, advance by 20ml\n q6H to goal rate of 55ml/hr x 24 hours\n 2. Monitor residuals q4H and hold tube feeding if >150ml\n 3. Will adjust tube feeding rate/formula PRN\n 12:52\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341903, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW. Code sepsis not initiated as BP >100/systolic. Patient\n arrived in MICU & did well until 1600.\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341904, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n Patient arrived in MICU & did well until 1600.\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342002, "text": "Sepsis without organ dysfunction\n Assessment:\n Tmax 99.5 oral; ABP 110-120/60-70 MAP >65; NSR with rare PVC\ns; HR\n 60-70; CVP 9-11; CO 3.2-3.8; Doppler pedal pulses, left DP easily\n palpable; cap refill <3; intubated and sedated on A/C, Fi02 40%, Peep\n 8, RR 24. Last ABG @ 1600 7.32/34/106. Lungs clear, diminished at\n bases. Moderate tan, thick secretions. Abdomen soft and distended;\n hypoactive BS; suctioned 325 cc of brown gastric secretions from OGT-\n occult (+). UO 20-30 cc/hr, urine yellow with sediment. Latest labs-\n BUN 27, CR 1.7, Lactate 3.4\n Action:\n Blood cultures x2 sent; Weaned off levophed; weaned versed and\n fentanyl; vent changes- dropped Fi02 to 40% from 60%, changed TV to 7L\n from 8L; Decompressed abdomen with intermittent low wall suction,\n informed team of (+) occultl; Followed ABG and blood chemistry; last\n CBC at 1700.\n Response:\n Maintained ABPP /60-70 with MAP >63 off levophed. CVP remains\n at 9-10; CO 3.7. Maintains intubated on A/C with Fi02 40%, Peep 8, RR\n 24. UO remains at 20-30 cc/hr.\n Plan:\n Monitor ABP and need for pressors. Monitor CVP and Monitor vent\n status, making adjustments as needed. Monitor abdomen for bowel sounds\n and distention. Monitor UO, BUN, CR, and lactate.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2192-08-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 342075, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 59 None\n Ideal tidal volume: 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: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT and on mech vent as per Metavision.\n Lung sounds ess clear after suct for sm=>mod th tan sput. Pt seemingly\n out of phase with vent on A/C resulting in increased PIPs; pt switched\n to PSV with good result and ABGs stable on PSV. Cont PSV.\n" }, { "category": "Respiratory ", "chartdate": "2192-08-17 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 341892, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 59 None\n Ideal tidal volume: 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: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: RESPIRATORY CARE: PT FROM HOSPITAL TO 4 VIA\n THE EW TODAY W/ SEPSIS. INTUBATED IN THE EW. ABG C/W A METABOLIC\n ACIDOSIS AND FAIR OXYGENATION REQUIRING 8 PEEP AND FIO2 .60. TARGET PH\n BY ICU TEAM IS 7.25. WILL C/W AC MODE AS TOLERATED.\n" }, { "category": "Physician ", "chartdate": "2192-08-17 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 341896, "text": "Chief Complaint: Respiratory Distress\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 86 year old female who presented from NH with respiratory distress and\n required intubation/mechanical ventilation.\n Was febrile to 103.\n CXR showed right sided infiltrate\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated, intubated\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1) CVA\n 2) History of falls\n 3) Recurrent UTIs\n 4) Osteoporosis\n 5) Dementia\n 6) Hypertension\n Occupation: Nursing Home\n Drugs:\n Tobacco:\n Alcohol: Previous use\n Other:\n Review of systems: Unable\n Flowsheet Data as of 12:34 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 38.6\nC (101.4\n HR: 98 (98 - 106) bpm\n BP: 110/59(71) {86/53(60) - 110/59(71)} mmHg\n RR: 21 (18 - 21) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,945 mL\n PO:\n TF:\n IVF:\n 1,945 mL\n Blood products:\n Total out:\n 0 mL\n 520 mL\n Urine:\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,425 mL\n Respiratory\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: 7.25/43/139//-8\n Ve: 10 L/min\n PaO2 / FiO2: 139\n Physical Examination\n Cardiovascular: (S1: Normal), (S2: Normal)\n Chest: CTA bilaterally\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 Abdominal: Soft, Non-tender, Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Cool\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n 08:32 AM\n 10:22 AM\n 11:01 AM\n TC02\n 18\n 18\n 20\n Other labs: Lactic Acid:5.1 mmol/L\n Assessment and Plan\n A:\n 1) Acute Respiratory Failure secondary to pneumonia\n Plan:\n - continue mechanical ventilation -> wean Fio2 as able\n - treat underlying pneumonia\n 2) Pneumonia/sepsis\n - levofloxacin/amikacin\n - has received 4-5 liters of fluid and perfusion is improving (urine\n output improved, lactate clearing)\n Plan:\n - Continue broad-spectrum antibiotics\n - Resuscitate to endpoints of urine output > 30 cc/hour, lactate < 2.5,\n normalized vitals, normal shock index,\n Addendum: During the afternoon, patient dropped blood pressure\n requiring levophed. CVP 5, CO 3.5, scvo2=70%. Will continue fluid\n resuscitation as likely preload-dependence. Add cortisol level and\n will give hydrocortisone if persistent hypotension. Reduce sedation\n as not moving much and this may help with the blood pressure. Continue\n to resuscitate to perfusion endpoints.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n Total time spent: 90 (patient is critically ill)\n" }, { "category": "Physician ", "chartdate": "2192-08-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 341996, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:00 AM\n MULTI LUMEN - START 12:50 PM\n EKG - At 02:00 PM\n ARTERIAL LINE - START 02:52 PM\n FEVER - 101.4\nF - 11:00 AM- pan- cultured\n -on Levophed overnight for hypotension, given albumin and IVF for\n volume and poor UOP\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Gentamicin - 10:47 PM\n Aztreonam - 06:08 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 04:05 AM\n Dextrose 50% - 06:47 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 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.7\nC (98\n HR: 77 (77 - 106) bpm\n BP: 127/50(73) {76/37(48) - 127/60(316)} mmHg\n RR: 22 (15 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 11 (4 - 15)mmHg\n CO/CI (Fick): (6.4 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 72 - 73\n Total In:\n 13,550 mL\n 2,528 mL\n PO:\n TF:\n 19 mL\n IVF:\n 9,911 mL\n 2,503 mL\n Blood products:\n 500 mL\n Total out:\n 1,255 mL\n 590 mL\n Urine:\n 955 mL\n 190 mL\n NG:\n 300 mL\n 400 mL\n Stool:\n Drains:\n Balance:\n 12,295 mL\n 1,938 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (450 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 31 cmH2O\n Plateau: 19 cmH2O\n Compliance: 45.5 cmH2O/mL\n SpO2: 98%\n ABG: 7.30/33/99./16/-8\n Ve: 10.8 L/min\n PaO2 / FiO2: 165\n Physical Examination\n HEENT:NCAT mucus membranes dry pale conjunctiva\n CV: RRR S1S2 no m/r/g\n PULM: rales, crackles at RLL, scant crackles at LLL\n ABD: distended, soft +bs throughout\n EXT: WWP 1+dp pulses\n Labs / Radiology\n 151 K/uL\n 9.8 g/dL\n 55 mg/dL\n 1.6 mg/dL\n 16 mEq/L\n 5.9 mEq/L\n 25 mg/dL\n 117 mEq/L\n 146 mEq/L\n 30.8 %\n 7.8 K/uL\n [image002.jpg]\n 10:22 AM\n 11:01 AM\n 02:29 PM\n 02:48 PM\n 04:44 PM\n 09:18 PM\n 01:55 AM\n 02:00 AM\n 04:05 AM\n 04:33 AM\n WBC\n 4.2\n 7.8\n Hct\n 33.4\n 30.8\n Plt\n 138\n 151\n Cr\n 1.4\n 1.6\n 1.6\n TropT\n 0.05\n TCO2\n 18\n 20\n 18\n 17\n 16\n 17\n 17\n Glucose\n 69\n 62\n 55\n Other labs: CK / CKMB / Troponin-T:69/4/0.05, Differential-Neuts:35.0\n %, Band:28.0 %, Lymph:11.0 %, Mono:7.0 %, Eos:0.0 %, Lactic Acid:4.9\n mmol/L, Albumin:1.8 g/dL, Ca++:6.6 mg/dL, Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia and septic physiology.\n Septic Shock: Current differential includes pneumonia vs. urosepsis\n vs. GI source. Cultures grew , wait for speciation but until\n then continue to cover broadly. Sputum and urine cultures pending.\n Patient was noted to have distended abdomen on presentation, CT abdomen\n shows distended bladder, b/l hydroureters and gas/stool in bowel with\n some mild bowel thickening. There is no indication of obstruction but\n patient has not passed gas/stool since admission (unclear if this is\n chronic diarrhea). This is likely ileus secondary to acute illness and\n less likely an infectious source. For hypotension the patient received\n large volume of IV NS, LR. Switched to D5 1/2NS w/bicarb d/t rising K\n and Na.\n - follow up sputum, urine cultures\n - continue vancomycin, aztreonam, gentamycin\n - IVF boluses with normal saline to maintain MAP > 65, urine output >\n 30 cc/hr, CVP 10-12\n - trend lactate\n - attempt to wean off levophed\n -monitor fever curve- patient initially febrile but became hypothermic\n overnight requiring bear hugger.\n -monitor WBC and diff\n Respiratory Failure: Patient on AC 500/8/60%. PCO2 on ventilator is\n 33. Will wean FIO2 as tolerated today. Likely secondary to pneumonia.\n -f/u cultures and continue abx as above\n - wean FiO2 as tolerated\n -wean off sedation as tolerated- this will also assist with bowel\n motility\n ARF: Creatinine 2.0 from baseline of 0.6. Likely prerenal in etiology\n secondary to volume depletion and septic shock.\n - IVF boluses to maintain urine output\n - trend creatinine\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with upward trending CE. This is likely demand\n ischemia in setting of hypotension. Now that BP and tachycardia under\n control, warm and perfusing, can follow-up cardiac function with echo.\n - recheck EKG now that tachycardia has improved\n - ECHO if possible to evaluate for MI or change from prior\n Hypertension:\n - holding all antihypertensives in the setting of hypotension\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n FEN: IVF- D5\n NS, if bicarb trends downward can add \n amps bicarb.\n Monitor and replete electrolytes as needed.\n Monitor K closely, add kayexelate if needed.\n NGT in place however has had high residuals overnight so should hold\n off on TF until bowel function improves.\n Prophylaxis: SC heparin, bowel regimen\n Communcation: Sister \n Code: DNR per nursing home record signed by patient's sister. Clarify\n goals of care with HCP.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:44 AM\n 18 Gauge - 10:00 AM\n 16 Gauge - 10:00 AM\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU Attending Coverage Addendum\n I have reviewed the pertinent history and labs and have examined the\n patient. I was physically present with the MICU team for the key\n portions of the services provided. I agree with the note above,\n including the assessment and plan. I would add and emphasize the\n following:\n Overnight the patient was resuscitate with fluids for a low CVP and\n with this her BP is better and extremities now warm and Levophed being\n titrated down. Lactate also trending down and U.O, somewhat better.\n On exam: Tm=101.4, P=71, BP=112/50, CVP=14, Po2=99 on 60% fi02 Sedated\n on vent Lungs show bronchia bs over RLL and to lesser extent at left\n base.\n Lab: WBC ony 7.8 but 28% bands CXR: RLL infiltrate and ? left\n effusion vs infiltrate Cortisol >40. Ucx ngtd BCx but not yet\n identified.\n Problems:\n 1. bacteremia and septic shock, improving with fluids,\n pressors, and abx (Aztreonam, Vanc, Levo, Gent), ? from lung or\n bladder, or abdominal source\n 2. RLL pneumonia\n 3. Renal insufficiency\n 4. EKG changes, likely demand ischemia\n 5. Prior DNR, currently reversed\n 6. Abd wall thickening on CT\n Plan:\n 1. Change fluids from RL to D5\n 2. Wean Fi02, levophed, versed, and fentanyl\n 3. Follow EKG\n 4. Continue antibiotics with gent trough\n 5. Talk to sister about end of life issues again\n Patient Critically ill. Total time: 50min\n , \n ------ Protected Section Addendum Entered By: , MD\n on: 14:34 ------\n" }, { "category": "Nursing", "chartdate": "2192-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342067, "text": "Mrs. is an 82 year old female with a history of breast CA (s/p\n XRT), CVA, baseline dementia, HTN, reflux, & recurrent UTI\ns, who\n presented on early am from after being found to be\n in respiratory distress with oxygen sats in 70s to 80\ns on r/a. Her\n EKG per report was within normal limits. Her exam was notable for\n audible rales and abdominal distension. Foley catheter was placed with\n 100 cc dark urine. Sent to EW, where she was emergently\n Intubated. T103. Code sepsis not initiated as BP >100/systolic.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Urine Cx () grew nothing yet. UA from EW shows\n many bacti but UA from later in the day shows few. Sputum Cx shows\n many organisms consistent w/oropharyngeal flora. Became hypotensive in\n MICU on afternoon, received fluid boluses & levophed IV. Treated\n w/IV levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission.\n Sepsis without organ dysfunction\n Assessment:\n Lactate down to low of 2.6 on . MAP 64-78. Systolic BP\n 90\ns-130\ns/. HR: 70\ns-80\ns SR no ectopy. CVP: CO: 3.4-3.5\n CI: 2 SVR: 1,221- 1,624.\n Action:\n Finished 2^nd liter D5\n NS. Titrated levophed down to 0.01-0.03\n mcg/kg/min. Levophed off X45min.\n Response:\n MAP maintained >65\n Plan:\n Continue to maintain MAP>65. Continue to titrate levophed down.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs: clear, diminished @ bases. Sx\ned scant to moderate thick tan\n secretions q 3 hrs. On CPAP 40%/ 8 PEEP/ 12 PS since 2130 .\n Continued on fentanyl 50mcg/hr & versed 1mg/hr.\n Action:\n ABG\ns: 7.31/ 27/96 on CPAP\n Response:\n ABG\ns w/am labs: 7.32/39/117\n Plan:\n Await RSBI in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 30-50cc/hr cloudy yellow urine w/sediment. BUN 28 Cr 1.6\n Action:\n Received D5\n NS @ 125cc/hr overnight. Levophed titrated down.\n Response:\n Patient is beginning to turn corner w/sepsis, thereby perfusing kidneys\n more efficiently.\n Plan:\n Continue to follow electrolytes & BUN/Cr. Continue to monitor u/o.\n Hct 25.6 this am down from 28.5. Guaic + brown emesis continues.\n" }, { "category": "Nursing", "chartdate": "2192-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342068, "text": "Mrs. is an 82 year old female with a history of breast CA (s/p\n XRT), CVA, baseline dementia, HTN, reflux, & recurrent UTI\ns, who\n presented on early am from after being found to be\n in respiratory distress with oxygen sats in 70s to 80\ns on r/a. Her\n EKG per report was within normal limits. Her exam was notable for\n audible rales and abdominal distension. Foley catheter was placed with\n 100 cc dark urine. Sent to EW, where she was emergently\n Intubated. T103. Code sepsis not initiated as BP >100/systolic.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Urine Cx () grew nothing yet. UA from EW shows\n many bacti but UA from later in the day shows few. Sputum Cx shows\n many organisms consistent w/oropharyngeal flora. Became hypotensive in\n MICU on afternoon, received fluid boluses & levophed IV. Treated\n w/IV levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission.\n Sepsis without organ dysfunction\n Assessment:\n Lactate down to low of 2.6 on . MAP 64-78. Systolic BP\n 90\ns-130\ns/. HR: 70\ns-80\ns SR no ectopy. CVP: CO: 3.4-3.5\n CI: 2 SVR: 1,221- 1,624.\n Action:\n Finished 2^nd liter D5\n NS. Titrated levophed down to 0.01-0.03\n mcg/kg/min. Levophed off X45min.\n Response:\n MAP maintained >65\n Plan:\n Continue to maintain MAP>65. Continue to titrate levophed down.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs: clear, diminished @ bases. Sx\ned scant to moderate thick tan\n secretions q 3 hrs. On CPAP 40%/ 8 PEEP/ 12 PS since 2130 .\n Continued on fentanyl 50mcg/hr & versed 1mg/hr.\n Action:\n ABG\ns: 7.31/ 27/96 on CPAP\n Response:\n ABG\ns w/am labs: 7.32/39/117\n Plan:\n Await RSBI in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 30-50cc/hr cloudy yellow urine w/sediment. BUN 28 Cr 1.6\n Action:\n Received D5\n NS @ 125cc/hr overnight. Levophed titrated down.\n Response:\n Patient is beginning to turn corner w/sepsis, thereby perfusing kidneys\n more efficiently.\n Plan:\n Continue to follow electrolytes & BUN/Cr. Continue to monitor u/o.\n Hct 25.6 this am down from 28.3. Guaic + brown emesis continues.\n" }, { "category": "Physician ", "chartdate": "2192-08-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 341962, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:00 AM\n MULTI LUMEN - START 12:50 PM\n EKG - At 02:00 PM\n ARTERIAL LINE - START 02:52 PM\n FEVER - 101.4\nF - 11:00 AM- pan- cultured\n -on Levophed overnight for hypotension\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Gentamicin - 10:47 PM\n Aztreonam - 06:08 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 04:05 AM\n Dextrose 50% - 06:47 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 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.7\nC (98\n HR: 77 (77 - 106) bpm\n BP: 127/50(73) {76/37(48) - 127/60(316)} mmHg\n RR: 22 (15 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 11 (4 - 15)mmHg\n CO/CI (Fick): (6.4 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 72 - 73\n Total In:\n 13,550 mL\n 2,528 mL\n PO:\n TF:\n 19 mL\n IVF:\n 9,911 mL\n 2,503 mL\n Blood products:\n 500 mL\n Total out:\n 1,255 mL\n 590 mL\n Urine:\n 955 mL\n 190 mL\n NG:\n 300 mL\n 400 mL\n Stool:\n Drains:\n Balance:\n 12,295 mL\n 1,938 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (450 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 31 cmH2O\n Plateau: 19 cmH2O\n Compliance: 45.5 cmH2O/mL\n SpO2: 98%\n ABG: 7.30/33/99./16/-8\n Ve: 10.8 L/min\n PaO2 / FiO2: 165\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 151 K/uL\n 9.8 g/dL\n 55 mg/dL\n 1.6 mg/dL\n 16 mEq/L\n 5.9 mEq/L\n 25 mg/dL\n 117 mEq/L\n 146 mEq/L\n 30.8 %\n 7.8 K/uL\n [image002.jpg]\n 10:22 AM\n 11:01 AM\n 02:29 PM\n 02:48 PM\n 04:44 PM\n 09:18 PM\n 01:55 AM\n 02:00 AM\n 04:05 AM\n 04:33 AM\n WBC\n 4.2\n 7.8\n Hct\n 33.4\n 30.8\n Plt\n 138\n 151\n Cr\n 1.4\n 1.6\n 1.6\n TropT\n 0.05\n TCO2\n 18\n 20\n 18\n 17\n 16\n 17\n 17\n Glucose\n 69\n 62\n 55\n Other labs: CK / CKMB / Troponin-T:69/4/0.05, Differential-Neuts:35.0\n %, Band:28.0 %, Lymph:11.0 %, Mono:7.0 %, Eos:0.0 %, Lactic Acid:4.9\n mmol/L, Albumin:1.8 g/dL, Ca++:6.6 mg/dL, Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:44 AM\n 18 Gauge - 10:00 AM\n 16 Gauge - 10:00 AM\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2192-08-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 341963, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:00 AM\n MULTI LUMEN - START 12:50 PM\n EKG - At 02:00 PM\n ARTERIAL LINE - START 02:52 PM\n FEVER - 101.4\nF - 11:00 AM- pan- cultured\n -on Levophed overnight for hypotension\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Gentamicin - 10:47 PM\n Aztreonam - 06:08 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 04:05 AM\n Dextrose 50% - 06:47 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 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.7\nC (98\n HR: 77 (77 - 106) bpm\n BP: 127/50(73) {76/37(48) - 127/60(316)} mmHg\n RR: 22 (15 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 11 (4 - 15)mmHg\n CO/CI (Fick): (6.4 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 72 - 73\n Total In:\n 13,550 mL\n 2,528 mL\n PO:\n TF:\n 19 mL\n IVF:\n 9,911 mL\n 2,503 mL\n Blood products:\n 500 mL\n Total out:\n 1,255 mL\n 590 mL\n Urine:\n 955 mL\n 190 mL\n NG:\n 300 mL\n 400 mL\n Stool:\n Drains:\n Balance:\n 12,295 mL\n 1,938 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (450 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 31 cmH2O\n Plateau: 19 cmH2O\n Compliance: 45.5 cmH2O/mL\n SpO2: 98%\n ABG: 7.30/33/99./16/-8\n Ve: 10.8 L/min\n PaO2 / FiO2: 165\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 151 K/uL\n 9.8 g/dL\n 55 mg/dL\n 1.6 mg/dL\n 16 mEq/L\n 5.9 mEq/L\n 25 mg/dL\n 117 mEq/L\n 146 mEq/L\n 30.8 %\n 7.8 K/uL\n [image002.jpg]\n 10:22 AM\n 11:01 AM\n 02:29 PM\n 02:48 PM\n 04:44 PM\n 09:18 PM\n 01:55 AM\n 02:00 AM\n 04:05 AM\n 04:33 AM\n WBC\n 4.2\n 7.8\n Hct\n 33.4\n 30.8\n Plt\n 138\n 151\n Cr\n 1.4\n 1.6\n 1.6\n TropT\n 0.05\n TCO2\n 18\n 20\n 18\n 17\n 16\n 17\n 17\n Glucose\n 69\n 62\n 55\n Other labs: CK / CKMB / Troponin-T:69/4/0.05, Differential-Neuts:35.0\n %, Band:28.0 %, Lymph:11.0 %, Mono:7.0 %, Eos:0.0 %, Lactic Acid:4.9\n mmol/L, Albumin:1.8 g/dL, Ca++:6.6 mg/dL, Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia and septic physiology.\n Septic Shock: Blood pressures in the 90s systolic on arrival to the\n intensive care unit. Patient febrile, tachycardiac with a bandemia and\n a lactic acidosis. Likely etiology is right sided pneumonia. Patient\n was noted to have distended abdomen on presentation to the emergency\n room but CT abdomen preliminarily is negative. She has now received\n over 5 liters normal saline with improvement in her blood pressure.\n She now has a central line in place.\n - follow up blood and urine cultures from emergency room\n - currently on vancomycin, aztreonam, levofloxacin for hospital\n acquired pneumonia\n - sputum culture if possible\n - IVF boluses with normal saline to maintain MAP > 65, urine output >\n 30 cc/hr, CVP 10-12\n - trend lactate to ensure improvement (now down to 5.1)\n - vasopressors as necessary to maintain blood pressure\n - hematocrit is elevated so no indication for transfusion\n Respiratory Failure: Now s/p intubation. PCO2 on ventilator is 40.\n Will wean oxygen as tolerated. Likely secondary to pneumonia.\n - continue ventilation at current settins\n - wean FiO2 as tolerated\n Acute Kidney Injury: Creatinine 2.0 from baseline of 0.6. Likely\n prerenal in etiology secondary to volume depletion and septic shock.\n - IVF boluses to maintain urine output\n - trend creatinine\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s.\n - recheck EKG now that tachycardia has improved\n - repeat cardiac enzymes in AM\n Hypertension:\n - holding all antihypertensives in the setting of hypotension\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n FEN: IVF as above, monitor electrolytes, NGT in place so will start\n tube feeds\n Prophylaxis: SC heparin\n Communcation: Sister \n Code: DNR per nursing home record signed by patient's sister. \n sister she now would like all interventions necessary to prolong life.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:44 AM\n 18 Gauge - 10:00 AM\n 16 Gauge - 10:00 AM\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2192-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342059, "text": "Mrs. is an 82 year old female with a history of breast CA (s/p\n XRT), CVA, baseline dementia, HTN, reflux, & recurrent UTI\ns, who\n presented on early am from after being found to be\n in respiratory distress with oxygen sats in 70s to 80\ns on r/a. Her\n EKG per report was within normal limits. Her exam was notable for\n audible rales and abdominal distension. Foley catheter was placed with\n 100 cc dark urine. Sent to EW, where she was emergently\n Intubated. T103. Code sepsis not initiated as BP >100/systolic.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Urine Cx () grew nothing yet. UA from EW shows\n many bacti but UA from later in the day shows few. Sputum Cx shows\n many organisms consistent w/oropharyngeal flora. Became hypotensive in\n MICU on afternoon, received fluid boluses & levophed IV. Treated\n w/IV levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission.\n Sepsis without organ dysfunction\n Assessment:\n Lactate down to low of 3.o on . MAP 64-78. Systolic BP\n 90\ns-130\ns/. HR: 70\ns-80\ns SR no ectopy. CVP: CO: 3.4-3.5\n CI: 2 SVR: 1,221- 1,624.\n Action:\n Finished 2^nd liter D5\n NS. Titrated levophed down to 0.1\n mcg/kg/min. Levophed off X45min.\n Response:\n MAP maintained >65\n Plan:\n Continue to maintain MAP>65. Continue to titrate levophed down.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs: clear, diminished @ bases. Sx\ned scant to moderate thick tan\n secretions q 3-4 hrs. On CPAP 40%/ 8 PEEP/ 12 PS since 2130 .\n Continued on fentanyl 50mcg/hr & versed 1mg/hr.\n Action:\n ABG\ns: 7.31/ 27/96 on CPAP\n Response:\n ABG\ns w/am labs:\n Plan:\n Await RSBI in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 30-50cc/hr cloudy yellow urine w/sediment. BUN 28 Cr 1.6\n Action:\n Received D5\n NS @ 125cc/hr overnight. Levophed titrated down.\n Response:\n Patient is beginning to turn corner w/sepsis, thereby perfusing kidneys\n more efficiently.\n Plan:\n Continue to follow electrolytes & BUN/Cr. Continue to monitor u/o.\n" }, { "category": "Nursing", "chartdate": "2192-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342060, "text": "Mrs. is an 82 year old female with a history of breast CA (s/p\n XRT), CVA, baseline dementia, HTN, reflux, & recurrent UTI\ns, who\n presented on early am from after being found to be\n in respiratory distress with oxygen sats in 70s to 80\ns on r/a. Her\n EKG per report was within normal limits. Her exam was notable for\n audible rales and abdominal distension. Foley catheter was placed with\n 100 cc dark urine. Sent to EW, where she was emergently\n Intubated. T103. Code sepsis not initiated as BP >100/systolic.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Urine Cx () grew nothing yet. UA from EW shows\n many bacti but UA from later in the day shows few. Sputum Cx shows\n many organisms consistent w/oropharyngeal flora. Became hypotensive in\n MICU on afternoon, received fluid boluses & levophed IV. Treated\n w/IV levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission.\n Sepsis without organ dysfunction\n Assessment:\n Lactate down to low of 3.o on . MAP 64-78. Systolic BP\n 90\ns-130\ns/. HR: 70\ns-80\ns SR no ectopy. CVP: CO: 3.4-3.5\n CI: 2 SVR: 1,221- 1,624.\n Action:\n Finished 2^nd liter D5\n NS. Titrated levophed down to 0.1\n mcg/kg/min. Levophed off X45min.\n Response:\n MAP maintained >65\n Plan:\n Continue to maintain MAP>65. Continue to titrate levophed down.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs: clear, diminished @ bases. Sx\ned scant to moderate thick tan\n secretions q 3 hrs. On CPAP 40%/ 8 PEEP/ 12 PS since 2130 .\n Continued on fentanyl 50mcg/hr & versed 1mg/hr.\n Action:\n ABG\ns: 7.31/ 27/96 on CPAP\n Response:\n ABG\ns w/am labs:\n Plan:\n Await RSBI in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 30-50cc/hr cloudy yellow urine w/sediment. BUN 28 Cr 1.6\n Action:\n Received D5\n NS @ 125cc/hr overnight. Levophed titrated down.\n Response:\n Patient is beginning to turn corner w/sepsis, thereby perfusing kidneys\n more efficiently.\n Plan:\n Continue to follow electrolytes & BUN/Cr. Continue to monitor u/o.\n" }, { "category": "Nursing", "chartdate": "2192-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342064, "text": "Mrs. is an 82 year old female with a history of breast CA (s/p\n XRT), CVA, baseline dementia, HTN, reflux, & recurrent UTI\ns, who\n presented on early am from after being found to be\n in respiratory distress with oxygen sats in 70s to 80\ns on r/a. Her\n EKG per report was within normal limits. Her exam was notable for\n audible rales and abdominal distension. Foley catheter was placed with\n 100 cc dark urine. Sent to EW, where she was emergently\n Intubated. T103. Code sepsis not initiated as BP >100/systolic.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Urine Cx () grew nothing yet. UA from EW shows\n many bacti but UA from later in the day shows few. Sputum Cx shows\n many organisms consistent w/oropharyngeal flora. Became hypotensive in\n MICU on afternoon, received fluid boluses & levophed IV. Treated\n w/IV levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission.\n Sepsis without organ dysfunction\n Assessment:\n Lactate down to low of 3.o on . MAP 64-78. Systolic BP\n 90\ns-130\ns/. HR: 70\ns-80\ns SR no ectopy. CVP: CO: 3.4-3.5\n CI: 2 SVR: 1,221- 1,624.\n Action:\n Finished 2^nd liter D5\n NS. Titrated levophed down to 0.1\n mcg/kg/min. Levophed off X45min.\n Response:\n MAP maintained >65\n Plan:\n Continue to maintain MAP>65. Continue to titrate levophed down.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs: clear, diminished @ bases. Sx\ned scant to moderate thick tan\n secretions q 3 hrs. On CPAP 40%/ 8 PEEP/ 12 PS since 2130 .\n Continued on fentanyl 50mcg/hr & versed 1mg/hr.\n Action:\n ABG\ns: 7.31/ 27/96 on CPAP\n Response:\n ABG\ns w/am labs: 7.32/39/117\n Plan:\n Await RSBI in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 30-50cc/hr cloudy yellow urine w/sediment. BUN 28 Cr 1.6\n Action:\n Received D5\n NS @ 125cc/hr overnight. Levophed titrated down.\n Response:\n Patient is beginning to turn corner w/sepsis, thereby perfusing kidneys\n more efficiently.\n Plan:\n Continue to follow electrolytes & BUN/Cr. Continue to monitor u/o.\n" }, { "category": "Nursing", "chartdate": "2192-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342065, "text": "Mrs. is an 82 year old female with a history of breast CA (s/p\n XRT), CVA, baseline dementia, HTN, reflux, & recurrent UTI\ns, who\n presented on early am from after being found to be\n in respiratory distress with oxygen sats in 70s to 80\ns on r/a. Her\n EKG per report was within normal limits. Her exam was notable for\n audible rales and abdominal distension. Foley catheter was placed with\n 100 cc dark urine. Sent to EW, where she was emergently\n Intubated. T103. Code sepsis not initiated as BP >100/systolic.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Urine Cx () grew nothing yet. UA from EW shows\n many bacti but UA from later in the day shows few. Sputum Cx shows\n many organisms consistent w/oropharyngeal flora. Became hypotensive in\n MICU on afternoon, received fluid boluses & levophed IV. Treated\n w/IV levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission.\n Sepsis without organ dysfunction\n Assessment:\n Lactate down to low of 3.o on . MAP 64-78. Systolic BP\n 90\ns-130\ns/. HR: 70\ns-80\ns SR no ectopy. CVP: CO: 3.4-3.5\n CI: 2 SVR: 1,221- 1,624.\n Action:\n Finished 2^nd liter D5\n NS. Titrated levophed down to 0.01-0.03\n mcg/kg/min. Levophed off X45min.\n Response:\n MAP maintained >65\n Plan:\n Continue to maintain MAP>65. Continue to titrate levophed down.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs: clear, diminished @ bases. Sx\ned scant to moderate thick tan\n secretions q 3 hrs. On CPAP 40%/ 8 PEEP/ 12 PS since 2130 .\n Continued on fentanyl 50mcg/hr & versed 1mg/hr.\n Action:\n ABG\ns: 7.31/ 27/96 on CPAP\n Response:\n ABG\ns w/am labs: 7.32/39/117\n Plan:\n Await RSBI in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 30-50cc/hr cloudy yellow urine w/sediment. BUN 28 Cr 1.6\n Action:\n Received D5\n NS @ 125cc/hr overnight. Levophed titrated down.\n Response:\n Patient is beginning to turn corner w/sepsis, thereby perfusing kidneys\n more efficiently.\n Plan:\n Continue to follow electrolytes & BUN/Cr. Continue to monitor u/o.\n" }, { "category": "Nursing", "chartdate": "2192-08-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341884, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. Per EMS notes her\n initial vitals in the field were T: 99.7 BP: 232/125 HR: 124 RR: 24 O2:\n 63% on 2L. She wa noted to be slow to respond and diaphrestic. She\n was suctioned with large amounts of secretions. Foley catheter was\n placed with 100 cc dark urine.\n In the emergency room her initial vitals were T: 103 HR: 130 BP: 114/89\n RR: 17 O2: 96% on 100% O2. She was emergently intubated. Her initial\n labs were notable for a WBC count of 3.2, band count of 23. Her\n initial blood gas was 7.21/40/96/17. Her creatinine was elevated at\n 2.0. She was started on vancomycin, levofloxacin and ceftriaxone. She\n received 3.5 liters of normal saline with a fourth bag hanging at the\n time of transfer.\n On 4, her sbp ranging in 90s-100s with cvp 4. pt received total\n of 7 liters ns and 2 liters lr. Sbp dropped to 60s when repositioned at\n 16:00. started on levophed. Cvp now . cardiac output 3.9, svv 5.\n pt tanked per svv, thus will continue levophed and avoid further ivf at\n this time. ? may need dobutamine.\n Sepsis without organ dysfunction\n Assessment:\n Sbp ranging 90s-100s initially at beginning of shift. R ij tlcl placed\n at bedside and confirmed via cxr. Aline also placed. Cvp from 4 up to\n 11. u.o. trending down as low as 27cc/hr. vigeleo monitor hooked up to\n monitor cardiac output, CI, and SVV. Ekg without sig. change md\n team, cardiac enzymes cycling. Afebrile. Pt feels very cool and clammy\n at extremities, warm at forehead and core of body. Ionized calcium .97.\n remains sedated on fentanyl 100mcg/hr and versed 3mg/hr. opens eyes at\n times and mae but appears comfortable. Bilat wrist restraints\n maintained for safety. + bld cx for gm negative rods from a peripheral\n blood draw.\n Action:\n Given total of 9 liters ivf with cvp up to 11. calcium repleted with 2\n gm calcium gluconate.\n Response:\n Sbp dropped to 60s when repositioned. Remained at 70s-80s supine.\n Started on levophed and titrated to maintain goal map of 65. cardiac\n output remains low at 3.8 to 3.6. svv remains low at 5 to 3. urine\n output remains marginal.\n Plan:\n Titrate levophed to maintain goal map >65. monitor cardiac output,\n cardiac index, svv. ? may need dobutamine. Continue sedation to\n maintain adequate ventilation. Continue current abx coverage.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Remains intubated on ac. Currently on .6x450x22+8. initial abg on\n 4 7.25/43.139 on ac: 1.0x500x16+5. FI02 was decreased to 60%\n with rate from 16 to 22, tidal volume decreased to 450 and peep up to\n 8. repeat abg: 7.23/41/76. no vent changes were made with repeat abg:\n 7.25/37/94. maintaining 02 sats in mid to upper 90s. lungs cta and\n diminished at bases. Suctioned for small amt tan thick secretions. Sent\n for sputum cx. bld cx x1 was sent in er. Urine cx sent as well.\n Initially t max 103 at .\n Action:\n Awaiting plan from team for ph goal for patient. No further vent\n changes made at this time per team. On iv abx ; aztreonam added.\n Response:\n Maintaining adequate 02 sats, currently afebrile, remains acidotic,\n awaiting further vent changes.\n Plan:\n Continue current vent settings and team discussing goal of ph, adjust\n vent settings accordingly. Iv abx, monitor micro data.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rising creatinine up to 2.0 from baseline of .6. decreasing u.o. in\n setting of sepsis. Currently tanked up with 9 liters lvf, on levophed\n to maintain map goal >65. pm k 3.3 from 4.1.\n Action:\n Continue to monitor creatinine, u.o., titrate levophed to maintain map\n >65.\n Response:\n Continues with hypotension requiring increased levophed drip. Continues\n with rising creatinine.\n Plan:\n Continue to tittate levophed to maintain map >65. monitor creatinine\n level and urine output. Awaiting order for k repletion.\n ------ Protected Section ------\n K 3.3. being repleted currently with 20 meq kcl. Will require total of\n 80 meq iv kcl per ss. Currently cvp 7, map 63, u;o. borderline low.\n Receiving another lr bolus. Also titrated fentanyl down to 75mcg/hr\n and versed to 2mg/hr as pt is very sedated now not moving extremities.\n This also may help her hypotension. Will also need to replete magnesium\n and phosphate. Md team to order.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:08 ------\n" }, { "category": "Nursing", "chartdate": "2192-08-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341874, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. Per EMS notes her\n initial vitals in the field were T: 99.7 BP: 232/125 HR: 124 RR: 24 O2:\n 63% on 2L. She wa noted to be slow to respond and diaphrestic. She\n was suctioned with large amounts of secretions. Foley catheter was\n placed with 100 cc dark urine.\n In the emergency room her initial vitals were T: 103 HR: 130 BP: 114/89\n RR: 17 O2: 96% on 100% O2. She was emergently intubated. Her initial\n labs were notable for a WBC count of 3.2, band count of 23. Her\n initial blood gas was 7.21/40/96/17. Her creatinine was elevated at\n 2.0. She was started on vancomycin, levofloxacin and ceftriaxone. She\n received 3.5 liters of normal saline with a fourth bag hanging at the\n time of transfer.\n On 4, her sbp ranging in 90s-100s with cvp 4. pt received total\n of 7 liters ns and 2 liters lr. Sbp dropped to 60s when repositioned at\n 16:00. started on levophed. Cvp now . cardiac output 3.9, svv 5.\n pt tanked per svv, thus will continue levophed and avoid further ivf at\n this time. ? may need dobutamine.\n Sepsis without organ dysfunction\n Assessment:\n Sbp ranging 90s-100s initially at beginning of shift. R ij tlcl placed\n at bedside and confirmed via cxr. Aline also placed. Cvp from 4 up to\n 11. u.o. trending down as low as 27cc/hr. vigeleo monitor hooked up to\n monitor cardiac output, CI, and SVV. Ekg without sig. change md\n team, cardiac enzymes cycling. Afebrile. Pt feels very cool and clammy\n at extremities, warm at forehead and core of body. Ionized calcium .97.\n remains sedated on fentanyl 100mcg/hr and versed 3mg/hr. opens eyes at\n times and mae but appears comfortable. Bilat wrist restraints\n maintained for safety. + bld cx for gm negative rods from a peripheral\n blood draw.\n Action:\n Given total of 9 liters ivf with cvp up to 11. calcium repleted with 2\n gm calcium gluconate.\n Response:\n Sbp dropped to 60s when repositioned. Remained at 70s-80s supine.\n Started on levophed and titrated to maintain goal map of 65. cardiac\n output remains low at 3.8 to 3.6. svv remains low at 5 to 3. urine\n output remains marginal.\n Plan:\n Titrate levophed to maintain goal map >65. monitor cardiac output,\n cardiac index, svv. ? may need dobutamine. Continue sedation to\n maintain adequate ventilation. Continue current abx coverage.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Remains intubated on ac. Currently on .6x450x22+8. initial abg on\n 4 7.25/43.139 on ac: 1.0x500x16+5. FI02 was decreased to 60%\n with rate from 16 to 22, tidal volume decreased to 450 and peep up to\n 8. repeat abg: 7.23/41/76. no vent changes were made with repeat abg:\n 7.25/37/94. maintaining 02 sats in mid to upper 90s. lungs cta and\n diminished at bases. Suctioned for small amt tan thick secretions. Sent\n for sputum cx. bld cx x1 was sent in er. Urine cx sent as well.\n Initially t max 103 at .\n Action:\n Awaiting plan from team for ph goal for patient. No further vent\n changes made at this time per team. On iv abx ; aztreonam added.\n Response:\n Maintaining adequate 02 sats, currently afebrile, remains acidotic,\n awaiting further vent changes.\n Plan:\n Continue current vent settings and team discussing goal of ph, adjust\n vent settings accordingly. Iv abx, monitor micro data.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rising creatinine up to 2.0 from baseline of .6. decreasing u.o. in\n setting of sepsis. Currently tanked up with 9 liters lvf, on levophed\n to maintain map goal >65. pm k 3.3 from 4.1.\n Action:\n Continue to monitor creatinine, u.o., titrate levophed to maintain map\n >65.\n Response:\n Continues with hypotension requiring increased levophed drip. Continues\n with rising creatinine.\n Plan:\n Continue to tittate levophed to maintain map >65. monitor creatinine\n level and urine output. Awaiting order for k repletion.\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341949, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n Sepsis without organ dysfunction\n Assessment:\n MAP ranged 62 to 71 w/systolic BP >90/ @ all times. Absent bowel\n sounds until 0400 . 170cc gastric residual of mixed undigested\n tube feedings & bilious fluid.@ ; 260cc residual @ 0400. On\n Vigileo, CO:3.4-3.9 CI: 2.0-2.1 SVR (per computer): 1,190\n 1,394.\n CVP: . Feet & hands cold. Ax temp 95.8\n 98.3. Lactate improved\n from 5.3 down to 4.9\n Action:\n Titrated levophed from 0.15-0.22 mcg/kg/min for MAP <65. Given 1L LR\n boluses X 4 overnight, for a total of 13 liters IVF since arrival in\n EW. Given 500cc albumin 5% for serum albumin 1.8. Tube feedings\n held. B DP\ns & PT\ns dopplerable. On & off Bair Hugger to maintain\n temp.\n Response:\n Maintained MAP>65.\n Plan:\n Titrate levophed to maintain MAP>65. Add vasopressin as next pressor\n when required. NPO until residual is <150cc.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs are clear w/diminished breath sounds @ bases. Sx\ned for small to\n scant amounts thick tan secretions q 4 hrs. ON A/C 60%/Vt 500/ RR 22/\n 8 PEEP.\n Action:\n ABG\ns @ 0200: 7.29/34/72\n Response:\n Repeat ABG\ns @ 0500: 7.30/33/99\n Plan:\n CXR done this am ().\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 11-30cc/hr BUN 26 (23) Cr 1.6 (1.4) Urine is cloudy\n w/sediment. UA as above.\n Action:\n Given LR boluses X 4 for u/o as well as BP. Maintenance IVF @ 150cc/hr\n as well.\n Response:\n Poor u/o.\n Plan:\n Continue to monitor u/o. Give fluid as needed.\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.3 Ca 6.0 (adjusted for low serum albumin: Ca:7.5) albumin\n 1.8 Mg 1.2 PO4:2.1 Na 146\n Action:\n Repleted w/80 mEq KCl IV in divided doses. Repleted w/4 Gm magnesium\n sulfate IV. Given 500cc albumin 5%. Repleted w/2 GM Ca gluconate IV.\n Given 2 packets neutraphos.\n Response:\n After repletion: K 6.0 Ca 6.8 (adjusted Ca: 8.0) Mg\n 2.7 PO4 2.9\n Plan:\n Follow labs. Replete w/care in this patient w/poor renal function.\n Two hours later, K=5.9, Mg 2.1, Ca 6.6, Na unchanged, PO4 2.7\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341952, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n Sepsis without organ dysfunction\n Assessment:\n MAP ranged 62 to 71 w/systolic BP >90/ @ all times. Absent bowel\n sounds until 0400 . 170cc gastric residual of mixed undigested\n tube feedings & bilious fluid.@ ; 260cc residual @ 0400. On\n Vigileo, CO:3.4-3.9 CI: 2.0-2.1 SVR (per computer): 1,190\n 1,394.\n CVP: . Feet & hands cold. Ax temp 95.8\n 98.3. Lactate improved\n from 5.3 down to 4.9\n Action:\n Titrated levophed from 0.15-0.22 mcg/kg/min for MAP <65. Given 1L LR\n boluses X 4 overnight, for a total of 13 liters IVF since arrival in\n EW. Given 500cc albumin 5% for serum albumin 1.8. Tube feedings\n held. B DP\ns & PT\ns dopplerable. On & off Bair Hugger to maintain\n temp.\n Response:\n Maintained MAP>65.\n Plan:\n Titrate levophed to maintain MAP>65. Add vasopressin as next pressor\n when required. NPO.. Evaluate patient for potential ileus.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs are clear w/diminished breath sounds @ bases. Sx\ned for small to\n scant amounts thick tan secretions q 4 hrs. ON A/C 60%/Vt 500/ RR 22/\n 8 PEEP.\n Action:\n ABG\ns @ 0200: 7.29/34/72\n Response:\n Repeat ABG\ns @ 0500: 7.30/33/99\n Plan:\n CXR done this am ().\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 11-30cc/hr BUN 26 (23) Cr 1.6 (1.4) Urine is cloudy\n w/sediment. UA as above.\n Action:\n Given LR boluses X 4 for u/o as well as BP. Maintenance IVF @ 150cc/hr\n as well.\n Response:\n Poor u/o.\n Plan:\n Continue to monitor u/o. Give fluid as needed.\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.3 Ca 6.0 (adjusted for low serum albumin: Ca:7.5) albumin\n 1.8 Mg 1.2 PO4:2.1 Na 146\n Action:\n Repleted w/80 mEq KCl IV in divided doses. Repleted w/4 Gm magnesium\n sulfate IV. Given 500cc albumin 5%. Repleted w/2 GM Ca gluconate IV.\n Given 2 packets neutraphos.\n Response:\n After repletion: K 6.0 Ca 6.8 (adjusted Ca: 8.0) Mg\n 2.7 PO4 2.9\n Plan:\n Follow labs. Replete w/care in this patient w/poor renal function.\n Two hours later, K=5.9, Mg 2.1, Ca 6.6, Na unchanged, PO4 2.7 Follow\n serum K.\n" }, { "category": "Nursing", "chartdate": "2192-08-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341867, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. Per EMS notes her\n initial vitals in the field were T: 99.7 BP: 232/125 HR: 124 RR: 24 O2:\n 63% on 2L. She wa noted to be slow to respond and diaphrestic. She\n was suctioned with large amounts of secretions. Foley catheter was\n placed with 100 cc dark urine.\n In the emergency room her initial vitals were T: 103 HR: 130 BP: 114/89\n RR: 17 O2: 96% on 100% O2. She was emergently intubated. Her initial\n labs were notable for a WBC count of 3.2, band count of 23. Her\n initial blood gas was 7.21/40/96/17. Her creatinine was elevated at\n 2.0. She was started on vancomycin, levofloxacin and ceftriaxone. She\n received 3.5 liters of normal saline with a fourth bag hanging at the\n time of transfer.\n On 4, her sbp ranging in 90s-100s with cvp 4. pt received total\n of 7 liters ns and 2 liters lr. Sbp dropped to 60s when repositioned at\n 16:00. started on levophed. Cvp now . cardiac output 3.9, svv 5.\n pt tanked per svv, thus will continue levophed and avoid further ivf at\n this time. ? may need dobutamine.\n Sepsis without organ dysfunction\n Assessment:\n Sbp ranging 90s-100s initially at beginning of shift. R ij tlcl placed\n at bedside and confirmed via cxr. Aline also placed. Cvp from 4 up to\n 11. u.o. trending down as low as 27cc/hr. vigeleo monitor hooked up to\n monitor cardiac output, CI, and SVV. Ekg without sig. change md\n team, cardiac enzymes cycling.\n Action:\n Given total of 9 liters ivf with cvp up to 11.\n Response:\n Sbp dropped to 60s when repositioned. Remained at 70s-80s supine.\n Started on levophed and titrated to maintain goal map of 65. cardiac\n output remains low at 3.8 to 3.6. svv remains low at 5 to 3. urine\n output remains marginal.\n Plan:\n Titrate levophed to maintain goal map >65. monitor cardiac output,\n cardiac index, svv. ? may need dobutamine.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Remains intubated on ac. Currently on .6x450x22+8.\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2192-08-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341869, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. Per EMS notes her\n initial vitals in the field were T: 99.7 BP: 232/125 HR: 124 RR: 24 O2:\n 63% on 2L. She wa noted to be slow to respond and diaphrestic. She\n was suctioned with large amounts of secretions. Foley catheter was\n placed with 100 cc dark urine.\n In the emergency room her initial vitals were T: 103 HR: 130 BP: 114/89\n RR: 17 O2: 96% on 100% O2. She was emergently intubated. Her initial\n labs were notable for a WBC count of 3.2, band count of 23. Her\n initial blood gas was 7.21/40/96/17. Her creatinine was elevated at\n 2.0. She was started on vancomycin, levofloxacin and ceftriaxone. She\n received 3.5 liters of normal saline with a fourth bag hanging at the\n time of transfer.\n On 4, her sbp ranging in 90s-100s with cvp 4. pt received total\n of 7 liters ns and 2 liters lr. Sbp dropped to 60s when repositioned at\n 16:00. started on levophed. Cvp now . cardiac output 3.9, svv 5.\n pt tanked per svv, thus will continue levophed and avoid further ivf at\n this time. ? may need dobutamine.\n Sepsis without organ dysfunction\n Assessment:\n Sbp ranging 90s-100s initially at beginning of shift. R ij tlcl placed\n at bedside and confirmed via cxr. Aline also placed. Cvp from 4 up to\n 11. u.o. trending down as low as 27cc/hr. vigeleo monitor hooked up to\n monitor cardiac output, CI, and SVV. Ekg without sig. change md\n team, cardiac enzymes cycling.\n Action:\n Given total of 9 liters ivf with cvp up to 11.\n Response:\n Sbp dropped to 60s when repositioned. Remained at 70s-80s supine.\n Started on levophed and titrated to maintain goal map of 65. cardiac\n output remains low at 3.8 to 3.6. svv remains low at 5 to 3. urine\n output remains marginal.\n Plan:\n Titrate levophed to maintain goal map >65. monitor cardiac output,\n cardiac index, svv. ? may need dobutamine.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Remains intubated on ac. Currently on .6x450x22+8. initial abg on\n 4 7.25/43.139 on ac: 1.0x450x16+5. FI02 was decreased to 60%\n with rate from 16 to 22 and peep up to 8. repeat abg: 7.23/41/76.\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2192-08-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341864, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. Per EMS notes her\n initial vitals in the field were T: 99.7 BP: 232/125 HR: 124 RR: 24 O2:\n 63% on 2L. She wa noted to be slow to respond and diaphrestic. She\n was suctioned with large amounts of secretions. Foley catheter was\n placed with 100 cc dark urine.\n In the emergency room her initial vitals were T: 103 HR: 130 BP: 114/89\n RR: 17 O2: 96% on 100% O2. She was emergently intubated. Her initial\n labs were notable for a WBC count of 3.2, band count of 23. Her\n initial blood gas was 7.21/40/96/17. Her creatinine was elevated at\n 2.0. She was started on vancomycin, levofloxacin and ceftriaxone. She\n received 3.5 liters of normal saline with a fourth bag hanging at the\n time of transfer.\n On 4, her sbp ranging in 90s-100s with cvp 4. pt received total\n of 7 liters ns and 2 liters lr. Sbp dropped to 60s when repositioned at\n 16:00. started on levophed. Cvp now . cardiac output 3.9, svv 5.\n pt tanked per svv, thus will continue levophed and avoid further ivf at\n this time. ? may need dobutamine.\n Sepsis without organ dysfunction\n Assessment:\n Sbp ranging 90s-100s initially at beginning of shift. R ij tlcl placed\n at bedside and confirmed via cxr. Aline also placed. Cvp from 4 up to\n 11. u.o. trending down as low as 27cc/hr. vigeleo monitor hooked up to\n monitor cardiac output, CI, and SVV.\n Action:\n Given total of 9 liters ivf with cvp up to 11.\n Response:\n Plan:\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341929, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n Sepsis without organ dysfunction\n Assessment:\n MAP ranged 62 to 71 w/systolic BP >90/ @ all times. Absent bowel\n sounds until 0400 . 170cc gastric residual of mixed undigested\n tube feedings & bilious fluid.@ . On Vigileo, CO:3.4-3.9 CI:\n 2.0-2.1 SVR (per computer): 1,190\n 1,394. CVP: . Feet & hands\n cold. Ax temp 95.8\n 98.3.\n Action:\n Titrated levophed from 0.15-0.22 mcg/kg/min for MAP <65. Given 1L LR\n boluses X 4 overnight, for a total of 13 liters IVF since arrival in\n EW. Given 500cc albumin 5% for serum albumin 1.8. Tube feedings\n held. B DP\ns & PT\ns dopplerable. On & off Bair Hugger to maintain\n temp.\n Response:\n Maintained MAP>65.\n Plan:\n Titrate levophed to maintain MAP>65. Add vasopressin as next pressor\n when required.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs are clear w/diminished breath sounds @ bases. Sx\ned for small to\n scant amounts thick tan secretions q 4 hrs. ON A/C 60%/Vt 500/ RR 22/\n 8 PEEP.\n Action:\n ABG\ns @ 0200: 7.29/34/72\n Response:\n Repeat ABG\ns @ 0500: 7.30/33/99\n Plan:\n CXR done this am ().\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 11-30cc/hr BUN 26 (23) Cr 1.6 (1.4) Urine is cloudy\n w/sediment. UA as above.\n Action:\n Given LR boluses X 4 for u/o as well as BP. Maintenance IVF @ 150cc/hr\n as well.\n Response:\n Poor u/o.\n Plan:\n Continue to monitor u/o. Give fluid as needed. Consider dopamine?\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.3 Ca 6.0 (adjusted for low serum albumin: Ca:7.5) albumin\n 1.8 Mg 1.2 PO4:2.1\n Action:\n Repleted w/80 mEq KCl IV in divided doses. Repleted w/4 Gm magnesium\n sulfate IV. Given 500cc albumin 5%. Repleted w/2 GM Ca gluconate IV.\n Given 2 packets neutraphos.\n Response:\n After repletion: K 6.0 Ca 6.8 (adjusted Ca: 8.0) Mg\n 2.7 PO4 2.9\n Plan:\n Follow labs. Replete w/care in this patient w/poor renal function.\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341931, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n Sepsis without organ dysfunction\n Assessment:\n MAP ranged 62 to 71 w/systolic BP >90/ @ all times. Absent bowel\n sounds until 0400 . 170cc gastric residual of mixed undigested\n tube feedings & bilious fluid.@ ; 260cc residual @ 0400. On\n Vigileo, CO:3.4-3.9 CI: 2.0-2.1 SVR (per computer): 1,190\n 1,394.\n CVP: . Feet & hands cold. Ax temp 95.8\n 98.3. Lactate improved\n from 5.3 down to 4.9\n Action:\n Titrated levophed from 0.15-0.22 mcg/kg/min for MAP <65. Given 1L LR\n boluses X 4 overnight, for a total of 13 liters IVF since arrival in\n EW. Given 500cc albumin 5% for serum albumin 1.8. Tube feedings\n held. B DP\ns & PT\ns dopplerable. On & off Bair Hugger to maintain\n temp.\n Response:\n Maintained MAP>65.\n Plan:\n Titrate levophed to maintain MAP>65. Add vasopressin as next pressor\n when required. NPO.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs are clear w/diminished breath sounds @ bases. Sx\ned for small to\n scant amounts thick tan secretions q 4 hrs. ON A/C 60%/Vt 500/ RR 22/\n 8 PEEP.\n Action:\n ABG\ns @ 0200: 7.29/34/72\n Response:\n Repeat ABG\ns @ 0500: 7.30/33/99\n Plan:\n CXR done this am ().\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 11-30cc/hr BUN 26 (23) Cr 1.6 (1.4) Urine is cloudy\n w/sediment. UA as above.\n Action:\n Given LR boluses X 4 for u/o as well as BP. Maintenance IVF @ 150cc/hr\n as well.\n Response:\n Poor u/o.\n Plan:\n Continue to monitor u/o. Give fluid as needed. Consider dopamine?\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.3 Ca 6.0 (adjusted for low serum albumin: Ca:7.5) albumin\n 1.8 Mg 1.2 PO4:2.1\n Action:\n Repleted w/80 mEq KCl IV in divided doses. Repleted w/4 Gm magnesium\n sulfate IV. Given 500cc albumin 5%. Repleted w/2 GM Ca gluconate IV.\n Given 2 packets neutraphos.\n Response:\n After repletion: K 6.0 Ca 6.8 (adjusted Ca: 8.0) Mg\n 2.7 PO4 2.9\n Plan:\n Follow labs. Replete w/care in this patient w/poor renal function.\n" }, { "category": "Respiratory ", "chartdate": "2192-08-18 00:00:00.000", "description": "Generic Note", "row_id": 341934, "text": "TITLE:\n Respiratory Care:\n Pt remains intubated and vented. See flowsheet for changes. Continues\n with met acidosis. Suctioned scant secretions. Pip\ns occaisionally\n high. Will continue with present settings, and follow abg\n" }, { "category": "Nursing", "chartdate": "2192-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342035, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, baseline dementia, and hypertension who presented on early\n am from after being found to be in respiratory distress\n with oxygen saturations in the 70s to 80\ns on r/a. Her EKG per report\n was within normal limits. Her exam was notable for audible rales and\n abdominal distension. Foley catheter was placed with 100 cc dark\n urine. Sent to EW, where she was emergently Intubated. T103.\n Code sepsis not initiated as BP >100/systolic. Peripheral BC from EW\n grew 4 out of 4 bottles positive for gram negative rods. Urine Cx\n () grew nothing yet. UA from EW shows many bacti but UA from later\n in the day shows few. Sputum Cx shows many organisms consistent\n w/oropharyngeal flora. Became hypotensive in MICU on afternoon,\n received fluid boluses & levophed IV. Treated w/IV levofloxacin, vanco\n aztreonam &genta. Lactate 9.0 on admission.\n Sepsis without organ dysfunction\n Assessment:\n Lactate down to low of 3.o on . MAP 64-78. Systolic BP\n 90\ns-130\ns/. CVP: CO: 3.4-3.5 CI: 2 SVR: 1,221-\n Action:\n Finished 2^nd liter D5\n NS. Titrated levophed down to 0.1\n mcg/kg/min. Levophed off X45min.\n Response:\n MAP maintained >65\n Plan:\n Continue to maintain MAP>65.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs: clear, diminished @ bases. Sx\ned scant thick tan secretions to\n none q 4 hrs. On CPAP 40%/ 8 PEEP/ 12 PS since 2130 .\n Action:\n ABG\ns: 7.31/ 27/96\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2192-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342036, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, baseline dementia, and hypertension who presented on early\n am from after being found to be in respiratory distress\n with oxygen saturations in the 70s to 80\ns on r/a. Her EKG per report\n was within normal limits. Her exam was notable for audible rales and\n abdominal distension. Foley catheter was placed with 100 cc dark\n urine. Sent to EW, where she was emergently Intubated. T103.\n Code sepsis not initiated as BP >100/systolic. Peripheral BC from EW\n grew 4 out of 4 bottles positive for gram negative rods. Urine Cx\n () grew nothing yet. UA from EW shows many bacti but UA from later\n in the day shows few. Sputum Cx shows many organisms consistent\n w/oropharyngeal flora. Became hypotensive in MICU on afternoon,\n received fluid boluses & levophed IV. Treated w/IV levofloxacin, vanco\n aztreonam &genta. Lactate 9.0 on admission.\n Sepsis without organ dysfunction\n Assessment:\n Lactate down to low of 3.o on . MAP 64-78. Systolic BP\n 90\ns-130\ns/. HR: 70\ns-80\ns SR no ectopy. CVP: CO: 3.4-3.5\n CI: 2 SVR: 1,221- 1,624.\n Action:\n Finished 2^nd liter D5\n NS. Titrated levophed down to 0.1\n mcg/kg/min. Levophed off X45min.\n Response:\n MAP maintained >65\n Plan:\n Continue to maintain MAP>65.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs: clear, diminished @ bases. Sx\ned scant thick tan secretions to\n none q 4 hrs. On CPAP 40%/ 8 PEEP/ 12 PS since 2130 . Continued\n on fentanyl 50mcg/hr & versed 1mg/hr.\n Action:\n ABG\ns: 7.31/ 27/96 on CPAP\n Response:\n ABG\ns w/am labs:\n Plan:\n Await RSBI in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 30-50cc/hr cloudy yellow urine w/sediment. BUN Cr\n Action:\n Received D5\n NS @ 125cc/hr overnight. Levophed titrated down.\n Response:\n Patient is beginning to turn corner w/sepsis, thereby perfusing kidneys\n more efficiently.\n Plan:\n Continue to follow electrolytes & BUN/Cr. Continue to monitor u/o.\n" }, { "category": "Nursing", "chartdate": "2192-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342037, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, baseline dementia, and hypertension who presented on early\n am from after being found to be in respiratory distress\n with oxygen saturations in the 70s to 80\ns on r/a. Her EKG per report\n was within normal limits. Her exam was notable for audible rales and\n abdominal distension. Foley catheter was placed with 100 cc dark\n urine. Sent to EW, where she was emergently Intubated. T103.\n Code sepsis not initiated as BP >100/systolic. Peripheral BC from EW\n grew 4 out of 4 bottles positive for gram negative rods. Urine Cx\n () grew nothing yet. UA from EW shows many bacti but UA from later\n in the day shows few. Sputum Cx shows many organisms consistent\n w/oropharyngeal flora. Became hypotensive in MICU on afternoon,\n received fluid boluses & levophed IV. Treated w/IV levofloxacin, vanco\n aztreonam &genta. Lactate 9.0 on admission.\n Sepsis without organ dysfunction\n Assessment:\n Lactate down to low of 3.o on . MAP 64-78. Systolic BP\n 90\ns-130\ns/. HR: 70\ns-80\ns SR no ectopy. CVP: CO: 3.4-3.5\n CI: 2 SVR: 1,221- 1,624.\n Action:\n Finished 2^nd liter D5\n NS. Titrated levophed down to 0.1\n mcg/kg/min. Levophed off X45min.\n Response:\n MAP maintained >65\n Plan:\n Continue to maintain MAP>65. Continue to titrate levophed down.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs: clear, diminished @ bases. Sx\ned scant thick tan secretions to\n none q 4 hrs. On CPAP 40%/ 8 PEEP/ 12 PS since 2130 . Continued\n on fentanyl 50mcg/hr & versed 1mg/hr.\n Action:\n ABG\ns: 7.31/ 27/96 on CPAP\n Response:\n ABG\ns w/am labs:\n Plan:\n Await RSBI in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 30-50cc/hr cloudy yellow urine w/sediment. BUN 28 Cr 1.6\n Action:\n Received D5\n NS @ 125cc/hr overnight. Levophed titrated down.\n Response:\n Patient is beginning to turn corner w/sepsis, thereby perfusing kidneys\n more efficiently.\n Plan:\n Continue to follow electrolytes & BUN/Cr. Continue to monitor u/o.\n" }, { "category": "Nursing", "chartdate": "2192-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342039, "text": "Mrs. is an 82 year old female with a history of breast CA (s/p\n XRT), CVA, baseline dementia, HTN, reflux, & recurrent UTI\ns, who\n presented on early am from after being found to be\n in respiratory distress with oxygen sats in 70s to 80\ns on r/a. Her\n EKG per report was within normal limits. Her exam was notable for\n audible rales and abdominal distension. Foley catheter was placed with\n 100 cc dark urine. Sent to EW, where she was emergently\n Intubated. T103. Code sepsis not initiated as BP >100/systolic.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Urine Cx () grew nothing yet. UA from EW shows\n many bacti but UA from later in the day shows few. Sputum Cx shows\n many organisms consistent w/oropharyngeal flora. Became hypotensive in\n MICU on afternoon, received fluid boluses & levophed IV. Treated\n w/IV levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission.\n Sepsis without organ dysfunction\n Assessment:\n Lactate down to low of 3.o on . MAP 64-78. Systolic BP\n 90\ns-130\ns/. HR: 70\ns-80\ns SR no ectopy. CVP: CO: 3.4-3.5\n CI: 2 SVR: 1,221- 1,624.\n Action:\n Finished 2^nd liter D5\n NS. Titrated levophed down to 0.1\n mcg/kg/min. Levophed off X45min.\n Response:\n MAP maintained >65\n Plan:\n Continue to maintain MAP>65. Continue to titrate levophed down.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs: clear, diminished @ bases. Sx\ned scant thick tan secretions to\n none q 4 hrs. On CPAP 40%/ 8 PEEP/ 12 PS since 2130 . Continued\n on fentanyl 50mcg/hr & versed 1mg/hr.\n Action:\n ABG\ns: 7.31/ 27/96 on CPAP\n Response:\n ABG\ns w/am labs:\n Plan:\n Await RSBI in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 30-50cc/hr cloudy yellow urine w/sediment. BUN 28 Cr 1.6\n Action:\n Received D5\n NS @ 125cc/hr overnight. Levophed titrated down.\n Response:\n Patient is beginning to turn corner w/sepsis, thereby perfusing kidneys\n more efficiently.\n Plan:\n Continue to follow electrolytes & BUN/Cr. Continue to monitor u/o.\n" }, { "category": "Respiratory ", "chartdate": "2192-08-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 342130, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation:\n Ideal body weight:\n Ideal tidal volume:\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position:\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure:\n Cuff volume:\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency:\n Sputum source/amount:\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Specialized Gas Therapy\n Nitric Oxide\n PPM used: ppm\n Indication:\n Effect of therapy: []\n Nitric Oxide trial:\n Comments:\n HeliOx:\n Additional O[2] by cannula: L/min\n Continuous nebulized bronchodilator:\n Comments:\n Recruitment Maneuvers Done\n CPAP pressure used: cm H2O\n Duration: sec\n Times per shift:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2192-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342033, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, baseline dementia, and hypertension who presented on early am\n from after being found to be in respiratory distress\n with oxygen saturations in the 70s to 80\ns on r/a. Her EKG per report\n was within normal limits. Her exam was notable for audible rales and\n abdominal distension. Foley catheter was placed with 100 cc dark\n urine. Sent to EW, where she was emergently Intubated. T103.\n Code sepsis not initiated as BP >100/systolic. Peripheral BC from EW\n grew 4 out of 4 bottles positive for gram negative rods. Urine Cx\n () grew nothing yet. UA from EW shows many bacti but UA from later\n in the day shows few. Sputum Cx shows many organisms consistent\n w/oropharyngeal flora. Became hypotensive in MICU on afternoon,\n received fluid boluses & levophed IV. Treated w/IV levofloxacin, vanco\n aztreonam &genta. Lactate 9.0 on admission.\n Sepsis without organ dysfunction\n Assessment:\n Lactate down to low of 3.o on .\n Action:\n Response:\n Plan:\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2192-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342034, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, baseline dementia, and hypertension who presented on early\n am from after being found to be in respiratory distress\n with oxygen saturations in the 70s to 80\ns on r/a. Her EKG per report\n was within normal limits. Her exam was notable for audible rales and\n abdominal distension. Foley catheter was placed with 100 cc dark\n urine. Sent to EW, where she was emergently Intubated. T103.\n Code sepsis not initiated as BP >100/systolic. Peripheral BC from EW\n grew 4 out of 4 bottles positive for gram negative rods. Urine Cx\n () grew nothing yet. UA from EW shows many bacti but UA from later\n in the day shows few. Sputum Cx shows many organisms consistent\n w/oropharyngeal flora. Became hypotensive in MICU on afternoon,\n received fluid boluses & levophed IV. Treated w/IV levofloxacin, vanco\n aztreonam &genta. Lactate 9.0 on admission.\n Sepsis without organ dysfunction\n Assessment:\n Lactate down to low of 3.o on . MAP 64-78. Systolic BP\n 90\ns-130\ns/. CVP: CO: 3.4-3.7 CI: 2-2.1 SVR:\n Action:\n Finished 2^nd liter D5\n NS. Titrated levophed down to 0.1\n mcg/kg/min. Levophed off X45min.\n Response:\n MAP maintained >65\n Plan:\n Continue to maintain MAP>65.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs: clear, diminished @ bases. Sx\ned scant thick tan secretions to\n none q 4 hrs. On CPAP 40%/ 8 PEEP/ 12 PS since 2130 .\n Action:\n ABG\ns: 7.31/ 27/96\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341911, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n Sepsis without organ dysfunction\n Assessment:\n MAP ranged 62 to 71 w/systolic BP >90/ @ all times.\n Action:\n Titrated levophed from 0.15-0.2 mcg/kg/min for MAP <65. Given 1L LR\n boluses X\n Response:\n Main\n Plan:\n Titrate levophed to maintain MAP>65. Add vasopressin as next pressor\n when required.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341912, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n Sepsis without organ dysfunction\n Assessment:\n MAP ranged 62 to 71 w/systolic BP >90/ @ all times.\n Action:\n Titrated levophed from 0.15-0.2 mcg/kg/min for MAP <65. Given 1L LR\n boluses X 4 overnight, for a total of 13 liters IVF since arrival in\n EW.\n Response:\n Maintained MAP>65.\n Plan:\n Titrate levophed to maintain MAP>65. Add vasopressin as next pressor\n when required.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs are clear w/diminished breath sounds @ bases. Sx\ned for small to\n scant amounts thick tan secretions q 4 hrs. ON A/C 60%/Vt 500/ RR 22/\n 8 PEEP.\n Action:\n ABG\ns @ 0200: 7.29/34/72\n Response:\n Repeat ABG\ns @ 0500:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341913, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n Sepsis without organ dysfunction\n Assessment:\n MAP ranged 62 to 71 w/systolic BP >90/ @ all times. Absent bowel\n sounds. 170cc gastric residual of mixed undigested tube feedings &\n bilious fluid.@ .\n Action:\n Titrated levophed from 0.15-0.2 mcg/kg/min for MAP <65. Given 1L LR\n boluses X 4 overnight, for a total of 13 liters IVF since arrival in\n EW. Given 500cc albumin 5% for serum albumin 1.8. Tube feedings\n held.\n Response:\n Maintained MAP>65.\n Plan:\n Titrate levophed to maintain MAP>65. Add vasopressin as next pressor\n when required.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs are clear w/diminished breath sounds @ bases. Sx\ned for small to\n scant amounts thick tan secretions q 4 hrs. ON A/C 60%/Vt 500/ RR 22/\n 8 PEEP.\n Action:\n ABG\ns @ 0200: 7.29/34/72\n Response:\n Repeat ABG\ns @ 0500:\n Plan:\n CXR done this am ().\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 11-30cc/hr BUN Cr Urine is cloudy w/sediment. UA as\n above.\n Action:\n Given LR boluses X 4 for u/o as well as BP. Maintenance IVF @ 150cc/hr\n as well.\n Response:\n Poor u/o.\n Plan:\n Continue to monitor u/o. Give fluid as needed. Consider dopamine?\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341914, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n Sepsis without organ dysfunction\n Assessment:\n MAP ranged 62 to 71 w/systolic BP >90/ @ all times. Absent bowel\n sounds. 170cc gastric residual of mixed undigested tube feedings &\n bilious fluid.@ . On Viileo, CO:3.4-3.9 CI: 2.0-2.1 SVR (per\n computer):\n Action:\n Titrated levophed from 0.15-0.2 mcg/kg/min for MAP <65. Given 1L LR\n boluses X 4 overnight, for a total of 13 liters IVF since arrival in\n EW. Given 500cc albumin 5% for serum albumin 1.8. Tube feedings\n held.\n Response:\n Maintained MAP>65.\n Plan:\n Titrate levophed to maintain MAP>65. Add vasopressin as next pressor\n when required.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs are clear w/diminished breath sounds @ bases. Sx\ned for small to\n scant amounts thick tan secretions q 4 hrs. ON A/C 60%/Vt 500/ RR 22/\n 8 PEEP.\n Action:\n ABG\ns @ 0200: 7.29/34/72\n Response:\n Repeat ABG\ns @ 0500:\n Plan:\n CXR done this am ().\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 11-30cc/hr BUN Cr Urine is cloudy w/sediment. UA as\n above.\n Action:\n Given LR boluses X 4 for u/o as well as BP. Maintenance IVF @ 150cc/hr\n as well.\n Response:\n Poor u/o.\n Plan:\n Continue to monitor u/o. Give fluid as needed. Consider dopamine?\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341915, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n Sepsis without organ dysfunction\n Assessment:\n MAP ranged 62 to 71 w/systolic BP >90/ @ all times. Absent bowel\n sounds. 170cc gastric residual of mixed undigested tube feedings &\n bilious fluid.@ . On Viileo, CO:3.4-3.9 CI: 2.0-2.1 SVR (per\n computer): 1,190\n 1,394. CVP: . Feet & hands cold. Ax temp\n 95.8-97.\n Action:\n Titrated levophed from 0.15-0.2 mcg/kg/min for MAP <65. Given 1L LR\n boluses X 4 overnight, for a total of 13 liters IVF since arrival in\n EW. Given 500cc albumin 5% for serum albumin 1.8. Tube feedings\n held. B DP\ns & PT\ns dopplerable. On & off Bair Hugger to maintain\n temp.\n Response:\n Maintained MAP>65.\n Plan:\n Titrate levophed to maintain MAP>65. Add vasopressin as next pressor\n when required.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs are clear w/diminished breath sounds @ bases. Sx\ned for small to\n scant amounts thick tan secretions q 4 hrs. ON A/C 60%/Vt 500/ RR 22/\n 8 PEEP.\n Action:\n ABG\ns @ 0200: 7.29/34/72\n Response:\n Repeat ABG\ns @ 0500:\n Plan:\n CXR done this am ().\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 11-30cc/hr BUN Cr Urine is cloudy w/sediment. UA as\n above.\n Action:\n Given LR boluses X 4 for u/o as well as BP. Maintenance IVF @ 150cc/hr\n as well.\n Response:\n Poor u/o.\n Plan:\n Continue to monitor u/o. Give fluid as needed. Consider dopamine?\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341916, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n Sepsis without organ dysfunction\n Assessment:\n MAP ranged 62 to 71 w/systolic BP >90/ @ all times. Absent bowel\n sounds. 170cc gastric residual of mixed undigested tube feedings &\n bilious fluid.@ . On Viileo, CO:3.4-3.9 CI: 2.0-2.1 SVR (per\n computer): 1,190\n 1,394. CVP: . Feet & hands cold. Ax temp\n 95.8-97.\n Action:\n Titrated levophed from 0.15-0.2 mcg/kg/min for MAP <65. Given 1L LR\n boluses X 4 overnight, for a total of 13 liters IVF since arrival in\n EW. Given 500cc albumin 5% for serum albumin 1.8. Tube feedings\n held. B DP\ns & PT\ns dopplerable. On & off Bair Hugger to maintain\n temp.\n Response:\n Maintained MAP>65.\n Plan:\n Titrate levophed to maintain MAP>65. Add vasopressin as next pressor\n when required.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs are clear w/diminished breath sounds @ bases. Sx\ned for small to\n scant amounts thick tan secretions q 4 hrs. ON A/C 60%/Vt 500/ RR 22/\n 8 PEEP.\n Action:\n ABG\ns @ 0200: 7.29/34/72\n Response:\n Repeat ABG\ns @ 0500:\n Plan:\n CXR done this am ().\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 11-30cc/hr BUN 26 (23) Cr 1.6 (1.4) Urine is cloudy\n w/sediment. UA as above.\n Action:\n Given LR boluses X 4 for u/o as well as BP. Maintenance IVF @ 150cc/hr\n as well.\n Response:\n Poor u/o.\n Plan:\n Continue to monitor u/o. Give fluid as needed. Consider dopamine?\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341917, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n Sepsis without organ dysfunction\n Assessment:\n MAP ranged 62 to 71 w/systolic BP >90/ @ all times. Absent bowel\n sounds. 170cc gastric residual of mixed undigested tube feedings &\n bilious fluid.@ . On Viileo, CO:3.4-3.9 CI: 2.0-2.1 SVR (per\n computer): 1,190\n 1,394. CVP: . Feet & hands cold. Ax temp\n 95.8-97.\n Action:\n Titrated levophed from 0.15-0.2 mcg/kg/min for MAP <65. Given 1L LR\n boluses X 4 overnight, for a total of 13 liters IVF since arrival in\n EW. Given 500cc albumin 5% for serum albumin 1.8. Tube feedings\n held. B DP\ns & PT\ns dopplerable. On & off Bair Hugger to maintain\n temp.\n Response:\n Maintained MAP>65.\n Plan:\n Titrate levophed to maintain MAP>65. Add vasopressin as next pressor\n when required.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs are clear w/diminished breath sounds @ bases. Sx\ned for small to\n scant amounts thick tan secretions q 4 hrs. ON A/C 60%/Vt 500/ RR 22/\n 8 PEEP.\n Action:\n ABG\ns @ 0200: 7.29/34/72\n Response:\n Repeat ABG\ns @ 0500:\n Plan:\n CXR done this am ().\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 11-30cc/hr BUN 26 (23) Cr 1.6 (1.4) Urine is cloudy\n w/sediment. UA as above.\n Action:\n Given LR boluses X 4 for u/o as well as BP. Maintenance IVF @ 150cc/hr\n as well.\n Response:\n Poor u/o.\n Plan:\n Continue to monitor u/o. Give fluid as needed. Consider dopamine?\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.3 Ca 6.0 (adjusted for low serum albumin: Ca:7.5) albumin\n 1.8 Mg 1.2\n Action:\n Repleted w/80 mEq KCl IV in divided doses. Repleted w/4 Gm magnesium\n sulfate IV. Given 500cc albumin 5%.\n Response:\n After repletion: K 6.0 Ca 6.8 (adjusted Ca: 8.0) Mg 2.7\n Plan:\n Follow labs. Replete w/care in this patient w/poor renal function.\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341918, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n Sepsis without organ dysfunction\n Assessment:\n MAP ranged 62 to 71 w/systolic BP >90/ @ all times. Absent bowel\n sounds. 170cc gastric residual of mixed undigested tube feedings &\n bilious fluid.@ . On Viileo, CO:3.4-3.9 CI: 2.0-2.1 SVR (per\n computer): 1,190\n 1,394. CVP: . Feet & hands cold. Ax temp\n 95.8-97.\n Action:\n Titrated levophed from 0.15-0.2 mcg/kg/min for MAP <65. Given 1L LR\n boluses X 4 overnight, for a total of 13 liters IVF since arrival in\n EW. Given 500cc albumin 5% for serum albumin 1.8. Tube feedings\n held. B DP\ns & PT\ns dopplerable. On & off Bair Hugger to maintain\n temp.\n Response:\n Maintained MAP>65.\n Plan:\n Titrate levophed to maintain MAP>65. Add vasopressin as next pressor\n when required.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs are clear w/diminished breath sounds @ bases. Sx\ned for small to\n scant amounts thick tan secretions q 4 hrs. ON A/C 60%/Vt 500/ RR 22/\n 8 PEEP.\n Action:\n ABG\ns @ 0200: 7.29/34/72\n Response:\n Repeat ABG\ns @ 0500:\n Plan:\n CXR done this am ().\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 11-30cc/hr BUN 26 (23) Cr 1.6 (1.4) Urine is cloudy\n w/sediment. UA as above.\n Action:\n Given LR boluses X 4 for u/o as well as BP. Maintenance IVF @ 150cc/hr\n as well.\n Response:\n Poor u/o.\n Plan:\n Continue to monitor u/o. Give fluid as needed. Consider dopamine?\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.3 Ca 6.0 (adjusted for low serum albumin: Ca:7.5) albumin\n 1.8 Mg 1.2 PO4:\n Action:\n Repleted w/80 mEq KCl IV in divided doses. Repleted w/4 Gm magnesium\n sulfate IV. Given 500cc albumin 5%. Repleted w/2 GM Ca gluconate IV.\n Given 2 packets neutraphos.\n Response:\n After repletion: K 6.0 Ca 6.8 (adjusted Ca: 8.0) Mg\n 2.7 PO4\n Plan:\n Follow labs. Replete w/care in this patient w/poor renal function.\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341920, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n Sepsis without organ dysfunction\n Assessment:\n MAP ranged 62 to 71 w/systolic BP >90/ @ all times. Absent bowel\n sounds. 170cc gastric residual of mixed undigested tube feedings &\n bilious fluid.@ . On Viileo, CO:3.4-3.9 CI: 2.0-2.1 SVR (per\n computer): 1,190\n 1,394. CVP: . Feet & hands cold. Ax temp\n 95.8-97.\n Action:\n Titrated levophed from 0.15-0.2 mcg/kg/min for MAP <65. Given 1L LR\n boluses X 4 overnight, for a total of 13 liters IVF since arrival in\n EW. Given 500cc albumin 5% for serum albumin 1.8. Tube feedings\n held. B DP\ns & PT\ns dopplerable. On & off Bair Hugger to maintain\n temp.\n Response:\n Maintained MAP>65.\n Plan:\n Titrate levophed to maintain MAP>65. Add vasopressin as next pressor\n when required.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs are clear w/diminished breath sounds @ bases. Sx\ned for small to\n scant amounts thick tan secretions q 4 hrs. ON A/C 60%/Vt 500/ RR 22/\n 8 PEEP.\n Action:\n ABG\ns @ 0200: 7.29/34/72\n Response:\n Repeat ABG\ns @ 0500:\n Plan:\n CXR done this am ().\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 11-30cc/hr BUN 26 (23) Cr 1.6 (1.4) Urine is cloudy\n w/sediment. UA as above.\n Action:\n Given LR boluses X 4 for u/o as well as BP. Maintenance IVF @ 150cc/hr\n as well.\n Response:\n Poor u/o.\n Plan:\n Continue to monitor u/o. Give fluid as needed. Consider dopamine?\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.3 Ca 6.0 (adjusted for low serum albumin: Ca:7.5) albumin\n 1.8 Mg 1.2 PO4:2.1\n Action:\n Repleted w/80 mEq KCl IV in divided doses. Repleted w/4 Gm magnesium\n sulfate IV. Given 500cc albumin 5%. Repleted w/2 GM Ca gluconate IV.\n Given 2 packets neutraphos.\n Response:\n After repletion: K 6.0 Ca 6.8 (adjusted Ca: 8.0) Mg\n 2.7 PO4 2.9\n Plan:\n Follow labs. Replete w/care in this patient w/poor renal function.\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341921, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n Sepsis without organ dysfunction\n Assessment:\n MAP ranged 62 to 71 w/systolic BP >90/ @ all times. Absent bowel\n sounds. 170cc gastric residual of mixed undigested tube feedings &\n bilious fluid.@ . On Viileo, CO:3.4-3.9 CI: 2.0-2.1 SVR (per\n computer): 1,190\n 1,394. CVP: . Feet & hands cold. Ax temp\n 95.8\n 98.3.\n Action:\n Titrated levophed from 0.15-0.2 mcg/kg/min for MAP <65. Given 1L LR\n boluses X 4 overnight, for a total of 13 liters IVF since arrival in\n EW. Given 500cc albumin 5% for serum albumin 1.8. Tube feedings\n held. B DP\ns & PT\ns dopplerable. On & off Bair Hugger to maintain\n temp.\n Response:\n Maintained MAP>65.\n Plan:\n Titrate levophed to maintain MAP>65. Add vasopressin as next pressor\n when required.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs are clear w/diminished breath sounds @ bases. Sx\ned for small to\n scant amounts thick tan secretions q 4 hrs. ON A/C 60%/Vt 500/ RR 22/\n 8 PEEP.\n Action:\n ABG\ns @ 0200: 7.29/34/72\n Response:\n Repeat ABG\ns @ 0500:\n Plan:\n CXR done this am ().\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 11-30cc/hr BUN 26 (23) Cr 1.6 (1.4) Urine is cloudy\n w/sediment. UA as above.\n Action:\n Given LR boluses X 4 for u/o as well as BP. Maintenance IVF @ 150cc/hr\n as well.\n Response:\n Poor u/o.\n Plan:\n Continue to monitor u/o. Give fluid as needed. Consider dopamine?\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.3 Ca 6.0 (adjusted for low serum albumin: Ca:7.5) albumin\n 1.8 Mg 1.2 PO4:2.1\n Action:\n Repleted w/80 mEq KCl IV in divided doses. Repleted w/4 Gm magnesium\n sulfate IV. Given 500cc albumin 5%. Repleted w/2 GM Ca gluconate IV.\n Given 2 packets neutraphos.\n Response:\n After repletion: K 6.0 Ca 6.8 (adjusted Ca: 8.0) Mg\n 2.7 PO4 2.9\n Plan:\n Follow labs. Replete w/care in this patient w/poor renal function.\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341922, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n Sepsis without organ dysfunction\n Assessment:\n MAP ranged 62 to 71 w/systolic BP >90/ @ all times. Absent bowel\n sounds. 170cc gastric residual of mixed undigested tube feedings &\n bilious fluid.@ . On Viileo, CO:3.4-3.9 CI: 2.0-2.1 SVR (per\n computer): 1,190\n 1,394. CVP: . Feet & hands cold. Ax temp\n 95.8\n 98.3.\n Action:\n Titrated levophed from 0.15-0.2 mcg/kg/min for MAP <65. Given 1L LR\n boluses X 4 overnight, for a total of 13 liters IVF since arrival in\n EW. Given 500cc albumin 5% for serum albumin 1.8. Tube feedings\n held. B DP\ns & PT\ns dopplerable. On & off Bair Hugger to maintain\n temp.\n Response:\n Maintained MAP>65.\n Plan:\n Titrate levophed to maintain MAP>65. Add vasopressin as next pressor\n when required.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs are clear w/diminished breath sounds @ bases. Sx\ned for small to\n scant amounts thick tan secretions q 4 hrs. ON A/C 60%/Vt 500/ RR 22/\n 8 PEEP.\n Action:\n ABG\ns @ 0200: 7.29/34/72\n Response:\n Repeat ABG\ns @ 0500:\n Plan:\n CXR done this am ().\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 11-30cc/hr BUN 26 (23) Cr 1.6 (1.4) Urine is cloudy\n w/sediment. UA as above.\n Action:\n Given LR boluses X 4 for u/o as well as BP. Maintenance IVF @ 150cc/hr\n as well.\n Response:\n Poor u/o.\n Plan:\n Continue to monitor u/o. Give fluid as needed. Consider dopamine?\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.3 Ca 6.0 (adjusted for low serum albumin: Ca:7.5) albumin\n 1.8 Mg 1.2 PO4:2.1\n Action:\n Repleted w/80 mEq KCl IV in divided doses. Repleted w/4 Gm magnesium\n sulfate IV. Given 500cc albumin 5%. Repleted w/2 GM Ca gluconate IV.\n Given 2 packets neutraphos.\n Response:\n After repletion: K 6.0 Ca 6.8 (adjusted Ca: 8.0) Mg\n 2.7 PO4 2.9\n Plan:\n Follow labs. Replete w/care in this patient w/poor renal function.\n" }, { "category": "Physician ", "chartdate": "2192-08-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342111, "text": "Chief Complaint: 82 year old female with a history of breast cancer,\n CVA, HTN, who presents from rehab with pneumonia and sepsis with gram\n negative rods in the blood non-speciated.\n 24 Hour Events:\n BLOOD CULTURED - At 09:46 AM\n EKG - At 12:00 PM\n BLOOD CULTURED - At 03:00 PM\n Attempted to wean patient off pressors yesterday. was off for about\n 1-1.5 hours and then patient had to go back on for low blood pressures.\n At 5 am levofed off. Fentanyl off, versed off. Urine culture growing\n back e. coli. 2 blood cultures now positive for e. coli as well.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Gentamicin - 10:47 PM\n Aztreonam - 10:00 PM\n Levofloxacin - 05:00 AM\n Vancomycin 1 gram IV q 48\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:38 PM\n Heparin Sodium - 04:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.3\nC (97.3\n HR: 77 (68 - 77) bpm\n BP: 121/55(77) {100/45(61) - 145/58(84)} mmHg\n RR: 16 (4 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 12 (9 - 17)mmHg\n Total In:\n 6,088 mL\n 560 mL\n PO:\n TF:\n IVF:\n 5,893 mL\n 560 mL\n Blood products:\n Total out:\n 1,430 mL\n 333 mL\n Urine:\n 685 mL\n 263 mL\n NG:\n 745 mL\n 70 mL\n Stool:\n Drains:\n Balance:\n 4,658 mL\n 227 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 420 (420 - 500) mL\n Vt (Spontaneous): 501 (410 - 640) mL\n PS : 12 cmH2O\n RR (Set): 24\n RR (Spontaneous): 17\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 26 cmH2O\n Plateau: 17 cmH2O\n Compliance: 46.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.32/39/117/18/-5\n Ve: 8.8 L/min\n PaO2 / FiO2: 293\n Physical Examination\n General\n intubated, sedated\n HEENT:NCAT mucus membranes dry pale conjunctiva\n CV: RRR S1S2 no m/r/g\n PULM: rales, crackles at RLL, scant crackles at LLL\n ABD: distended, soft +bs throughout\n EXT: WWP 1+dp pulses\n Labs / Radiology\n 104 K/uL\n 8.5 g/dL\n 78 mg/dL\n 1.5 mg/dL\n 18 mEq/L\n 4.8 mEq/L\n 28 mg/dL\n 116 mEq/L\n 142 mEq/L\n 25.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:19 AM\n 09:45 AM\n 10:39 AM\n 03:39 PM\n 04:52 PM\n 09:18 PM\n 09:30 PM\n 09:47 PM\n 05:00 AM\n 05:13 AM\n WBC\n 8.9\n Hct\n 28.2\n 28.3\n 25.6\n Plt\n 104\n Cr\n 1.7\n 1.6\n 1.6\n 1.5\n TCO2\n 18\n 17\n 18\n 14\n 21\n Glucose\n 72\n 111\n 110\n 78\n Other labs: PT / PTT / INR:15.2/41.4/1.3, CK / CKMB /\n Troponin-T:69/4/0.05, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.1\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia and septic physiology.\n Septic Shock: Current differential includes pneumonia vs. urosepsis\n vs. GI source. Cultures currently growing e. coli in the urine and the\n blood. Sputum cultures with polys and 4+ oropharyngeal flora. Patient\n was noted to have distended abdomen on presentation, CT abdomen shows\n distended bladder, b/l hydroureters and gas/stool in bowel with some\n mild bowel thickening. There is no indication of obstruction but\n patient has not passed gas/stool since admission (unclear if this is\n chronic diarrhea). This is likely ileus secondary to acute illness and\n less likely an infectious source. For hypotension the patient received\n large volume of IV NS, LR. Switched to D5 1/2NS w/bicarb d/t rising K\n and Na.\n - follow up sputum, urine cultures\n - currently on vancomycin, aztreonam, gentamycin, levofloxacin\n - would like to peel off an antibiotic given that now growing e. coli\n in the urine and in the blood\n - currently off all pressors, off sedation\n - currently now hypertensive\n - lactate this AM 2.6 which is down from 3.4\n -monitor WBC, CBC, diff - this morning patient dropped crit, monitor\n fever curve- patient initially febrile but became hypothermic overnight\n requiring bear hugger.\n Respiratory Failure: Patient on ******** Will wean FIO2 as tolerated\n today. Likely secondary to pneumonia.\n -f/u cultures and continue abx as above\n - wean FiO2 as tolerated\n -wean off sedation as tolerated- this will also assist with bowel\n motility\n Hematocrit drop\n - will check crit this afternoon\n - guiac stools (if has any), send anemia studies\n ARF: Creatinine 2.0 from baseline of 0.6 today improved. Likely\n prerenal in etiology secondary to volume depletion and septic shock.\n - IVF boluses to maintain urine output\n - trend creatinine\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with upward trending CE. This is likely demand\n ischemia in setting of hypotension. Now that BP and tachycardia under\n control, warm and perfusing, can follow-up cardiac function with echo.\n - recheck EKG now that tachycardia has improved\n - ECHO if possible to evaluate for MI or change from prior\n Hypertension:\n - holding all antihypertensives in the setting of hypotension\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n FEN: IVF- D5\n NS, if bicarb trends downward can add \n amps bicarb.\n -Monitor and replete electrolytes as needed.\n -Monitor K closely, add kayexelate if needed.\n -NGT in place however has had high residuals overnight so should hold\n off on TF until bowel function improves.\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: DNR per nursing home record signed by patient's sister. Clarify\n goals of care with HCP.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2192-08-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342112, "text": "Chief Complaint: 82 year old female with a history of breast cancer,\n CVA, HTN, who presents from rehab with pneumonia and sepsis with gram\n negative rods in the blood non-speciated.\n 24 Hour Events:\n BLOOD CULTURED - At 09:46 AM\n EKG - At 12:00 PM\n BLOOD CULTURED - At 03:00 PM\n Attempted to wean patient off pressors yesterday. was off for about\n 1-1.5 hours and then patient had to go back on for low blood\n pressures. At 5 am levofed off. Fentanyl off, versed off. Urine\n culture growing back e. coli. 2 blood cultures now positive for e. coli\n as well.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Gentamicin - 10:47 PM\n Aztreonam - 10:00 PM\n Levofloxacin - 05:00 AM\n Vancomycin 1 gram IV q 48\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:38 PM\n Heparin Sodium - 04:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.3\nC (97.3\n HR: 77 (68 - 77) bpm\n BP: 121/55(77) {100/45(61) - 145/58(84)} mmHg\n RR: 16 (4 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 12 (9 - 17)mmHg\n Total In:\n 6,088 mL\n 560 mL\n PO:\n TF:\n IVF:\n 5,893 mL\n 560 mL\n Blood products:\n Total out:\n 1,430 mL\n 333 mL\n Urine:\n 685 mL\n 263 mL\n NG:\n 745 mL\n 70 mL\n Stool:\n Drains:\n Balance:\n 4,658 mL\n 227 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 420 (420 - 500) mL\n Vt (Spontaneous): 501 (410 - 640) mL\n PS : 12 cmH2O\n RR (Set): 24\n RR (Spontaneous): 17\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 26 cmH2O\n Plateau: 17 cmH2O\n Compliance: 46.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.32/39/117/18/-5\n Ve: 8.8 L/min\n PaO2 / FiO2: 293\n Physical Examination\n General\n intubated, sedated\n HEENT:NCAT mucus membranes dry pale conjunctiva\n CV: RRR S1S2 no m/r/g\n PULM: rales, crackles at RLL, scant crackles at LLL\n ABD: distended, soft +bs throughout\n EXT: WWP 1+dp pulses\n Labs / Radiology\n 104 K/uL\n 8.5 g/dL\n 78 mg/dL\n 1.5 mg/dL\n 18 mEq/L\n 4.8 mEq/L\n 28 mg/dL\n 116 mEq/L\n 142 mEq/L\n 25.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:19 AM\n 09:45 AM\n 10:39 AM\n 03:39 PM\n 04:52 PM\n 09:18 PM\n 09:30 PM\n 09:47 PM\n 05:00 AM\n 05:13 AM\n WBC\n 8.9\n Hct\n 28.2\n 28.3\n 25.6\n Plt\n 104\n Cr\n 1.7\n 1.6\n 1.6\n 1.5\n TCO2\n 18\n 17\n 18\n 14\n 21\n Glucose\n 72\n 111\n 110\n 78\n Other labs: PT / PTT / INR:15.2/41.4/1.3, CK / CKMB /\n Troponin-T:69/4/0.05, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.1\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia and septic physiology.\n Septic Shock: Current differential includes pneumonia vs. urosepsis\n vs. GI source. Cultures currently growing e. coli in the urine and the\n blood. Sputum cultures with polys and 4+ oropharyngeal flora. Patient\n was noted to have distended abdomen on presentation, CT abdomen shows\n distended bladder, b/l hydroureters and gas/stool in bowel with some\n mild bowel thickening. There is no indication of obstruction but\n patient has not passed gas/stool since admission (unclear if this is\n chronic diarrhea). This is likely ileus secondary to acute illness and\n less likely an infectious source. For hypotension the patient received\n large volume of IV NS, LR. Switched to D5 1/2NS w/bicarb d/t rising K\n and Na.\n - follow up sputum, urine cultures\n - currently on vancomycin, aztreonam, gentamycin, levofloxacin\n - would like to peel off an antibiotic given that now growing e. coli\n in the urine and in the blood\n - currently off all pressors, off sedation\n - currently now hypertensive\n - lactate this AM 2.6 which is down from 3.4\n -monitor WBC, CBC, diff\n decreased hct this AM, monitor fever curve-\n patient initially febrile but became hypothermic overnight requiring\n bear hugger.\n Respiratory Failure: Patient on ******** Will wean FIO2 as tolerated\n today. Likely secondary to pneumonia.\n -f/u cultures and continue abx as above\n - wean FiO2 as tolerated\n -wean off sedation as tolerated- this will also assist with bowel\n motility\n Hematocrit drop\n - will check crit this afternoon\n - guiac stools (if has any), send anemia studies\n ARF: Creatinine 2.0 from baseline of 0.6 today improved. Likely\n prerenal in etiology secondary to volume depletion and septic shock.\n - IVF boluses to maintain urine output\n - trend creatinine\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with upward trending CE. This is likely demand\n ischemia in setting of hypotension. Now that BP and tachycardia under\n control, warm and perfusing, can follow-up cardiac function with echo.\n - recheck EKG now that tachycardia has improved\n - ECHO if possible to evaluate for MI or change from prior\n Hypertension:\n - holding all antihypertensives in the setting of hypotension\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n FEN: IVF- D5\n NS, if bicarb trends downward can add \n amps bicarb.\n -Monitor and replete electrolytes as needed.\n -Monitor K closely, add kayexelate if needed.\n -NGT in place however has had high residuals overnight so should hold\n off on TF until bowel function improves.\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: DNR per nursing home record signed by patient's sister. Clarify\n goals of care with HCP.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2192-08-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342114, "text": "Chief Complaint: 82 year old female with a history of breast cancer,\n CVA, HTN, who presents from rehab with pneumonia and sepsis with gram\n negative rods in the blood non-speciated.\n 24 Hour Events:\n BLOOD CULTURED - At 09:46 AM\n EKG - At 12:00 PM\n BLOOD CULTURED - At 03:00 PM\n Attempted to wean patient off pressors yesterday. was off for about\n 1-1.5 hours and then patient had to go back on for low blood\n pressures. At 5 am levofed off. Fentanyl off, versed off. Urine\n culture growing back e. coli. 2 blood cultures now positive for e. coli\n as well.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Gentamicin - 10:47 PM\n Aztreonam - 10:00 PM\n Levofloxacin - 05:00 AM\n Vancomycin 1 gram IV q 48\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:38 PM\n Heparin Sodium - 04:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.3\nC (97.3\n HR: 77 (68 - 77) bpm\n BP: 121/55(77) {100/45(61) - 145/58(84)} mmHg\n RR: 16 (4 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 12 (9 - 17)mmHg\n Total In:\n 6,088 mL\n 560 mL\n PO:\n TF:\n IVF:\n 5,893 mL\n 560 mL\n Blood products:\n Total out:\n 1,430 mL\n 333 mL\n Urine:\n 685 mL\n 263 mL\n NG:\n 745 mL\n 70 mL\n Stool:\n Drains:\n Balance:\n 4,658 mL\n 227 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 420 (420 - 500) mL\n Vt (Spontaneous): 501 (410 - 640) mL\n PS : 12 cmH2O\n RR (Set): 24\n RR (Spontaneous): 17\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 26 cmH2O\n Plateau: 17 cmH2O\n Compliance: 46.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.32/39/117/18/-5\n Ve: 8.8 L/min\n PaO2 / FiO2: 293\n Physical Examination\n General\n intubated, sedated\n HEENT:NCAT mucus membranes dry pale conjunctiva\n CV: RRR S1S2 no m/r/g\n PULM: rales, crackles at RLL, scant crackles at LLL\n ABD: distended, soft +bs throughout\n EXT: WWP 1+dp pulses\n Labs / Radiology\n 104 K/uL\n 8.5 g/dL\n 78 mg/dL\n 1.5 mg/dL\n 18 mEq/L\n 4.8 mEq/L\n 28 mg/dL\n 116 mEq/L\n 142 mEq/L\n 25.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:19 AM\n 09:45 AM\n 10:39 AM\n 03:39 PM\n 04:52 PM\n 09:18 PM\n 09:30 PM\n 09:47 PM\n 05:00 AM\n 05:13 AM\n WBC\n 8.9\n Hct\n 28.2\n 28.3\n 25.6\n Plt\n 104\n Cr\n 1.7\n 1.6\n 1.6\n 1.5\n TCO2\n 18\n 17\n 18\n 14\n 21\n Glucose\n 72\n 111\n 110\n 78\n Other labs: PT / PTT / INR:15.2/41.4/1.3, CK / CKMB /\n Troponin-T:69/4/0.05, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.1\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia and septic physiology.\n Septic Shock: Current differential includes pneumonia vs. urosepsis\n vs. GI source. Cultures currently growing e. coli in the urine and the\n blood. Sputum cultures with polys and 4+ oropharyngeal flora. Patient\n was noted to have distended abdomen on presentation, CT abdomen shows\n distended bladder, b/l hydroureters and gas/stool in bowel with some\n mild bowel thickening. There is no indication of obstruction but\n patient has not passed gas/stool since admission (unclear if this is\n chronic diarrhea). This is likely ileus secondary to acute illness and\n less likely an infectious source. For hypotension the patient received\n large volume of IV NS, LR. Switched to D5 1/2NS w/bicarb d/t rising K\n and Na.\n - follow up sputum, urine cultures\n - currently on vancomycin, aztreonam, gentamycin, levofloxacin\n - would like to peel off an antibiotic given that now growing e. coli\n in the urine and in the blood\n - currently off all pressors, off sedation\n - currently now hypertensive\n - lactate this AM 2.6 which is down from 3.4\n -monitor WBC, CBC, diff\n decreased hct this AM\n monitor fever curve- patient initially febrile but became hypothermic\n requiring bear hugger, now normothermic\n Respiratory Failure: Initially respiratory failure thought to be due\n to pneumonia. Patient on CPAP Vt 420, PEEP 8, FiO2 40%..\n -culture data from sputum thus far has grown orophyaryngeal flora only\n - patient would be candidate for extubation if mental status were\n better, currently no gag as per nursing, however unclear if at baseline\n patient has gag\n -off sedation\n #) Hematocrit drop\n - Patient guaic positive in the ED, have not sent stool\n studies as patient has had no stool, however suspect positive\n - Coffee ground emesis from NG tube\n - Ordered iron studies for AM tomorrow\n ARF: Creatinine 2.0 from baseline of 0.6 today improved. Likely\n prerenal in etiology secondary to volume depletion and septic shock.\n - IVF boluses to maintain urine output\n - trend creatinine\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with upward trending CE. This is likely demand\n ischemia in setting of hypotension. Now that BP and tachycardia under\n control, warm and perfusing, can follow-up cardiac function with echo.\n - recheck EKG now that tachycardia has improved\n - ECHO if possible to evaluate for MI or change from prior\n Hypertension:\n - holding all antihypertensives in the setting of hypotension\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n FEN: IVF- D5\n NS, if bicarb trends downward can add \n amps bicarb.\n -Monitor and replete electrolytes as needed.\n -Monitor K closely, add kayexelate if needed.\n -NGT in place however has had high residuals overnight so should hold\n off on TF until bowel function improves.\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: DNR per nursing home record signed by patient's sister. Clarify\n goals of care with HCP.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2192-08-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342117, "text": "Chief Complaint: 82 year old female with a history of breast cancer,\n CVA, HTN, who presents from rehab with pneumonia and sepsis with gram\n negative rods in the non-speciated.\n 24 Hour Events:\n CULTURED - At 09:46 AM\n EKG - At 12:00 PM\n CULTURED - At 03:00 PM\n Attempted to wean patient off pressors yesterday. was off for about\n 1-1.5 hours and then patient had to go back on for low \n pressures. At 5 am levofed off. Fentanyl off, versed off. Urine\n culture growing back e. coli. 2 cultures now positive for e. coli\n as well.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Gentamicin - 10:47 PM\n Aztreonam - 10:00 PM\n Levofloxacin - 05:00 AM\n Vancomycin 1 gram IV q 48\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:38 PM\n Heparin Sodium - 04:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.3\nC (97.3\n HR: 77 (68 - 77) bpm\n BP: 121/55(77) {100/45(61) - 145/58(84)} mmHg\n RR: 16 (4 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 12 (9 - 17)mmHg\n Total In:\n 6,088 mL\n 560 mL\n PO:\n TF:\n IVF:\n 5,893 mL\n 560 mL\n products:\n Total out:\n 1,430 mL\n 333 mL\n Urine:\n 685 mL\n 263 mL\n NG:\n 745 mL\n 70 mL\n Stool:\n Drains:\n Balance:\n 4,658 mL\n 227 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 420 (420 - 500) mL\n Vt (Spontaneous): 501 (410 - 640) mL\n PS : 12 cmH2O\n RR (Set): 24\n RR (Spontaneous): 17\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 26 cmH2O\n Plateau: 17 cmH2O\n Compliance: 46.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.32/39/117/18/-5\n Ve: 8.8 L/min\n PaO2 / FiO2: 293\n Physical Examination\n General\n intubated, sedated\n HEENT:NCAT mucus membranes dry pale conjunctiva\n CV: RRR S1S2 no m/r/g\n PULM: rales, crackles at RLL, scant crackles at LLL\n ABD: distended, soft +bs throughout\n EXT: WWP 1+dp pulses\n Labs / Radiology\n 104 K/uL\n 8.5 g/dL\n 78 mg/dL\n 1.5 mg/dL\n 18 mEq/L\n 4.8 mEq/L\n 28 mg/dL\n 116 mEq/L\n 142 mEq/L\n 25.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:19 AM\n 09:45 AM\n 10:39 AM\n 03:39 PM\n 04:52 PM\n 09:18 PM\n 09:30 PM\n 09:47 PM\n 05:00 AM\n 05:13 AM\n WBC\n 8.9\n Hct\n 28.2\n 28.3\n 25.6\n Plt\n 104\n Cr\n 1.7\n 1.6\n 1.6\n 1.5\n TCO2\n 18\n 17\n 18\n 14\n 21\n Glucose\n 72\n 111\n 110\n 78\n Other labs: PT / PTT / INR:15.2/41.4/1.3, CK / CKMB /\n Troponin-T:69/4/0.05, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.1\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia and septic physiology.\n Septic Shock: Current differential includes pneumonia vs. urosepsis\n vs. GI source. Cultures currently growing e. coli in the urine and the\n . Sputum cultures with polys and 4+ oropharyngeal flora. Patient\n was noted to have distended abdomen on presentation, CT abdomen shows\n distended bladder, b/l hydroureters and gas/stool in bowel with some\n mild bowel thickening. There is no indication of obstruction but\n patient has not passed gas/stool since admission (unclear if this is\n chronic diarrhea). This is likely ileus secondary to acute illness and\n less likely an infectious source. For hypotension the patient received\n large volume of IV NS, LR. Switched to D5 1/2NS w/bicarb d/t rising K\n and Na.\n - sputum cx/urine cx as above\n - currently on vancomycin, aztreonam, gentamycin, levofloxacin\n - would like to peel off an antibiotic given that now growing e. coli\n in the urine and in the , wait on speciation until this\n evening\n - currently off all pressors, off sedation\n - currently now hypertensive\n - lactate this AM 2.6 which is down from 3.4\n -monitor WBC, CBC, diff\n decreased hct this AM\n monitor fever curve- patient initially febrile but became hypothermic\n requiring bear hugger, now normothermic\n Respiratory Failure: Initially respiratory failure thought to be due to\n pneumonia. Patient on CPAP Vt 420, PEEP 8, FiO2 40%..\n -culture data from sputum thus far has grown orophyaryngeal flora only\n - patient would be candidate for extubation if mental status were\n better, currently no gag as per nursing, however unclear if at baseline\n patient has gag\n -off sedation\n Hematocrit drop\n -Patient guaic positive in the ED, have not sent stool studies as\n patient has had no stool, however suspect positive\n - Coffee ground emesis from NG tube\n - Ordered iron studies for AM tomorrow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n to 1.5. Likely prerenal in etiology secondary to volume depletion and\n septic shock\n likely ATN.\n - IVF boluses to maintain urine output\n - trend creatinine\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with upward trending CE. This is likely demand\n ischemia in setting of hypotension. Now that BP and tachycardia under\n control, warm and perfusing, can follow-up cardiac function with echo.\n - recheck EKG now that tachycardia has improved\n - ECHO ordered, not yet completed, unlikely to get done over the\n weekend\n - troponins on were 0.02, 0.03, 0.05\n - no troponins drawn yesterday\n - put in add on troponins for this AM\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension\n - gave 10 IV hydral in the setting now of hypertension to 200 may be in\n the setting of agitation\n - will hold on lisinopril in the setting of acute renal failure\n - written for metoprolol 25 mg PO BID, will continue to uptitrate as\n tolerated by heart rate and pressure and use hydral PRN as needed\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n - will call today to try to find out what baseline mental\n status is, question as to whether patient has gag at baseline, what her\n baseline orientation is etc\n FEN:\n - pt currently with high residuals so not getting tube feeds\n - will start IV maintenance fluids at 100 cc/ hr of normal saline as\n patient not eating\n - patient with evidence of stool in distal , give her fleets\n enema today, hope that that will improve residuals and allow for tube\n feedings\n -Monitor and replete electrolytes as needed.\n -Monitor K closely, add kayexelate if needed.\n -NGT in place with coffee ground emesis\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: DNR per nursing home record signed by patient's sister. Clarify\n goals of care with HCP.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2192-08-17 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 341821, "text": "Chief Complaint: Respiratory Distress\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 86 year old female who presented from NH with respiratory distress and\n required intubation/mechanical ventilation.\n Was febrile to 103.\n CXR showed right sided infiltrate\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated, intubated\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1) CVA\n 2) History of falls\n 3) Recurrent UTIs\n 4) Osteoporosis\n 5) Dementia\n 6) Hypertension\n Occupation: Nursing Home\n Drugs:\n Tobacco:\n Alcohol: Previous use\n Other:\n Review of systems:\n Flowsheet Data as of 12:34 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 38.6\nC (101.4\n HR: 98 (98 - 106) bpm\n BP: 110/59(71) {86/53(60) - 110/59(71)} mmHg\n RR: 21 (18 - 21) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,945 mL\n PO:\n TF:\n IVF:\n 1,945 mL\n Blood products:\n Total out:\n 0 mL\n 520 mL\n Urine:\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,425 mL\n Respiratory\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: 7.25/43/139//-8\n Ve: 10 L/min\n PaO2 / FiO2: 139\n Physical Examination\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 Abdominal: Soft, Non-tender, Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Cool\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n 08:32 AM\n 10:22 AM\n 11:01 AM\n TC02\n 18\n 18\n 20\n Other labs: Lactic Acid:5.1 mmol/L\n Assessment and Plan\n A:\n 1) Acute Respiratory Failure secondary to pneumonia\n Plan:\n - continue mechanical ventilation -> wean Fio2 as able\n - treat underlying pneumonia\n 2) Pneumonia/sepsis\n - levofloxacin/amikacin\n - has received 4-5 liters of fluid and perfusion is improving (urine\n output improved, lactate clearing)\n Plan:\n - Continue broad-spectrum antibiotics\n - Resuscitate to endpoints of urine output > 30 cc/hour, lactate < 2.5,\n normalized vitals, shock index,\n 3)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n Total time spent: 35\n" }, { "category": "Physician ", "chartdate": "2192-08-17 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 341829, "text": "Chief Complaint: Respiratory Failure, Sepsis\n HPI:\n Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. Per EMS notes her\n initial vitals in the field were T: 99.7 BP: 232/125 HR: 124 RR: 24 O2:\n 63% on 2L. She wa noted to be slow to respond and diaphrestic. She\n was suctioned with large amounts of secretions. Foley catheter was\n placed with 100 cc dark urine.\n In the emergency room her initial vitals were T: 103 HR: 130 BP: 114/89\n RR: 17 O2: 96% on 100% O2. She was emergently intubated. Her initial\n labs were notable for a WBC count of 3.2, band count of 23. Her\n initial blood gas was 7.21/40/96/17. Her creatinine was elevated at\n 2.0. She was started on vancomycin, levofloxacin and ceftriaxone. She\n received 3.5 liters of normal saline with a fourth bag hanging at the\n time of transfer.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Other medications:\n Home Medications:\n Omeprazole 20 mg daily\n OystCal + D 500/200 \n Namenda 10 mg \n Potassium 20 meq \n Tramadol 25 mg \n Tylenol 650 mg Q6H:PRN\n Multivitamin daily\n Aricept 10 mg QHS\n Albuterol nebulizers 1 amp Q4H:PRN\n Loperamide 2 mg daily:PRN\n Past medical history:\n Family history:\n Social History:\n 1. Hypokalemia.\n 2. Breast cancer, status post radiation therapy with\n lumpectomy in .\n 3. Cerebrovascular accident.\n 4. History of falls.\n 5. Arthritis.\n 6. Status post hysterectomy.\n 7. Hypertension.\n 8. Recurrent urinary tract infections.\n 9. Cardiomegaly seen on chest x-ray.\n 10. Osteoporosis.\n Unknown\n Occupation: Retired\n Drugs: None\n Tobacco: None\n Alcohol: Previous\n Other: Comes from \n Review of systems:\n Constitutional: Fever\n Cardiovascular: Tachycardia\n Nutritional Support: Tube feeds\n Respiratory: Dyspnea, Respiratory Distress\n Gastrointestinal: Abdominal Distension\n Genitourinary: Decreased urine output\n Flowsheet Data as of 01:36 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.4\nC (99.4\n HR: 102 (97 - 106) bpm\n BP: 94/48(58) {86/48(58) - 110/59(71)} mmHg\n RR: 21 (18 - 22) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n CVP: 5 (4 - 5)mmHg\n Total In:\n 3,042 mL\n PO:\n TF:\n IVF:\n 3,042 mL\n Blood products:\n Total out:\n 0 mL\n 670 mL\n Urine:\n 670 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,372 mL\n Respiratory\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 14 cmH2O\n SpO2: 100%\n ABG: 7.25/43/139//-8\n Ve: 10 L/min\n PaO2 / FiO2: 232\n Physical Examination\n Vitals: T: 101.4 HR: 106 BP: 86/53 RR: 18 O2:95% on 100% FiO2\n General: Intubated, sedated no acute distress\n HEENT: Sclera anicteric, MM dry, oropharynx clear\n Neck: JVP flat\n CV: tachycardia, s1 + s2, no mumurs, rubs, gallops\n Chest: Coarse breath sounds right > left, no wheezes\n GI: Soft, non-tender, non-distended, +BS\n GU: Foley draining dark urine\n Ext: Right side contracted, cool, clammy, 2+ pulses\n Labs / Radiology\n 302\n 15.2\n 272\n 2.0\n 29\n 17\n 112\n 4.1\n 144\n 51.5\n 3.2\n [image002.jpg]\n \n 2:33 A9/12/ 08:32 AM\n \n 10:20 P9/12/ 10:22 AM\n \n 1:20 P9/12/ 11:01 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 TC02\n 18\n 18\n 20\n Other labs: PT / PTT / INR://1.2, CK / CKMB / Troponin-T:62//0.03, ALT\n / AST:21/20, Alk Phos / T Bili:126/0.4, Differential-Neuts:47, Band:23,\n Lymph:9, Mono:3, Eos:2, Lactic Acid:5.1 mmol/L, Ca++:7.9, Mg++:1.8,\n PO4:3.1\n Imaging: CXR: evidence of right sided pneumonia.\n CT abdomen: preliminary read negative\n Microbiology: Blood culture x 2 pending\n ECG: EKG: Sinus tachycardia with rate of 139, left axis deviation,\n normal intervals, ST depressions in V4-V6.\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia and septic physiology.\n Septic Shock: Blood pressures in the 90s systolic on arrival to the\n intensive care unit. Patient febrile, tachycardiac with a bandemia and\n a lactic acidosis. Likely etiology is right sided pneumonia. Patient\n was noted to have distended abdomen on presentation to the emergency\n room but CT abdomen preliminarily is negative. She has now received\n over 5 liters normal saline with improvement in her blood pressure.\n She now has a central line in place.\n - follow up blood and urine cultures from emergency room\n - currently on vancomycin, aztreonam, levofloxacin for hospital\n acquired pneumonia\n - sputum culture if possible\n - IVF boluses with normal saline to maintain MAP > 65, urine output >\n 30 cc/hr, CVP 10-12\n - trend lactate to ensure improvement (now down to 5.1)\n - vasopressors as necessary to maintain blood pressure\n - hematocrit is elevated so no indication for transfusion\n Respiratory Failure: Now s/p intubation. PCO2 on ventilator is 40.\n Will wean oxygen as tolerated. Likely secondary to pneumonia.\n - continue ventilation at current settins\n - wean FiO2 as tolerated\n Acute Kidney Injury: Creatinine 2.0 from baseline of 0.6. Likely\n prerenal in etiology secondary to volume depletion and septic shock.\n - IVF boluses to maintain urine output\n - trend creatinine\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s.\n - recheck EKG now that tachycardia has improved\n - repeat cardiac enzymes in AM\n Hypertension:\n - holding all antihypertensives in the setting of hypotension\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n FEN: IVF as above, monitor electrolytes, NGT in place so will start\n tube feeds\n Prophylaxis: SC heparin\n Communcation: Sister \n Code: DNR per nursing home record signed by patient's sister. \n sister she now would like all interventions necessary to prolong life.\n Disposition: ICU care for now\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:00 AM\n 16 Gauge - 10:00 AM\n Multi Lumen - 12:50 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Pantoprazole\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341905, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows\n" }, { "category": "Nursing", "chartdate": "2192-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341907, "text": "Mrs. is an 82 year old female with a history of breast cancer,\n CVA, and hypertension who presents from after being found\n to be in respiratory distress with oxygen saturations in the 70s to 80s\n on room air. Per EMS report the patient was found at approximately\n 3:30 AM by staff at to be in moderate to severe\n respiratory distress. She received an albuterol nebulizer. Her EKG\n per report was within normal limits. Her exam was notable for audible\n rales and abdominal distension. She received 40 mg IV lasix, 1\n sublingual nitroglyerin and was assisted with bag mouth ventilation.\n An oropharyngeal airway was placed in the field. She wa noted to be\n slow to respond and diaphorettic. She was suctioned with large amounts\n of secretions. Foley catheter was placed with 100 cc dark urine. Sent\n to EW, where she was emergently Intubated. T103. Code sepsis not\n initiated as BP >100/systolic. Received 3L NS in EW. Given vanco,\n levofloxacin & ceftriaxone IV. Patient arrived in MICU & did well until\n 1600. Dropped BP, received fluid boluses & started on levophed.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Started on aztreonam & received 120mg IV gentamycin\n X1. Urine Cx () grew nothing yet. UA from EW shows many bacti but\n UA from later in the day shows few. Sputum Cx shows many organisms\n consistent w/oropharyngeal flora.\n" }, { "category": "Nursing", "chartdate": "2192-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342088, "text": "Mrs. is an 82 year old female with a history of breast CA (s/p\n XRT), CVA, baseline dementia, HTN, reflux, & recurrent UTI\ns, who\n presented on early am from after being found to be\n in respiratory distress with oxygen sats in 70s to 80\ns on r/a. Her\n EKG per report was within normal limits. Her exam was notable for\n audible rales and abdominal distension. Foley catheter was placed with\n 100 cc dark urine. Sent to EW, where she was emergently\n Intubated. T103. Code sepsis not initiated as BP >100/systolic.\n Peripheral BC from EW grew 4 out of 4 bottles positive for gram\n negative rods. Urine Cx () grew nothing yet. UA from EW shows\n many bacti but UA from later in the day shows few. Sputum Cx shows\n many organisms consistent w/oropharyngeal flora. Became hypotensive in\n MICU on afternoon, received fluid boluses & levophed IV. Treated\n w/IV levofloxacin, vanco aztreonam &genta. Lactate 9.0 on admission.\n Sepsis without organ dysfunction\n Assessment:\n Lactate down to low of 2.6 on . MAP 64-78. Systolic BP\n 90\ns-130\ns/. HR: 70\ns-80\ns SR no ectopy. CVP: CO: 3.4-3.5\n CI: 2 SVR: 1,221- 1,624.\n Action:\n Finished 2^nd liter D5\n NS. IVF @ KVO since 0200. Titrated levophed\n down to 0.01-0.03 mcg/kg/min. Levophed off X2 overnight & presently\n off since 0600.\n Response:\n MAP maintained >65\n Plan:\n Continue to maintain MAP>65.\n Pneumonia, bacterial, hospital acquired (non-VAP)\n Assessment:\n Lungs: clear, diminished @ bases. Sx\ned scant to moderate thick tan\n secretions q 3 hrs. On CPAP 40%/ 8 PEEP/ 12 PS since 2130 .\n Continued on fentanyl 50mcg/hr & versed 1mg/hr until 0530 when they\n were turned off.\n Action:\n ABG\ns: 7.31/ 27/96 on CPAP\n Response:\n ABG\ns w/am labs: 7.32/39/117 RSBI in 30\n Plan:\n Cont to wean. Assess for readiness for extubation. Continue to assess\n gag & cough off sedation.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/o 30-50cc/hr cloudy yellow urine w/sediment. BUN 28 (no\n change) Cr 1.5 (1.6)\n Action:\n Received D5\n NS @ 125cc/hr overnight. Levophed titrated down.\n Response:\n Patient is beginning to turn corner w/sepsis, thereby perfusing kidneys\n more efficiently.\n Plan:\n Continue to follow electrolytes & BUN/Cr. Continue to monitor u/o.\n Hct 25.6 this am down from 28.3. Guaic + brown emesis continues.\n" }, { "category": "Physician ", "chartdate": "2192-08-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342092, "text": "Chief Complaint: 82 year old female with a history of breast cancer,\n CVA, HTN, who presents from rehab with pneumonia and sepsis with gram\n negative rods in the blood non-speciated.\n 24 Hour Events:\n BLOOD CULTURED - At 09:46 AM\n EKG - At 12:00 PM\n BLOOD CULTURED - At 03:00 PM\n Attempted to wean patient off pressors yesterday. was off for about\n 1-1.5 hours and then patient had to go back on for low blood pressures.\n Patient fluid was switched from LR to d51/2 NS yesterday for elevated\n K.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Gentamicin - 10:47 PM\n Aztreonam - 10:00 PM\n Levofloxacin - 05:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:38 PM\n Heparin Sodium - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.3\nC (97.3\n HR: 77 (68 - 77) bpm\n BP: 121/55(77) {100/45(61) - 145/58(84)} mmHg\n RR: 16 (4 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 12 (9 - 17)mmHg\n Total In:\n 6,088 mL\n 560 mL\n PO:\n TF:\n IVF:\n 5,893 mL\n 560 mL\n Blood products:\n Total out:\n 1,430 mL\n 333 mL\n Urine:\n 685 mL\n 263 mL\n NG:\n 745 mL\n 70 mL\n Stool:\n Drains:\n Balance:\n 4,658 mL\n 227 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 420 (420 - 500) mL\n Vt (Spontaneous): 501 (410 - 640) mL\n PS : 12 cmH2O\n RR (Set): 24\n RR (Spontaneous): 17\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 26 cmH2O\n Plateau: 17 cmH2O\n Compliance: 46.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.32/39/117/18/-5\n Ve: 8.8 L/min\n PaO2 / FiO2: 293\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 8.5 g/dL\n 78 mg/dL\n 1.5 mg/dL\n 18 mEq/L\n 4.8 mEq/L\n 28 mg/dL\n 116 mEq/L\n 142 mEq/L\n 25.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:19 AM\n 09:45 AM\n 10:39 AM\n 03:39 PM\n 04:52 PM\n 09:18 PM\n 09:30 PM\n 09:47 PM\n 05:00 AM\n 05:13 AM\n WBC\n 8.9\n Hct\n 28.2\n 28.3\n 25.6\n Plt\n 104\n Cr\n 1.7\n 1.6\n 1.6\n 1.5\n TCO2\n 18\n 17\n 18\n 14\n 21\n Glucose\n 72\n 111\n 110\n 78\n Other labs: PT / PTT / INR:15.2/41.4/1.3, CK / CKMB /\n Troponin-T:69/4/0.05, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.1\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia and septic physiology.\n Septic Shock: Current differential includes pneumonia vs. urosepsis\n vs. GI source. Cultures grew , wait for speciation but until\n then continue to cover broadly. Sputum cultures with polys and 4+\n oropharyngeal flora and urine cultures pending. Patient was noted to\n have distended abdomen on presentation, CT abdomen shows distended\n bladder, b/l hydroureters and gas/stool in bowel with some mild bowel\n thickening. There is no indication of obstruction but patient has not\n passed gas/stool since admission (unclear if this is chronic diarrhea).\n This is likely ileus secondary to acute illness and less likely an\n infectious source. For hypotension the patient received large volume of\n IV NS, LR. Switched to D5 1/2NS w/bicarb d/t rising K and Na.\n - follow up sputum, urine cultures\n - continue vancomycin, aztreonam, gentamycin\n - IVF boluses with normal saline to maintain MAP > 65, urine output >\n 30 cc/hr, CVP 10-12\n - trend lactate\n - attempt to wean off levophed as tolerated\n -monitor WBC, CBC, diff - this morning patient dropped crit, monitor\n fever curve- patient initially febrile but became hypothermic overnight\n requiring bear hugger.\n Respiratory Failure: Patient on ******** Will wean FIO2 as tolerated\n today. Likely secondary to pneumonia.\n -f/u cultures and continue abx as above\n - wean FiO2 as tolerated\n -wean off sedation as tolerated- this will also assist with bowel\n motility\n ARF: Creatinine 2.0 from baseline of 0.6 today improved. Likely\n prerenal in etiology secondary to volume depletion and septic shock.\n - IVF boluses to maintain urine output\n - trend creatinine\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with upward trending CE. This is likely demand\n ischemia in setting of hypotension. Now that BP and tachycardia under\n control, warm and perfusing, can follow-up cardiac function with echo.\n - recheck EKG now that tachycardia has improved\n - ECHO if possible to evaluate for MI or change from prior\n Hypertension:\n - holding all antihypertensives in the setting of hypotension\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n FEN: IVF- D5\n NS, if bicarb trends downward can add \n amps bicarb.\n -Monitor and replete electrolytes as needed.\n -Monitor K closely, add kayexelate if needed.\n -NGT in place however has had high residuals overnight so should hold\n off on TF until bowel function improves.\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: DNR per nursing home record signed by patient's sister. Clarify\n goals of care with HCP.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2192-08-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342093, "text": "Chief Complaint: 82 year old female with a history of breast cancer,\n CVA, HTN, who presents from rehab with pneumonia and sepsis with gram\n negative rods in the blood non-speciated.\n 24 Hour Events:\n BLOOD CULTURED - At 09:46 AM\n EKG - At 12:00 PM\n BLOOD CULTURED - At 03:00 PM\n Attempted to wean patient off pressors yesterday. was off for about\n 1-1.5 hours and then patient had to go back on for low blood pressures.\n Patient fluid was switched from LR to d51/2 NS yesterday for elevated\n K.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Gentamicin - 10:47 PM\n Aztreonam - 10:00 PM\n Levofloxacin - 05:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:38 PM\n Heparin Sodium - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.3\nC (97.3\n HR: 77 (68 - 77) bpm\n BP: 121/55(77) {100/45(61) - 145/58(84)} mmHg\n RR: 16 (4 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 12 (9 - 17)mmHg\n Total In:\n 6,088 mL\n 560 mL\n PO:\n TF:\n IVF:\n 5,893 mL\n 560 mL\n Blood products:\n Total out:\n 1,430 mL\n 333 mL\n Urine:\n 685 mL\n 263 mL\n NG:\n 745 mL\n 70 mL\n Stool:\n Drains:\n Balance:\n 4,658 mL\n 227 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 420 (420 - 500) mL\n Vt (Spontaneous): 501 (410 - 640) mL\n PS : 12 cmH2O\n RR (Set): 24\n RR (Spontaneous): 17\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 26 cmH2O\n Plateau: 17 cmH2O\n Compliance: 46.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.32/39/117/18/-5\n Ve: 8.8 L/min\n PaO2 / FiO2: 293\n Physical Examination\n General\n intubated, sedated\n HEENT:NCAT mucus membranes dry pale conjunctiva\n CV: RRR S1S2 no m/r/g\n PULM: rales, crackles at RLL, scant crackles at LLL\n ABD: distended, soft +bs throughout\n EXT: WWP 1+dp pulses\n Labs / Radiology\n 104 K/uL\n 8.5 g/dL\n 78 mg/dL\n 1.5 mg/dL\n 18 mEq/L\n 4.8 mEq/L\n 28 mg/dL\n 116 mEq/L\n 142 mEq/L\n 25.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:19 AM\n 09:45 AM\n 10:39 AM\n 03:39 PM\n 04:52 PM\n 09:18 PM\n 09:30 PM\n 09:47 PM\n 05:00 AM\n 05:13 AM\n WBC\n 8.9\n Hct\n 28.2\n 28.3\n 25.6\n Plt\n 104\n Cr\n 1.7\n 1.6\n 1.6\n 1.5\n TCO2\n 18\n 17\n 18\n 14\n 21\n Glucose\n 72\n 111\n 110\n 78\n Other labs: PT / PTT / INR:15.2/41.4/1.3, CK / CKMB /\n Troponin-T:69/4/0.05, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:90.0 %, Band:5.0 %, Lymph:3.0 %, Mono:2.0 %, Eos:0.0\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.1\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia and septic physiology.\n Septic Shock: Current differential includes pneumonia vs. urosepsis\n vs. GI source. Cultures grew , wait for speciation but until\n then continue to cover broadly. Sputum cultures with polys and 4+\n oropharyngeal flora and urine cultures pending. Patient was noted to\n have distended abdomen on presentation, CT abdomen shows distended\n bladder, b/l hydroureters and gas/stool in bowel with some mild bowel\n thickening. There is no indication of obstruction but patient has not\n passed gas/stool since admission (unclear if this is chronic diarrhea).\n This is likely ileus secondary to acute illness and less likely an\n infectious source. For hypotension the patient received large volume of\n IV NS, LR. Switched to D5 1/2NS w/bicarb d/t rising K and Na.\n - follow up sputum, urine cultures\n - continue vancomycin, aztreonam, gentamycin\n - IVF boluses with normal saline to maintain MAP > 65, urine output >\n 30 cc/hr, CVP 10-12\n - trend lactate\n - attempt to wean off levophed as tolerated\n -monitor WBC, CBC, diff - this morning patient dropped crit, monitor\n fever curve- patient initially febrile but became hypothermic overnight\n requiring bear hugger.\n Respiratory Failure: Patient on ******** Will wean FIO2 as tolerated\n today. Likely secondary to pneumonia.\n -f/u cultures and continue abx as above\n - wean FiO2 as tolerated\n -wean off sedation as tolerated- this will also assist with bowel\n motility\n Hematocrit drop\n - will check crit this afternoon\n - guiac stools (if has any), send anemia studies\n ARF: Creatinine 2.0 from baseline of 0.6 today improved. Likely\n prerenal in etiology secondary to volume depletion and septic shock.\n - IVF boluses to maintain urine output\n - trend creatinine\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with upward trending CE. This is likely demand\n ischemia in setting of hypotension. Now that BP and tachycardia under\n control, warm and perfusing, can follow-up cardiac function with echo.\n - recheck EKG now that tachycardia has improved\n - ECHO if possible to evaluate for MI or change from prior\n Hypertension:\n - holding all antihypertensives in the setting of hypotension\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n FEN: IVF- D5\n NS, if bicarb trends downward can add \n amps bicarb.\n -Monitor and replete electrolytes as needed.\n -Monitor K closely, add kayexelate if needed.\n -NGT in place however has had high residuals overnight so should hold\n off on TF until bowel function improves.\n Prophylaxis: SC heparin, bowel regimen\n Access: RIJ\n Communcation: Sister \n Code: DNR per nursing home record signed by patient's sister. Clarify\n goals of care with HCP.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2192-08-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 342654, "text": "Chief Complaint: sepsis and 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 82 yo women with h/o breast CA, admitted with urosepsis, respiratory\n failure. Has improved. Ventilator weaned down, and having ++\n secretions. Off versed overnight. Having diarrhea.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:00 AM\n URINE CULTURE - At 12:23 AM\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Gentamicin - 11:00 PM\n Vancomycin - 08:10 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 PM\n Fentanyl - 05:57 PM\n Dextrose 50% - 06:53 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n SSI\n lopressor\n lisinopril\n donepezil\n nimenda\n tylenol\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 09:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36\nC (96.8\n HR: 90 (67 - 108) bpm\n BP: 162/61(95) {124/45(67) - 190/75(112)} mmHg\n RR: 36 (0 - 37) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 4 (4 - 9)mmHg\n Total In:\n 823 mL\n 1,045 mL\n PO:\n TF:\n 79 mL\n 140 mL\n IVF:\n 554 mL\n 325 mL\n Blood products:\n Total out:\n 2,500 mL\n 650 mL\n Urine:\n 2,500 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,677 mL\n 395 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 414 (305 - 473) mL\n PS : 5 cmH2O\n RR (Spontaneous): 33\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 94\n PIP: 11 cmH2O\n SpO2: 92%\n ABG: ///21/\n Ve: 14 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 : , Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Unable to stand\n Skin: Warm, Rash:\n Neurologic: No(t) Follows simple commands, Responds to: Tactile\n stimuli, Movement: Not assessed, Tone: Not assessed, no left leg\n movements\n Labs / Radiology\n 8.8 g/dL\n 133 K/uL\n 90 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 144 mEq/L\n 26.8 %\n 22.8 K/uL\n [image002.jpg]\n 07:34 AM\n 03:29 PM\n 03:16 AM\n 03:31 AM\n 07:50 PM\n 04:10 AM\n 05:33 AM\n 06:00 AM\n 07:59 PM\n 03:58 AM\n WBC\n 17.0\n 22.6\n 22.8\n Hct\n 28.6\n 27.1\n 26.8\n Plt\n 91\n 104\n 133\n Cr\n 1.0\n 0.8\n 0.7\n 0.7\n TCO2\n 19\n 22\n 20\n 22\n 24\n Glucose\n 95\n 37\n 40\n 145\n 61\n 90\n Other labs: PT / PTT / INR:15.1/26.8/1.3, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:92.1 %, Band:5.0 %, Lymph:4.4 %, Mono:3.0 %, Eos:0.4\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.6\n mg/dL, Mg++:1.7 mg/dL, PO4:2.0 mg/dL\n Microbiology: Urine cx. with E. coli and Providencia\n Assessment and Plan\n Respiratory failure: Seems grossly fluid overloaded. Will diurese.\n Does not seem ready to extubate given tachypnea and poor cough.\n Pulmonary Edema: IV diuresis.\n UTI: Change gentamicin to amikacin as providentia has intermediate\n resistence to tobra.\n HTN:\n Anemia: Stable\n ARF: improved\n Diarrhea: Follow up C. diff\n ICU Care\n Nutrition:\n Comments: restart TFs\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 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: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2192-08-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 341980, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:00 AM\n MULTI LUMEN - START 12:50 PM\n EKG - At 02:00 PM\n ARTERIAL LINE - START 02:52 PM\n FEVER - 101.4\nF - 11:00 AM- pan- cultured\n -on Levophed overnight for hypotension, given albumin and IVF for\n volume and poor UOP\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Gentamicin - 10:47 PM\n Aztreonam - 06:08 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 04:05 AM\n Dextrose 50% - 06:47 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 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.7\nC (98\n HR: 77 (77 - 106) bpm\n BP: 127/50(73) {76/37(48) - 127/60(316)} mmHg\n RR: 22 (15 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 11 (4 - 15)mmHg\n CO/CI (Fick): (6.4 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 72 - 73\n Total In:\n 13,550 mL\n 2,528 mL\n PO:\n TF:\n 19 mL\n IVF:\n 9,911 mL\n 2,503 mL\n Blood products:\n 500 mL\n Total out:\n 1,255 mL\n 590 mL\n Urine:\n 955 mL\n 190 mL\n NG:\n 300 mL\n 400 mL\n Stool:\n Drains:\n Balance:\n 12,295 mL\n 1,938 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (450 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 31 cmH2O\n Plateau: 19 cmH2O\n Compliance: 45.5 cmH2O/mL\n SpO2: 98%\n ABG: 7.30/33/99./16/-8\n Ve: 10.8 L/min\n PaO2 / FiO2: 165\n Physical Examination\n HEENT:NCAT mucus membranes dry pale conjunctiva\n CV: RRR S1S2 no m/r/g\n PULM: rales, crackles at RLL, scant crackles at LLL\n ABD: distended, soft +bs throughout\n EXT: WWP 1+dp pulses\n Labs / Radiology\n 151 K/uL\n 9.8 g/dL\n 55 mg/dL\n 1.6 mg/dL\n 16 mEq/L\n 5.9 mEq/L\n 25 mg/dL\n 117 mEq/L\n 146 mEq/L\n 30.8 %\n 7.8 K/uL\n [image002.jpg]\n 10:22 AM\n 11:01 AM\n 02:29 PM\n 02:48 PM\n 04:44 PM\n 09:18 PM\n 01:55 AM\n 02:00 AM\n 04:05 AM\n 04:33 AM\n WBC\n 4.2\n 7.8\n Hct\n 33.4\n 30.8\n Plt\n 138\n 151\n Cr\n 1.4\n 1.6\n 1.6\n TropT\n 0.05\n TCO2\n 18\n 20\n 18\n 17\n 16\n 17\n 17\n Glucose\n 69\n 62\n 55\n Other labs: CK / CKMB / Troponin-T:69/4/0.05, Differential-Neuts:35.0\n %, Band:28.0 %, Lymph:11.0 %, Mono:7.0 %, Eos:0.0 %, Lactic Acid:4.9\n mmol/L, Albumin:1.8 g/dL, Ca++:6.6 mg/dL, Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia and septic physiology.\n Septic Shock: Current differential includes pneumonia vs. urosepsis\n vs. GI source. Cultures grew , wait for speciation but until\n then continue to cover broadly. Sputum and urine cultures pending.\n Patient was noted to have distended abdomen on presentation, CT abdomen\n shows distended bladder, b/l hydroureters and gas/stool in bowel with\n some mild bowel thickening. There is no indication of obstruction but\n patient has not passed gas/stool since admission (unclear if this is\n chronic diarrhea). This is likely ileus secondary to acute illness and\n less likely an infectious source. For hypotension the patient received\n large volume of IV NS, LR. Switched to D5 1/2NS w/bicarb d/t rising K\n and Na.\n - follow up sputum, urine cultures\n - continue vancomycin, aztreonam, gentamycin\n - IVF boluses with normal saline to maintain MAP > 65, urine output >\n 30 cc/hr, CVP 10-12\n - trend lactate\n - attempt to wean off levophed\n -monitor fever curve- patient initially febrile but became hypothermic\n overnight requiring bear hugger.\n -monitor WBC and diff\n Respiratory Failure: Patient on AC 500/8/60%. PCO2 on ventilator is\n 33. Will wean FIO2 as tolerated today. Likely secondary to pneumonia.\n -f/u cultures and continue abx as above\n - wean FiO2 as tolerated\n -wean off sedation as tolerated- this will also assist with bowel\n motility\n ARF: Creatinine 2.0 from baseline of 0.6. Likely prerenal in etiology\n secondary to volume depletion and septic shock.\n - IVF boluses to maintain urine output\n - trend creatinine\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with upward trending CE. This is likely demand\n ischemia in setting of hypotension. Now that BP and tachycardia under\n control, warm and perfusing, can follow-up cardiac function with echo.\n - recheck EKG now that tachycardia has improved\n - ECHO if possible to evaluate for MI or change from prior\n Hypertension:\n - holding all antihypertensives in the setting of hypotension\n Dementia: Currently intubated to difficult to assess mental status.\n - holding namenda and aricept for now\n FEN: IVF- D5\n NS, if bicarb trends downward can add \n amps bicarb.\n Monitor and replete electrolytes as needed.\n Monitor K closely, add kayexelate if needed.\n NGT in place however has had high residuals overnight so should hold\n off on TF until bowel function improves.\n Prophylaxis: SC heparin, bowel regimen\n Communcation: Sister \n Code: DNR per nursing home record signed by patient's sister. Clarify\n goals of care with HCP.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:44 AM\n 18 Gauge - 10:00 AM\n 16 Gauge - 10:00 AM\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2192-08-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342882, "text": "Chief Complaint: 82 year old female with history of breast cancer, CVA,\n htn, who presents from rehab with pneumonia and urosepsis.\n 24 Hour Events:\n EKG - At 12:30 AM\n Yesterday patient placed back on higher pressure support for tachypnea\n to . Per nursing patient with less yellow secretions, now more thin\n and watery. Started on amikacin with providencia stuartii and e. coli\n in urine. C. diff negative. Repeat urine culture now negative.\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Gentamicin - 11:00 PM\n Vancomycin - 08:10 AM\n Amikacin - 05:04 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:07 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Pantoprazole (Protonix) - 12:31 AM\n Fentanyl - 04:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.4\nC (97.6\n HR: 75 (65 - 93) bpm\n BP: 170/53(89) {128/48(72) - 182/75(108)} mmHg\n RR: 27 (16 - 37) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 64.8 kg\n Height: 66 Inch\n CVP: 7 (-2 - 7)mmHg\n Total In:\n 1,851 mL\n 356 mL\n PO:\n TF:\n 586 mL\n 346 mL\n IVF:\n 475 mL\n 10 mL\n Blood products:\n Total out:\n 3,470 mL\n 700 mL\n Urine:\n 3,470 mL\n 640 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n -1,619 mL\n -344 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 316 (316 - 460) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 119\n PIP: 16 cmH2O\n SpO2: 97%\n ABG: 7.49/31/121/22/2\n Ve: 9.4 L/min\n PaO2 / FiO2: 303\n Physical Examination\n General\n intubated, not sedated, not responding to commands\n Cards\n RRR, nl s1/s2, no murmur appreciated\n Pulm\n decreased breath sounds right side compared to left, + rhonchi\n on right , left lung clear\n Abdomen - + BS, soft, non-tender\n Extremities\n 2+ radial pulses b/l, 1+ edema of arms, 2+ edema of feet\n b/l to mid calf, WWP, no clubbing or cyanosis\n Labs / Radiology\n 195 K/uL\n 8.7 g/dL\n 141 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 112 mEq/L\n 141 mEq/L\n 26.1 %\n 24.0 K/uL\n [image002.jpg]\n 03:31 AM\n 07:50 PM\n 04:10 AM\n 05:33 AM\n 06:00 AM\n 07:59 PM\n 03:58 AM\n 05:43 PM\n 08:36 PM\n 03:46 AM\n WBC\n 22.6\n 22.8\n 24.0\n Hct\n 27.1\n 26.8\n 26.1\n Plt\n 104\n 133\n 195\n Cr\n 0.8\n 0.7\n 0.7\n 0.8\n 0.9\n TCO2\n 20\n 22\n 24\n 24\n Glucose\n 37\n 40\n 145\n 61\n 90\n 104\n 141\n Other labs: PT / PTT / INR:13.9/26.8/1.2, CK / CKMB /\n Troponin-T:73/4/0.14, ALT / AST:22/24, Alk Phos / T Bili:66/0.4,\n Differential-Neuts:92.1 %, Band:5.0 %, Lymph:4.4 %, Mono:3.0 %, Eos:0.4\n %, Lactic Acid:2.6 mmol/L, Albumin:2.2 g/dL, LDH:161 IU/L, Ca++:7.3\n mg/dL, Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n who presents from rehab with pneumonia, urinary tract infection, and\n septic physiology.\n Septic Shock: Patient was with SIRS with E coli in blood and urine,\n as well as providencia stuartii in urine. CXR shows bibasilar\n consolidations as well concerning for possible pneumonia. Sputum\n culture with gram + cocci however this has not grown out so far in\n speciation. There is some mild enteritis as wel as CTl. Presentation\n lactate was 3.4, then trended down.\n - repeat sputum culture - GRAM STAIN (Final ): >25 PMNs and <10\n epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM\n POSITIVE COCCI. IN PAIRS AND CHAINS.\n 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Final ): SPARSE GROWTH OROPHARYNGEAL\n FLORA.\n - urine culture 9./17\n no growth final\n - c. diff negative \n - Urine -urine cx - URINE CULTURE (Final ):\n ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..\n PROVIDENCIA STUARTII. 10,000-100,000 ORGANISMS/ML..\n - currently on amikacin and vancomycin, still with tachypneia,\n although secretions have improved\n - allergy to PCN\n - currently off all pressors, now hypertensive\n - wbc count continuese to trend up with bandemia\n repeat Ucx is clean,\n c diff negative, may suggest that pneumonia is not being adequately\n treated, however patient remains afebrile\n - chest x-ray from yesterday\n 1) No significant change since with right pleural\n effusion\n and basilar opacity, likely atelectasis.\n 2) Unchanged support lines and tubes.\n -continue to monitor fever curve, WBC\n Respiratory Failure: Initially respiratory failure likely due to\n pneumonia. Patient on pressure support with 40% O2; with improved\n secretions, hoever patient remains tachypneic with significant work of\n breathing, patient with present but impaired gag reflex\n -culture data and antibiotics as above\n - Suction PRN\n - consider again increasing pressure support\n - off sedation\n Hypertension:\n - initially holding anti-hypertensives in the setting of hypotension\n - IV hydral PRN for elevated blood pressure, but trying to get on\n better beta blocker/ace regimen\n - increased lisinopril today to 5\n -increased metoprolol to 75 TID this morning\n - lasix today for blood pressure control as well as fluid removal\n Anemia: Hematocrit drop; normocytic normochromic with iron profile\n sugesting chornic disease or infection. It is not that likely massive\n GI bleed in patient that did not move bowels since blood is prokinetic.\n Will guaiac stool when available.\n - crit is stable\n -Patient guaic positive in the ED, guiac positive stool\n - Coffee ground emesis from NG tube; guaiac negative\n - likely requires outpatient colonscopy, which is non-emergent\n - continue to follow\n ARF: Creatinine 2.0 on admission, from baseline of 0.6 today improved\n baseline. Likely prerenal in etiology secondary to volume depletion\n and septic shock\n likely ATN. No cast seen in UA, but it was not\n fresh. Today\ns eGFR is 46 (MDRD formula) so may restart ACEI.\n - continue to follow\n EKG Changes: Patient with ST depressions in the setting of sinus\n tachycardia to the 130s with multiple negative troponins. This was\n likely demand ischemia in setting of hypotension. repeat EKG from \n EKG Sinus rhythm. Premature ventricular contractions. Poor R wave\n progression may be lead placement or possible old anterior myocardial\n infarction. Compared to\n the previous tracing of axis has shifted rightward. Ventricular\n ectopy is new. ECHO from - IMPRESSION: Mild focal LV systolic\n dysfunction. Mildly dilated right ventricle. Mild to moderate aortic\n regurgitation. Moderately dilated ascending aorta.\n Dementia: Currently intubated to difficult to assess mental status.\n - namenda and aricept yesterday\n FEN:\n - tube feeds\n -check pm lytes, replete electrolytes as needed.\n Prophylaxis: SC heparin, holding bowel regimen for diarrhea\n Access: RIJ\n Communcation: Sister \n Code: Full Code.\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 01:49 PM 55 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:50 PM\n Arterial Line - 02:52 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": "2192-08-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 344092, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 03:08 PM\n -40mg IV lasix with good urine output (approx 500cc)\n -medications changed to PO if possible to avoid excess urine, decreased\n free water flushes with TFs\n -switched to AC overnight for persistent apnea\n Allergies:\n Aspirin\n Unknown;\n Penicillins\n Unknown;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 06:19 PM\n Vancomycin - 08:00 AM\n Metronidazole - 09:06 PM\n Amikacin - 09:07 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 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: 37.2\nC (98.9\n HR: 73 (57 - 78) bpm\n BP: 144/58(81) {128/51(71) - 165/71(96)} mmHg\n RR: 15 (11 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77 kg (admission): 66.5 kg\n Height: 66 Inch\n Total In:\n 2,294 mL\n 358 mL\n PO:\n TF:\n 324 mL\n 238 mL\n IVF:\n 1,400 mL\n 71 mL\n Blood products:\n Total out:\n 2,400 mL\n 790 mL\n Urine:\n 2,400 mL\n 790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -106 mL\n -432 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 430 (319 - 480) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 3\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 18 cmH2O\n Plateau: 16 cmH2O\n SpO2: 100%\n ABG: ///32/\n Ve: 7.3 L/min\n Physical Examination\n GEN: Intubated, sedated\n HEENT: NCAT MMM anicteric pale conjunctiva\n CV: RRR S1S2\n PULM: rhonchi at mid-lung fields, likely intubation otherwise clear\n while supine\n ABD: soft, distended, nontender +bs no palp masses\n EXT: WWP 1+ bipedal edema 1+dp pulses no cyanosis\n SKIN: no new lesions, rashes noted\n Labs / Radiology\n 666 K/uL\n 8.0 g/dL\n 152 mg/dL\n 1.1 mg/dL\n 32 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 102 mEq/L\n 138 mEq/L\n 24.9 %\n 15.4 K/uL\n [image002.jpg]\n 03:46 AM\n 09:00 PM\n 01:47 AM\n 02:07 AM\n 04:35 AM\n 05:32 AM\n 04:12 AM\n 08:43 AM\n 02:53 PM\n 05:54 AM\n WBC\n 24.0\n 26.1\n 16.1\n 15.7\n 15.4\n Hct\n 26.1\n 28.7\n 22.5\n 23.4\n 24.9\n Plt\n 195\n 312\n 583\n 548\n 666\n Cr\n 0.9\n 0.9\n 1.1\n 1.1\n 1.0\n 1.1\n TropT\n 0.10\n TCO2\n 28\n 27\n 28\n Glucose\n 141\n 69\n 216\n 83\n 105\n 152\n Other labs: PT / PTT / INR:15.5/27.6/1.4, CK / CKMB /\n Troponin-T:37/3/0.10, ALT / AST:, Alk Phos / T Bili:79/0.3,\n Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,\n Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic\n Acid:1.0 mmol/L, Albumin:2.3 g/dL, LDH:256 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 82 year old female with a history of breast cancer, CVA, hypertension\n with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL\n aspiration PNA presents from medical floor after likely PEA arrest now\n with worsening mental status than on previous transfer now 48 hours\n after the event.\n # Cardiopulmomary Arrest: Patient found pulseless, ashen, and cool,\n down for no longer than 10 minutes. Patient not monitored on telemetry\n at the time of the event. She quickly regained rhythm after intubation\n and 1gm epinephrine w/ CPR. In the setting of underlying RLL\n infiltrate, concern for worsening pulmonary edema on the floor, most\n likely etiology respiratory arrest w/ mucous plug. No further events\n since admission to ICU, although continues to have episodes of apnea\n while on PS.\n - treat underlying cause of PNA, provide respiratory support with\n ventilator for now\n - continue to trend lactate\n - monitor on telemetry, patient appears to be hemodynamically stable\n -CT head to evaluate for any acute insults that may be causing her\n apneic periods\n .\n # Hypercarbic Respiratory Failure: S/p intubation x2. Hypercarbic\n likely to arrest d/t pulmonary etiology (mucus plugging, apneic\n period). Overnight with significant secretions needing frequent\n suctioning. Will continue to wean as tolerated to PS although not ready\n for extubation. Will discuss goals of care with niece this morning\n (extubation, trach placement etc.)\n - Wean FIO2 as tolerated, to PS\n - weak cough, no gag per RT\n - suction prn, nebs prn\n - -d/w family re: trach\n .\n # HAP/Aspiration PNA/sepsis: Patient on broad spectrum coverage since\n admission, has grown GPC pairs/clusters in sputum and E.coli in blood\n and urine. CT from showed persistent RLL infiltrate. CBC showing\n new bands on diff in setting of code.\n - continue vanc/levo/flagyl, patient currently on day 11 of ABX, (3\n more days)\n - sputum from - GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND\n CLUSTERS.\n RESPIRATORY CULTURE (Preliminary): NO GROWTH.\n- only positive blood culture so far from - ESCHERICHIA COLI\n |\nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 4 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCEFUROXIME------------ 4 S\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n .\n # Urosepsis: E.coli bacteremia, and e.coli/providencia UTI. Repeat\n cultures have been negative. Has been on amikacin, last day .\n - f/u amikacin levels this morning\n .\n # Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6, currently\n on CVVH. Likely prerenal in etiology secondary to episode of\n hypoperfusion.\n - suspect that some of renal failure is likely due to poor forward flow\n and patient looks volume overloaded by physical exam\n - trend creatinine\n - goal I/O is negative 1 liter per day, would give lasix as\n needed to achieve this\n .\n # Hypertension: On lisinopril, metoprolol as outpatient\n - restart lisinopril today, uptitrate as tolerated\n - lasix 40mg IV qd, monitor UOP\n .\n # Dementia: Currently intubated without need for sedative medications.\n Concern for possible cerebral ischemic insult during her PEA arrest\n that may be causing her apnea.\n - continue namenda and aricept\n - -CT head as above\n .\n FEN: tubes feeds, monitor electrolytes, repleted K aggressively this\n morning for K of 2.6\n .\n # Prophylaxis: SC heparin, d/c bowel regimen in the setting of\n persistent diarrhea, PPI\n .\n # Communcation: Sister , will decide on trach in\n the morning\n .\n # Code: FC - plan to reassess with sister today\n .\n # Disposition: ICU care for now\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:32 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:15 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 ERROR: In note patient is said to be on CVVH. This is an error and\n should be disregarded. Patient is currently not on any form of HD and\n has not been during this admission.\n ------ Protected Section Addendum Entered By: , MD\n on: 10:46 ------\n" }, { "category": "Nutrition", "chartdate": "2192-08-31 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 344282, "text": "Comments:\n Noted per family meeting, plan to withdraw care & extubated patient\n tomorrow.\n Will sign off at this time.\n" }, { "category": "Radiology", "chartdate": "2192-08-17 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1033707, "text": " 12:12 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Assess RIJ placement, r/o pneumothorax.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p RIJ placement.\n REASON FOR THIS EXAMINATION:\n Assess RIJ placement, r/o pneumothorax.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf FRI 3:30 PM\n Right IJ ending at cavoatrial junction. No pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 82-year-old woman status post right IJ placement, assess for right\n IJ placement and rule out pneumothorax.\n\n TECHNIQUE: Portable chest radiograph, single view.\n\n COMPARISON: Compared to chest radiograph from done at 5:40\n in the morning.\n\n FINDINGS: Placement of the new right IJ. Right IJ ending at the cavoatrial\n junction. No pneumothorax. Again noted is the increased opacification in the\n right middle lung and retrocardial, unchanged. The endotracheal tube is\n ending around 7 cm above carina. The nasogastric tube ends in the stomach.\n\n IMPRESSION: Right IJ ending at the cavoatrial junction. No pneumothorax.\n Rest of the study unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2192-08-17 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1033708, "text": ", W. MED 12:12 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Assess RIJ placement, r/o pneumothorax.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p RIJ placement.\n REASON FOR THIS EXAMINATION:\n Assess RIJ placement, r/o pneumothorax.\n ______________________________________________________________________________\n PFI REPORT\n Right IJ ending at cavoatrial junction. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2192-08-17 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 1033617, "text": " 6:26 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ? ischemic bowel? no PO contrast\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with dilated loops of bowel and gastroparesis and guiac +\n stool\n REASON FOR THIS EXAMINATION:\n ? ischemic bowel? no PO contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc FRI 7:26 AM\n No obstruction. No mesenteric ischemia at this time; arterial supply patent.\n Short segment of small bowel thickening could be enteritis. However, small amt\n intraperitoneal fluid of unclear etiology. Bilateral hydroureter could be due\n to markedly distended bladder. Rectum and sigmoid distended with fecal\n matter.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old woman with sepsis and guaiac-positive stool, with\n dilated loops of bowel.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis following administration of intravenous contrast material. No oral\n contrast was administered. Intravenous contrast material was administered\n despite elevated creatinine by the request of the ED staff. Multiplanar\n reformatted images were also obtained.\n\n CT ABDOMEN WITH IV CONTRAST: At the lung bases, focal consolidation is\n present bilaterally, without pleural effusion. The heart is somewhat\n enlarged, but there is no pericardial effusion.\n\n In the abdomen, the aorta is normal in caliber, although it takes a markedly\n tortuous course through the abdomen. A moderate degree of atherosclerotic\n calcification is present, but the branch vessels all remain patent.\n\n A small amount of simple fluid tracks through the mesentery.\n\n The liver is unremarkable. The gallbladder is somewhat distended, although\n without wall thickening or stones. The spleen, stomach (containing\n nasogastric tube) and duodenum are unremarkable.\n\n There is a single, horseshoe kidney connected along the upper pole of both\n kidneys. The kidneys contain multiple simple cysts, and there is mild\n hydronephrosis and hydroureter bilaterally. Hydroureter extends to the\n ureterovesical junction, but no obstructing calculus is present. The urinary\n bladder is markedly distended, despite the presence of a Foley catheter.\n\n The adrenal glands are not definitively identified.\n\n There is no free air in the abdomen. There is no intrahepatic biliary ductal\n (Over)\n\n 6:26 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ? ischemic bowel? no PO contrast\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n dilatation, or pneumobilia. Simple cysts are present in the liver. The\n pancreas is unremarkable.\n\n CT PELVIS WITH IV CONTRAST: The rectum and sigmoid colon are distended with\n dense fecal matter, and the rectal tube is in place. More proximal loops of\n large bowel are filled with air and large in caliber, but there is no small\n bowel dilatation to suggest obstruction. In the colon, there is no bowel wall\n thickening to suggest mesenteric ischemia. Multiple loops of small bowel are\n normal in caliber, and overall, there is no evidence of mesenteric ischemia.\n Only a short segment of proximal small bowel demonstrates mild wall thickening\n (3:34, 36).\n\n As previously mentioned, the urinary bladder is distended, despite the\n presence of a Foley catheter. The uterus is involuted or absent. There are\n no adnexal abnormalities. There is no free fluid in the pelvis. There is no\n pelvic, inguinal, mesenteric or retroperitoneal lymphadenopathy.\n\n OSSEOUS STRUCTURES: Alignment of the lumbar spine is markedly abnormal, with\n anterior wedge deformities of L3 and L4, with degenerative changes between L2\n and L5. There is retrolisthesis of L4 on L5, with evidence of bony fusion at\n L4-5 and at L2-3. The spinal canal is narrowed at L4-5.\n\n No acute fracture is identified. There are no worrisome lytic or sclerotic\n bony lesions. Soft tissues are unremarkable. Severe degenerative changes are\n also present in both hip joints.\n\n IMPRESSIONS:\n 1. No evidence of mesenteric ischemia at this time. Abdominal arterial\n supply is patent throughout.\n 2. Focal segment of wall thickening in the small bowel is nonspecific.\n 3. Rectum and sigmoid colon distended with dense fecal matter.\n 4. Horseshoe kidney with bilateral hydroureter extending to the\n ureterovesical junction, with a markedly distended bladder, despite the\n presence of a Foley catheter. Hydroureter likely secondary to bladder\n distention. No obstructing calculi are identified.\n 5. Multiple renal and hepatic simple cysts.\n 6. Severe degenerative changes in the lower lumbar spine and hips, with\n retrolisthesis of L4 on L5, with bony fusion.\n 7. A small amount of fluid tracking through the mesentery, of unclear\n etiology.\n 8. Consolidation at both lung bases may reflect multifocal pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2192-08-17 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1033615, "text": " 5:39 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate for appropriate tube placemetn\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with acute resp distress, s/p ETT, NGT placement.\n REASON FOR THIS EXAMINATION:\n evaluate for appropriate tube placemetn\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old woman with acute respiratory distress, status post\n ETT and NG tube placement.\n\n COMPARISON: Chest radiograph of approximately one hour earlier, under the\n name, EU Critical, .\n\n SINGLE SEMI-UPRIGHT VIEW OF THE CHEST AT 5:40 A.M.: The lungs are well\n expanded, and again, there is increased opacity in the right mid lung,\n centrally base, as well as retrocardiac opacity. The upper lung zones are\n well aerated. The pulmonary vasculature is normal in caliber. The heart is\n not enlarged, and there is no hilar or mediastinal enlargement.\n\n An endotracheal tube is in place, terminating approximately 2.2 cm from the\n carina and can be retracted 1-2 cm for standard positioning. Nasogastric tube\n extends into the stomach and off the bottom of the radiograph.\n\n Soft tissue and bony structures are unremarkable. There is no pneumothorax.\n\n IMPRESSION:\n 1. ETT 2.2 cm from carina can be retracted 1-2 cm for standard positioning.\n Appropriate nasogastric tube placement.\n 2. Bilateral lower lobe consolidation could represent multifocal pneumonia\n secondary to aspiration.\n\n" }, { "category": "Echo", "chartdate": "2192-08-20 00:00:00.000", "description": "Report", "row_id": 95442, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension/ CVA/Breast Cancer/Sepsis.\nHeight: (in) 66\nWeight (lb): 171\nBSA (m2): 1.87 m2\nBP (mm Hg): 147/62\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 10:26\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient. No VSD.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid\ninferior - hypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\nParadoxic septal motion consistent with conduction abnormality/ventricular\npacing.\n\nAORTA: Normal aortic diameter at the sinus level. Moderately dilated ascending\naorta.\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. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. Trivial MR.\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.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm). Bilateral pleural\neffusions.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is mild regional left ventricular\nsystolic dysfunction with mild hypokinesis of the basal to mid inferior septum\nand inferior wall. There is no ventricular septal defect. The right\nventricular cavity is mildly dilated with normal free wall contractility. The\nascending aorta is moderately dilated. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. Mild to moderate (+)\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. Trivial mitral regurgitation is seen. There\nis moderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Mild focal LV systolic dysfunction. Mildly dilated right\nventricle. Mild to moderate aortic regurgitation. Moderately dilated ascending\naorta.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-08-24 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1035093, "text": " 8:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please evaluate for NGT position. Thanks.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with recent stroke; extuabted today.\n REASON FOR THIS EXAMINATION:\n Please evaluate for NGT position. Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:37 P.M., \n\n HISTORY: Recent stroke. Extubated. Check NG tube position.\n\n IMPRESSION: AP chest compared to through 19:\n\n Left lower lobe collapse, moderate left and moderate-to-large right pleural\n effusion unchanged since . Mass-like lesion lateral to the _____\n but not obscuring the right hilus could be a lung abscess or fissural pleural\n effusion. Nasogastric tube passes below the diaphragm and out of view. Heart\n size normal. Dr. was paged to report these findings at the time of\n dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-08-27 00:00:00.000", "description": "FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE", "row_id": 1035427, "text": " 11:31 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please evaluate for PICC. PICC RN unable to place at bedside\n Admitting Diagnosis: PNEUMONIA\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with sepsis UTI. Needs PICC for long term antibiotics\n REASON FOR THIS EXAMINATION:\n Please evaluate for PICC. PICC RN unable to place at bedside\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: Dr. with , the Attending Radiologist, performed\n the procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right basilic\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a double lumen PICC line measuring 50 cm in length was then\n placed through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was 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 5-French\n double lumen PICC line placement via the right 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": "ECG", "chartdate": "2192-08-27 00:00:00.000", "description": "Report", "row_id": 252158, "text": "Sinus rhythm\nDelayed R wave progression with late precordial QRS transition\nBorderline prolonged Q-Tc interval\nDiffuse T abnormalities\nFindings are nonspecific but cannot exclude in part ischemia - clinical\ncorrelation is suggested\nSince previous tracing of the same date, rate slower, late precordial QRS\ntransition more prominent and further T waves changes seen\n\n" }, { "category": "ECG", "chartdate": "2192-08-27 00:00:00.000", "description": "Report", "row_id": 252367, "text": "Sinus rhythm with borderline sinus tachycardia\nDelayed R wave progression with late precordial QRS transition\nProbable left ventricular hypertrophy\nDiffuse ST-T wave changes\nFindings are nonspecific\nSince previous tracing of , rate faster, and further ST-T wave changes\npresent\n\n" }, { "category": "ECG", "chartdate": "2192-08-23 00:00:00.000", "description": "Report", "row_id": 252368, "text": "Sinus rhythm. Poor R wave progression is suggestive of anteroseptal myocardial\ninfarction of indeterminate age. Inferolateral ST-T wave changes. Cannot rule\nout myocardial ischemia. Compared to the previous tracing of inferior\nST-T wave changes are more prominent. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2192-08-21 00:00:00.000", "description": "Report", "row_id": 252369, "text": "Sinus rhythm. Left axis deviation. Probable left anterior fascicular block.\nSlightly delayed precordial R wave progression may be due to lead placememnt.\nCompared to the previous tracing of ventricular ectopy is no longer\npresent. No other diagnostic interim changes.\n\n" }, { "category": "ECG", "chartdate": "2192-08-20 00:00:00.000", "description": "Report", "row_id": 252370, "text": "Sinus rhythm. Premature ventricular contractions. Poor R wave progression may\nbe lead placement or possible old anterior myocardial infarction. Compared to\nthe previous tracing of axis has shifted rightward. Ventricular ectopy\nis new.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2192-08-18 00:00:00.000", "description": "Report", "row_id": 252371, "text": "Sinus rhythm. Left axis deviation. Non-specific ST-T wave changes.\nCompared to the previous tracing of the rate has increased.\nEvidence for left ventricular hypertrophy is no longer seen. T wave\ninversions in leads V4-V6 are no longer seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2192-08-17 00:00:00.000", "description": "Report", "row_id": 252372, "text": "Sinus tachycardia. Left axis deviation. Left ventricular hypertrophy with\nsecondary repolarization abnormalities in leads V4-V6. Non-specific ST-T wave\nchanges elsewhere. Lateral apical T wave inversions may be due to left\nventricular hypertrophy but cannot rule out myocardial ischemia. Compared to\nthe previous tracing of the rate has decreased.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2192-08-17 00:00:00.000", "description": "Report", "row_id": 252373, "text": "Sinus tachycardia with extensive artifact. Left ventricular hypertrophy with\nsecondary repolarization changes. Mild intraventricular conduction delay.\nDiffuse ST-T wave changes in the inferior and anterolateral leads. Clinical\ncorrelation is suggested. Compared to the previous tracing of the\nventricular rate is markedly faster. Atrial ectopy is absent and diffuse\nST-T wave changes are more prominent.\n\n" } ]

[ { "category": "ECG", "chartdate": "2192-04-12 00:00:00.000", "description": "Report", "row_id": 265733, "text": "Sinus rhythm. P-R interval prolongation. Compared to the previous tracing\nof the rate has slowed. The P-R interval has increased (0.33 seconds).\nThe rate has slowed. There is delayed precordial R wave progression. The\ninferior ST-T wave abnormalities persist. The T waves are now upright in\nleads V4-V6. The axis remains rightward. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2192-04-11 00:00:00.000", "description": "Report", "row_id": 265734, "text": "Sinus rhythm\nFirst degree A-V block\nLong QTc interval\nInferior T wave changes are nonspecific\nSince previous tracing, no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2192-04-13 00:00:00.000", "description": "Report", "row_id": 1301913, "text": "Neuro: alert and oriented x 3, mae, following commands correctly, denies pain, continues with diladid pca and prn flexaril and ibuprofin.\n\nCardiac: 1st degree heart block in the 60's, no ectopy noted, palpible pedial pulses, skin warm dry and intact, afebrile.\n\nResp: lungs coarse in bases, on ra satting 93-95%, is coughing and deep breathing and is using i/s though only pulling 250-400 with i/s.\n\nSkin: chest with dsd that is cdi, ct dsd is cdi.\n\nGi/Gu: tolerating po's abd soft round and nontender, good bowel sounds, on riss, making good u/o.\n\nPlan: f2 later today if heart rhythm remains good, increase activity as tolerates, monitor blood sugars, encourage to cough and deep breath and to use i/s.\n" }, { "category": "Nursing/other", "chartdate": "2192-04-11 00:00:00.000", "description": "Report", "row_id": 1301910, "text": "csru update\nNEURO: AWAKE, INTUBATED. MAEW IN BED. NODDING TO QUESTIONS, FOLLOWING COMMANDS.\n\nCV: VSS AS PER FLOWSHEET. TO CSRU ON LOW DOSE NEO, PRESENTLY BEING WEANED. NSR IN 90'S, EPISODES OF PVC. MGSO4 AND KCL GIVEN W/ EFFECT. EPICARDIAL WIRES IN PLACE. (SCREW LEAD ALSO PLACED INRA-OP) CVP7-13.\n\nRESP: LUNGS W/ COARSE INSP WHEEZE UPPER FIELDS. NEBS ORDERED. ON VENTOLIN AT HOME. ON CPAP AT THIS TIME, DUE FOR ABG. CT W/ MIN SANG DNG, NO AIR KEAK.\n\nGI/GU: UOP BRISK, ABD SOFT. MIN BILOUS DNG VIA OGT.\n\nPAIN: LOW PAIN TOLERANCE PER MOTHER. PAIN SERVICES CONSULTED. DILAUDID PCA ORDERED. DAILY METHADONE DOSING TO CONTINUE.\n\nSOCIAL: MOTHER IN TO, PACKET GIVEN. TO RETURN THIS AFTERNOON.\n\nASSESS: STABLE POST-OP. RESTLESS W/ ETT AT PRESENT.\n\nPLAN: CPAP ABG, EXTUBATE AS INDICATED. DILAUDID PCA.\n" }, { "category": "Nursing/other", "chartdate": "2192-04-12 00:00:00.000", "description": "Report", "row_id": 1301911, "text": "Neuro: alert and oriented x 3, mae, following commands correctly, diladid pca for pain and morphine, when pt falls asleep awakes with lots of pain, very hard to assess pain as pt is apprehensive and reports that every movement is a 10 out of 10 and at rest is 10 out of 10.\n\nCardiac: nsr with lots of pvcs throughout night, started on nitro gtt, started on iv lopressor, palpible pedial pulses, skin warm dry and intact, +2 edema in extremities, afebrile.\n\nResp: lungs dim in bases, on 4 liters nc with ra sats of 100%, ct system with no air leak draining small amounts of serosang, does not cough and deep breath and only would do i/s x 2 only up to 250 each time and refused to do any more.\n\nSkin: chest with dsd that is cdi, ct dsd is cdi.\n\nGi/Gu: tolerating po's, abd soft round and nontender with good bowel sounds, on riss, making good hourly u/o.\n\nPlan: ? pain service to start a basal rate for pt or ? restarting all home dose of pain meds now that pt is taking po's, encourage pt to cough and deep breath and to use i/s, wean nitro as tolerates, monitor blood sugars.\n" }, { "category": "Nursing/other", "chartdate": "2192-04-12 00:00:00.000", "description": "Report", "row_id": 1301912, "text": "NEURO: PASSIVE/AGGRESSIVE MOOD. MORE COOPERATIVE THIS PM. A&OX3. MAE, NO DEFICITS, FOLLOWS COMMANDS.\nPAIN: PAIN SERVICE INTO FOLLOW. DILAUDID PCA INCREASED TO 0.5MG QITH LOCKOUT 6MINUTES 1HR LIMIT 5MG. METHADONE INCREASED AND PRN FLEXERIL, IBUPROFEN ADDED. PT CONTINUES STATES HAS PAIN BUT BETTER THIS PM.\nCV: HR 80 WITH PR INTERAL .28 THIS AM. LOPRESSOR 12.5MG THIS AM PR INTERVAL TO 0.38 AND THEN IN AND OUT CHB. BP TOLERATES CHANGE IN RHYTHM.HR WITH PVC'S (COUPLETS NOTED AND 1 6BEAT RUN--LYTES REPLETED WITH CONTINUANCE OF PVC'S)EP INTO SEE NO INTERVENTION NEEDED FEEL IN WILL IMPROVE ON OWN. PT A WIRES DO NOT SENSE BUT WILL CAPTURE. V WIRES SENSE AND CAPTURE. UNABLE TO APACE WHEN IN CHB. PALP PEDAL PULSES. CHEST TUBES DC'D. ALINE DC'D, LT IJ CORDIS CHANGED OVER WIRE TO TRIPLE LUMEN CVL DUE TO POOR ACCESS.\nRESP: LUNG INITIALLY DIM AT BASE, NOW COARSE SOUNDING. POOR DEEP BREATHING AND COUGHING DUE TO PAIN. PT INSTRUCTED OF THE IMPORTANCE OF C/DB. IS TO 250. ON RA THIS AM WITH SATS >95%, NOW SATS LOWER +/- NEED FOR O2 1-2L\nGI/GU: TOL PO'S, ATE DINNER. FOLEY PATENT. GREAT UOP AFTER AM LASIX 20MG IV. ABD SOFT. +BS. NO NAUSEA\nENDO: BS COVERED PER SS.\nPLAN: CONTINUE TO ASSESS RHYTHM. CONT ENCOURAGE C/DB. WEAN O2 AS TOL. INCREASE ACT AS TOL. TX F2 IN AM.\n" } ]

[ { "category": "Radiology", "chartdate": "2110-04-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1188594, "text": " 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for interval change\n Admitting Diagnosis: SEIZURE DISORDER;PNEUMONIA;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year-old female with history of encephalitis s/p L hemispherectomy\n at 19 who presented from an OSH with continued lethargy in the setting of UTI\n with ecoli and pseudomonas from trach on .\n REASON FOR THIS EXAMINATION:\n Eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of encephalitis status post hemispherectomy at\n 19, presenting from an outside hospital with continued lethargy in the setting\n of UTI with E. coli and pseudomonas from the trach on . Evaluate\n for interval change.\n\n COMPARISON: Chest radiograph from . Chest CT from .\n\n FINDINGS: The tracheostomy tube is unchanged in position. The left\n subclavian catheter ends in the mid SVC. Lung volumes remain low. A\n moderate-to-large right pleural effusion is increased, while a\n small-to-moderate left pleural effusion does not appear significantly changed.\n Right mid and lower lung heterogeneous opacities are unchanged. Retrocardiac\n consolidation is unchanged. Mild cardiomegaly is unchanged.\n\n IMPRESSION:\n\n 1. Increased moderate-to-large right pleural effusion and unchanged\n small-to-moderate left pleural effusion.\n\n 2. Right mid/lower lung heterogeneous opacities are not significantly changed\n and are some combination of atelectasis and pneumonia.\n\n 3. Unchanged retrocardiac consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2110-04-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1187972, "text": " 6:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PICC line placement, ?PNA\n Admitting Diagnosis: SEIZURE DISORDER;PNEUMONIA;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman w/ encephalitis s/p L hemispherectomy, trach\n dependent p/w increased secretions, lethargy. ?aspiration PNA\n REASON FOR THIS EXAMINATION:\n PICC line placement, ?PNA\n ______________________________________________________________________________\n WET READ: KKgc TUE 8:33 PM\n LUE PICC extends to the lower RA/IVC, recommended to at least 6-7 cm to\n position it in the lower SVC. Kkaliann d/w Dr. at 8:30 p.m .\n Trach tube ends 2.8 cm above carina. Right upper lobe opacities, concerning\n for aspiration/ infection.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Encephalitis, status post PICC line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n left PICC line. The course of the line is unremarkable, the tip of the line\n projects over the right atrium. To ensure correct position of the lines, it\n has to be pulled back by approximately 8 cm.\n\n Newly appeared signs of mild pulmonary edema. Unchanged moderate\n cardiomegaly. New retrocardiac atelectasis. Unchanged position of the\n tracheostomy tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-04-22 00:00:00.000", "description": "REPLACE G OR C TUBE, ALL INCL.", "row_id": 1189733, "text": " 11:30 AM\n G-TUBE PLACMENT Clip # \n Reason: Please eplace g-tube\n Admitting Diagnosis: SEIZURE DISORDER;PNEUMONIA;URINARY TRACT INFECTION\n ********************************* CPT Codes ********************************\n * REPLACE G OR C TUBE, ALL INCL. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with encephalitis - found to have defective\n g-tube\n REASON FOR THIS EXAMINATION:\n Please eplace g-tube\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 43-year-old female with encephalitis.\n Patient has a longstanding G-tube which has cracked and needs replacement.\n\n CLINICIANS: Dr. and Dr. performed the procedure.\n The attending, Dr. , was present and supervising during the entire\n procedure.\n\n Lidocaine gel was used for local anesthesia.\n\n PROCEDURE DETAILS: Informed consent was obtained from the healthcare proxy\n outlining the risks and benefits of the procedure. The patient was brought to\n the angiography suite and placed supine on the imaging table. A preprocedure\n timeout and huddle was performed per protocol. The indwelling catheter\n and the skin around it was prepped and draped in the usual sterile fashion.\n\n wire was then passed through the gastric port of the existing G-tube\n and coiled in the lumen. The catheter was then gently pulled out over the\n wire after deflating the retaining balloon. A new 18-French G-tube was then\n placed over the wire with tip within the stomach lumen confirmed by injection\n of diluted contrast. The retaining balloon was then inflated with 7 cc of\n diluted contrast. The external disc was pushed to the skin level and\n retaining sutures were placed above the disc. Sterile dressings were applied.\n The patient withstood the procedure well and had no immediate complications\n and was shifted to the floor in stable condition.\n\n IMPRESSION: Uncomplicated replacement of a cracked 18-French MIC G-tube with\n a similar sized new G-tube. No immediate complications.\n\n" }, { "category": "Radiology", "chartdate": "2110-04-16 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1188899, "text": " 9:22 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ALP has continued to trend up. Please assess for biliary tra\n Admitting Diagnosis: SEIZURE DISORDER;PNEUMONIA;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with Rassmusen's encephalitis s/p L hemispherectomy,\n seizures, trach/G-tube dependent admitted with E. Coli UTI and Pseudomonas PNA,\n now with uptrending ALP.\n REASON FOR THIS EXAMINATION:\n ALP has continued to trend up. Please assess for biliary tract disease.\n ______________________________________________________________________________\n WET READ: ENYa WED 9:57 AM\n No gallstones or biliary abnormality. Normal CBD measures 3mm.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 43-year-old woman, status post left hemispherectomy, with seizure\n and multiple other disease, now presenting with E. coli urinary tract\n infection and Pseudomonas pneumonia with uptrending alkaline phosphatase.\n Assess for biliary abnormalities.\n\n COMPARISON: Multiple prior studies with the latest CT abdomen and pelvis on\n .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in echotexture without\n focal lesions. There is no intrahepatic or extrahepatic biliary ductal\n dilatation. The normal CBD measures 3 mm in diameter. The gallbladder is\n normal without gallstones or pericholecystic fluid. The spleen measures 9.2\n cm. There is normal hepatopetal portal venous flow. The visualized IVC and\n aorta are grossly unremarkable. The pancreatic tail is not well assessed\n secondary to bowel gas obscuration, but the remaining pancreas is normal.\n There is no ascites.\n\n IMPRESSION: Normal right upper quadrant ultrasound, without biliary\n abnormality.\n\n" }, { "category": "Radiology", "chartdate": "2110-04-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1188100, "text": " 5:01 PM\n CHEST (PA & LAT) Clip # \n Reason: Pneumonia vs. pulmonary edema, interval changes?\n Admitting Diagnosis: SEIZURE DISORDER;PNEUMONIA;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with increased trach secretions, ?PNA\n REASON FOR THIS EXAMINATION:\n Pneumonia vs. pulmonary edema, interval changes?\n ______________________________________________________________________________\n WET READ: 12:10 AM\n Bilateral perihilar opacities, likely pulmonary edema, appears wose which is\n likely due to technique. Small pleural effusions. Left PICC ends in the low\n SVC.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: Pneumonia versus pulmonary edema.\n\n Comparison is made with prior study performed a day earlier.\n\n Bilateral extensive opacities larger on the right side appear worse likely due\n to pulmonary edema. Bilateral pleural effusions larger on the right side are\n probably unchanged. Cardiomegaly is stable. Tracheostomy tube is in standard\n position. Left PICC tip is in the mid to low SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-04-13 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1188576, "text": " 8:17 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Source of bilateral diffuse infiltrates? Pulmonary edema? Ef\n Admitting Diagnosis: SEIZURE DISORDER;PNEUMONIA;URINARY TRACT INFECTION\n Field of view: 38\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year-old female with history of encephalitis s/p L hemispherectomy\n at 19 who presented from an OSH with continued lethargy in the setting of UTI\n with ecoli and pseudomonas from trach on .\n REASON FOR THIS EXAMINATION:\n Source of bilateral diffuse infiltrates? Pulmonary edema? Effusions?\n Consolidations?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SUN 9:50 PM\n 1. Moderate to large pleural effusions bilaterally with adjacent 3.\n compressive atelectasis.\n 2. Opacification in right upper lobe is concerning for infectious etiology,\n other considerations are asymmetric edema versus hemorrhage.\n 3. Left hilar lymph node.\n 4. small pericardial effusion.\n 5. ett and left picc in std position.\n d/w dr. at 9;50pm on via tel.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral pulmonary opacities seen on recent chest radiographs as\n well as increased lethargy and positive cultures from a tracheostomy tube in a\n patient whose history is significant for encephalitis status post\n remote left hemispherectomy.\n\n COMPARISON: Chest radiographs from , & a CT from \n\n TECHNIQUE: Axial CT images were acquired through the thorax without\n intravenous contrast. Coronal and sagittal reformatted images were also\n reviewed.\n\n FINDINGS: Pleural effusions are moderate on the right and small on the left\n with expected overlying subsegmental atelectasis. In addition, there is\n multifocal consolidation and ground glass opacification, most notable in the\n right upper lobe, consistent with pneumonia. There is no pericardial\n effusion. A tracheostomy tube is appropriately positioned. A moderate amount\n of secretions are seen within the distal trachea as well as the mainstem\n bronchi bilaterally.\n\n The heart and great vessels are normal. A left peripherally inserted central\n catheter terminates in the caudal aspect of the superior vena cava. There is\n no hilar, mediastinal or axillary lymphadenopathy. A neural stimulating\n pacing device is visualized in the subcutaneous tissues of the left hemithorax\n anteriorly.\n\n The study is not tailored for precise characterization of subdiaphragmatic\n contents. Nevertheless note is made of a gastrostomy tube which appears\n (Over)\n\n 8:17 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Source of bilateral diffuse infiltrates? Pulmonary edema? Ef\n Admitting Diagnosis: SEIZURE DISORDER;PNEUMONIA;URINARY TRACT INFECTION\n Field of view: 38\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n appropriately positioned. Bony structures reveal no suspicious sclerotic or\n lytic lesions. Note is made of a thoracolumbar scoliotic curvature.\n\n IMPRESSION: Multifocal pneumonia with bilateral right greater than left\n pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2110-04-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1187988, "text": " 10:06 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please evaluate PICC line placement. Please evaluate lung f\n Admitting Diagnosis: SEIZURE DISORDER;PNEUMONIA;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with PICC line moved and admitted with likely pneumonia, may\n also have component of pulmonary edema in setting of lasix being held.\n REASON FOR THIS EXAMINATION:\n Please evaluate PICC line placement. Please evaluate lung fields.\n ______________________________________________________________________________\n WET READ: KKgc TUE 11:41 PM\n LUE PICC now ends in the mid SVC level. Interval increase in the airspace\n opacities in the right lung, suggests asymmetric pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: PICC line, followup.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the PICC line has been\n pulled back, the tip now projects over the upper-to-mid SVC. Unchanged\n moderate cardiomegaly and unchanged bilateral parenchymal opacities that have\n neither increased nor decreased in extent. Presence of a small right pleural\n effusion cannot be excluded. No newly appeared focal parenchymal opacities.\n Unchanged position of the pacemaker.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-04-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1188418, "text": " 9:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Fluid overload vs pna? Worsening fluid overload?\n Admitting Diagnosis: SEIZURE DISORDER;PNEUMONIA;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with cough, sob, on trach, with pna, holding her lasix.\n Worsening cough and more secretions.\n REASON FOR THIS EXAMINATION:\n Fluid overload vs pna? Worsening fluid overload?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n CLINICAL HISTORY: 43-year-old woman with cough and shortness of breath.\n\n FINDINGS: Comparison is made to previous study from .\n\n Unchanged left-sided pacemaker. There is a tracheostomy tube. There is a\n left-sided PICC line with distal lead tip in the mid SVC. Cardiac silhouette\n is enlarged but stable. There are again noted bilateral pleural effusions and\n opacities, right side worse than left, consistent with confluent pulmonary\n edema. Overall, the findings are stable.\n\n\n" }, { "category": "Echo", "chartdate": "2110-04-14 00:00:00.000", "description": "Report", "row_id": 70629, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Valvular heart disease.\nHeight: (in) 65\nWeight (lb): 210\nBSA (m2): 2.02 m2\nBP (mm Hg): 86/57\nHR (bpm): 53\nStatus: Inpatient\nDate/Time: at 10:42\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. Normal interatrial septum. No\nASD by 2D or color Doppler.\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 chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. 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. No MS.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting bradycardia (HR<60bpm).\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. The diameters of aorta at the sinus, ascending and arch levels are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic stenosis or aortic regurgitation. No masses or\nvegetations are seen on the aortic valve. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. No mass or vegetation is seen on the mitral valve. The\nestimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , no change.\n\n\n" }, { "category": "ECG", "chartdate": "2110-04-10 00:00:00.000", "description": "Report", "row_id": 162021, "text": "Sinus bradycardia. Normal tracing. Compared to the previous tracing\nof the P-R interval is now normal.\n\n" }, { "category": "ECG", "chartdate": "2110-04-08 00:00:00.000", "description": "Report", "row_id": 162022, "text": "Sinus bradycardia with slight A-V conduction delay. Otherwise, normal tracing.\nSince the previous tracing of sinus bradycardia is now present and the\nP-R interval is longer.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2101-01-05 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1222321, "text": " 11:18 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with sob\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: An 83-year-old man with shortness of breath. Rule out\n infiltrate.\n\n COMPARISON: Multiple priors, most recent from .\n\n FINDINGS: There are bilateral pleural effusions on today's examination, new\n since the film. The lungs are otherwise clear of any focal opacities.\n Plate-like atelectasis is seen bilaterally. The cardiac silhouette appears\n mildly larger than compared to the prior study. Patient's known underlying\n subcarinal bronchogenic cyst was better evaluated on CT. The aorta shows mild\n tortuosity. No evidence of pneumothorax is seen.\n\n IMPRESSION:\n 1. Small bilateral pleural effusions.\n 2. Cardiac silhouette appears mildly larger in size than compared to the\n prior study. Patient's known underlying subcarinal bronchogenic cyst was\n better evaluated on CT.\n\n" }, { "category": "Echo", "chartdate": "2101-01-06 00:00:00.000", "description": "Report", "row_id": 102207, "text": "PATIENT/TEST INFORMATION:\nIndication: Reevaluation of pericardial effusion and early tamponade physiology. New afib with anterior pleuritic chest pain.\nHeight: (in) 68\nWeight (lb): 160\nBSA (m2): 1.86 m2\nBP (mm Hg): 143/80\nHR (bpm): 126\nStatus: Inpatient\nDate/Time: at 10:09\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Overall normal LVEF (>55%). Beat-to-beat\nvariability on LVEF due to irregular rhythm/premature beats.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification.\n\nTRICUSPID VALVE: Mild [1+] TR. Mild PA systolic hypertension.\n\nPERICARDIUM: Small to moderate pericardial effusion. Effusion circumferential.\nEchocardiographic signs of tamponade may be absent in the presence of elevated\nright sided pressures.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm). The rhythm appears to be\natrial fibrillation.\n\nConclusions:\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Overall left ventricular systolic function is normal\n(LVEF>55%). There is considerable beat-to-beat variability of the left\nventricular ejection fraction due to an irregular rhythm/premature beats.\nRight ventricular chamber size and free wall motion are normal. The mitral\nvalve leaflets are mildly thickened. There is mild pulmonary artery systolic\nhypertension. There is a small to moderate sized pericardial effusion. The\neffusion appears circumferential. Echocardiographic signs of tamponade may be\nabsent in the presence of elevated right sided pressures.\n\nIMPRESSION: Mild to moderate circumferential pericardial effusion. There are\nno definitive signs of tamponade however the presence of atrial fibrillation\nand pulmonary hypertension may mean that echo signs of tamponade are absent.\n\nCompared with the prior study (images reviewed) of , the right atrium\ndoes not appear to have sustained collapse on the current study.\n\n\n" }, { "category": "Echo", "chartdate": "2101-01-05 00:00:00.000", "description": "Report", "row_id": 102208, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 60\nWeight (lb): 160\nBSA (m2): 1.70 m2\nBP (mm Hg): 149/60\nHR (bpm): 55\nStatus: Inpatient\nDate/Time: at 16:19\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\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. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Moderate pericardial effusion. Effusion circumferential. No RV\ndiastolic collapse. Sustained RA diastolic collapse, c/w low filling pressures\nor early tamponade. Echocardiographic signs of tamponade may be absent in the\npresence of elevated right sided pressures.\n\nConclusions:\nThe left atrium is moderately dilated. The left atrium is elongated. Left\nventricular wall thickness, cavity size and regional/global systolic function\nare normal (LVEF >55%). Right ventricular chamber size and free wall motion\nare normal. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is moderate pulmonary artery\nsystolic hypertension. There is a moderate sized pericardial effusion. The\neffusion appears circumferential. No right ventricular diastolic collapse is\nseen. There is sustained right atrial collapse, consistent with low filling\npressures or early tamponade. Echocardiographic signs of tamponade may be\nabsent in the presence of elevated right sided pressures.\n\nIMPRESSION: Moderate circumferential pericardial effusion with evidence of\nright atrial collapse but no frank tamponade. Preserved biventricular regional\nand global systolic function.\n\n\n" }, { "category": "ECG", "chartdate": "2101-01-10 00:00:00.000", "description": "Report", "row_id": 296014, "text": "Atrial fibrillation with a rapid ventricular response. Intraventricular\nconduction defect. Modest diffuse ST-T wave changes. Compared to the previous\ntracing of atrial fibrillation is new. Lateral ST-T wave changes are\nalso new. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2101-01-07 00:00:00.000", "description": "Report", "row_id": 296015, "text": "Sinus rhythm with atrial ectopy. There are Q waves in the anterior leads\nconsistent with possible infarction or lead placement. Compared to the\nprevious tracing of the rhythm has changed and possible old infarction\nis new.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2101-01-06 00:00:00.000", "description": "Report", "row_id": 296016, "text": "The initial beat is sinus followed by a junctional rhythm. Ventricular ectopy.\nCompared to the previous tracing of atrial fibrillation is no longer\npresent.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2101-01-05 00:00:00.000", "description": "Report", "row_id": 296017, "text": "Atrial fibrillation with rapid ventricular response. Compared to the previous\ntracing the rate and rhythm have changed.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2101-01-05 00:00:00.000", "description": "Report", "row_id": 296018, "text": "Sinus bradycardia. Isolated premature atrial contractions. ST-T wave\nabnormalities are non-specific. Consider pericarditis. Compared to the\nprevious tracing of ST-T wave changes are slightly more prominent.\nClinical correlation is suggested.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2148-07-08 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1020116, "text": ", D. MED SICU-A 4:10 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: please assess for DVt\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with ILD and persistent fevers despite abx\n REASON FOR THIS EXAMINATION:\n please assess for DVt\n ______________________________________________________________________________\n PFI REPORT\n No DVT in bilateral lower extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1021015, "text": " 3:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval progression\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with IPF\n REASON FOR THIS EXAMINATION:\n evaluate for interval progression\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: Newly occurred right-sided extensive pneumothorax with moderate\n midline shift and beginning depression of the right hemidiaphragm. The\n formerly placed right-sided central venous access line has been removed.\n Findings have been communicated by Dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-08 00:00:00.000", "description": "ABDOMEN U.S. (PORTABLE)", "row_id": 1020114, "text": " 4:08 PM\n ABDOMEN U.S. (PORTABLE) Clip # \n Reason: please assess gall bladder\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with interstitial lung disease and presistent fevers despite\n abx\n REASON FOR THIS EXAMINATION:\n please assess gall bladder\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old woman with interstitial lung disease and persistent\n fever despite antibiotics; please assess gallbladder.\n\n COMPARISON: None.\n\n FINDINGS: Liver demonstrates diffuse echogenicity may reflect fatty\n infiltration. There are no focal hepatic lesions or masses; however,\n evaluation of the liver is limited due to diffuse echogenicity. There is no\n intrahepatic biliary dilation. The CBD measures up to 8 mm, appropriate in\n the setting of cholecystectomy. The gallbladder fossa is unremarkable. The\n portal vein is patent with forward flow. There is no hydronephrosis. The\n right kidney measures 11.5 cm. The left kidney measures 11.1 cm. There is no\n splenomegaly with the spleen measuring 11.2 cm. There is no free fluid.\n Limited visualization of the pancreatic and retroperitoneal region is\n unremarkable. Aorta is normal in caliber in the visualized course.\n\n IMPRESSION: Diffusely increased hepatic echogenicity may reflect fatty\n infiltration. Other advanced liver disease, including significant hepatic\n fibrosis and cirrhosis cannot be excluded on this study.\n\n" }, { "category": "Radiology", "chartdate": "2148-07-08 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1020115, "text": " 4:10 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: please assess for DVt\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with ILD and persistent fevers despite abx\n REASON FOR THIS EXAMINATION:\n please assess for DVt\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb MON 6:55 PM\n No DVT in bilateral lower extremity.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old woman with interstitial lung disease and persistent\n fevers despite antibiotics, evaluate for DVT.\n\n FINDINGS: Grayscale and Doppler evaluation of bilateral common femoral,\n superficial femoral, popliteal veins demonstrate normal compressibility, flow,\n augmentation. There is no intraluminal thrombus.\n\n IMPRESSION: No DVT in bilateral lower extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1021249, "text": " 3:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with IPF c/b PTX now s/p chest tube\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 50-year-old female with IPF complicated by pneumothorax.\n Evaluate for interval change.\n\n Single AP chest radiograph compared to prior exam obtained five hours prior\n shows reduction in the size of small-to-moderate right apical/medial\n pneumothorax and resolution of right chest wall subcutaneous emphysema. Right\n mid lung chest tube and tracheostomy remain in place. Left IJ central venous\n catheter terminates in the left brachiocephalic vein. Bilateral airspace\n consolidation is unchanged. The cardiomediastinal contour is stable.\n\n" }, { "category": "Radiology", "chartdate": "2148-07-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1019952, "text": " 12:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tachypnea\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with resp failure and h/o ILD\n REASON FOR THIS EXAMINATION:\n tachypnea\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KYg MON 10:28 AM\n Compared to prior exam, there is increased edema and bibasilar atelectasis.\n The left IJ central venous catheter shows unusual position, which may be\n secondary to patient positioning. Recommend non-rotated AP chest radiograph.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 58-year-old female with respiratory failure and history of\n interstitial lung disease.\n\n AP chest radiograph compared to , there is worsening edema and\n bibasilar atelectasis. The cardiomediastinal contour is partially obscured.\n Tracheostomy remains in place. Attention is recommended to the unusual course\n of the tip of the left IJ central venous catheter, which may be related to\n patient position, on subsequent non-rotated film.\n\n" }, { "category": "Radiology", "chartdate": "2148-07-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1019953, "text": ", R. MED SICU-A 12:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tachypnea\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with resp failure and h/o ILD\n REASON FOR THIS EXAMINATION:\n tachypnea\n ______________________________________________________________________________\n PFI REPORT\n Compared to prior exam, there is increased edema and bibasilar atelectasis.\n The left IJ central venous catheter shows unusual position, which may be\n secondary to patient positioning. Recommend non-rotated AP chest radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2148-06-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1017222, "text": " 9:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p VATS RLL wedge resection\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p VATS RLL wedge resection\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: 58-year-old female status post VATS for right lower lobe wedge\n resection, pulmonary fibrosis.\n\n COMPARISON: .\n\n FINDINGS: Right-sided VATS has been performed with right apical chest tube\n placement. No pneumothorax is identified. Right lower lobe linear opacity\n likely reflects atelectasis. Left lower lobe opacity in a retrocardiac\n location suggests atelectasis from splinting, status post procedure. Diffuse\n interstitial abnormality consistent with fibrosis again noted.\n\n IMPRESSION:\n 1. No detectable pneumothorax, status post VATS procedure for fibrosis.\n\n 2. Bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2148-06-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1017756, "text": " 7:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with ARDS\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old woman with ARDS, please evaluate interval change.\n\n Comparison is made to the prior study of .\n\n PORTABLE AP RADIOGRAPH OF THE CHEST: The right IJ line, endotracheal tube,\n and NG tube are in the satisfactory position. The Dobbhoff tube distal tip\n projects at the level of diaphragm and needs to be advanced. There has been\n interval partial resolution of the densities within the upper lobes of both\n lungs suggesting improving pulmonary edema. The remainder of the lung appear\n unchanged. The elevated left hemidiaphragm and the right subpulmonic effusion\n appear unchanged. No pneumothorax is detected.\n\n IMPRESSION:\n 1. Improving focal densities of both upper lobes suggesting improving\n pulmonary edema. The remainder of the consolidative changes of the ARDS\n appear unchanged.\n 2. Unchanged right subpulmonic effusion.\n 3. The distal tip of Dobbhoff tube projects at the level of gastroesophageal\n junction and needs to be advanced.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1017988, "text": " 2:56 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: RIJ/swan placement\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with ARDS\n REASON FOR THIS EXAMINATION:\n RIJ/swan placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: ARDS, please evaluate new Swan-Ganz placement.\n\n COMPARISON: Chest radiograph approximately 10 hours previous.\n\n FINDINGS: A new right internal jugular central venous sheath with Swan-Ganz\n catheter is noted with tip to distal in the right intralobar pulmonary artery.\n The tip of the endotracheal tube is difficult to fully evaluate given adjacent\n esophageal probe and NG tube. Small bilateral effusions and diffuse\n widespread parenchymal disease is again noted without significant change.\n\n IMPRESSION:\n\n 1. New Swan-Ganz catheter with distal tip within the distal intralobar\n pulmonary artery. Recommend withdrawal into the main pulmonary artery to\n prevent arterial damage.\n\n 2. Difficult to visualize tip of endotracheal tube on current study. This may\n be further evaluated on repeat chest examination to assess Swan-Ganz.\n\n 3. No significant change to the appearance of bilateral parenchymal opacities.\n\n Findings relayed to Dr. at the time of dictation.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1017371, "text": " 10:25 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for ptx s/p chest drain removal\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with RML/RLL wedge\n REASON FOR THIS EXAMINATION:\n eval for ptx s/p chest drain removal\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: Right lung wedge resection. Chest drain removed. Rule out\n pneumothorax.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Small right pleural effusion has probably increased following removal of the\n right pleural drain, but there is no pneumothorax. Diffuse infiltrative\n pulmonary abnormality is stable. Moderate cardiomegaly is longstanding.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018066, "text": " 4:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with ARDS\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr WED 1:39 PM\n No interval change.\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n INDICATION: ARDS.\n\n FINDINGS: Indwelling devices are unchanged in position except for slight\n retraction of the Swan-Ganz catheter, still terminating in the right pulmonary\n artery. Cardiomediastinal contours are unchanged. Widespread pulmonary\n opacities as well as bilateral pleural effusions also appear unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018067, "text": ", P. TSURG SICU-A 4:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with ARDS\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n PFI REPORT\n No interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-22 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1017603, "text": " 9:52 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: CTA Chest, PE Protocol\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with increasing o2 requirement.\n REASON FOR THIS EXAMINATION:\n CTA Chest, PE Protocol\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 58-year-old woman with increasing O2 requirement.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT-acquired images were obtained through the chest after the\n administration of 100 cc of IV Optiray contrast. Multiplanar reformats were\n reviewed.\n\n HISTORY: 58-year-old woman with interstitial lung disease, post-VATS.\n\n FINDINGS: There is no pulmonary embolus to the segmental level although\n evaluation beyond the subsegmental level is limited. There is extensive\n bilateral consolidation with air bronchograms and interlobular septal\n thickening, with relative sparing of the upper lobes and right lung base.\n\n There is no pleural or pericardial effusion. Heart is mildly enlarged,\n unchanged.\n\n The bones do not demonstrate any suspicious lytic or blastic lesions.\n\n Although this exam was not optimized for subdiaphragmatic diagnosis, the liver\n demonstrates fatty infiltration, unchanged.\n\n IMPRESSION:\n\n Near complete bilateral consolidation with septal thickening likely represents\n marked pulmonary edema, although underlying pneumonia, pulmonary hemorrhage or\n ARDS cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2148-06-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1017553, "text": " 10:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pt with desat to 80\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n pt with desat to 80\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Hypoxia.\n\n CHEST\n\n Comparison is made with the prior chest x-ray of .\n\n Comparison to this film shows a background of diffuse interstitial fibrosis\n but in addition some new opacities are seen particularly on the left side\n which would be consistent with either a bronchopneumonia or possibly a failure\n pattern. Bilateral effusions are present.\n\n IMPRESSION: Increasing opacities with bilateral effusions, failure or failure\n with underlying pneumonia is suspected.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-28 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1018479, "text": " 11:54 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with interstitial lung disease, ARDS, CXR somewhat improved\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n CONTRAINDICATIONS for IV CONTRAST:\n prevention of renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old woman with interstitial lung disease and ARDS and\n improvement on chest radiograph. Please evaluate interval change.\n\n Comparison is made to the prior study of and CT of chest of , .\n\n TECHNIQUE: Axial MDCT images were obtained from the thoracic inlet to the\n upper abdomen with no IV contrast administration. Sagittal and coronal\n reformatted images were obtained.\n\n CT OF CHEST WITH NO IV CONTRAST: There is a gradient in the amount of\n improvement in the lungs with the significant improvement in the upper lobes\n and the least improvement in the lower lobes. The consolidative and ground-\n glass opacities of the upper lobes have mostly improved. Consolidative\n changes of the lung bases are relatively unchanged. The background\n interstitial lung disease is still visualized with traction bronchiectasis and\n subpleural irregular densities. The honeycombing is still present at the\n bases. The patient is status post VATS procedure with the biopsy performed\n from the lateral portion of the right middle lobe.\n\n The soft tissue windows demonstrate the endotracheal tube above the carina.\n The NG tube is in place. No central pathologically enlarged nodes are noted.\n The visualized portions of the upper abdomen appear unremarkable. This study\n is not designed to evaluate abdominal structures.\n\n IMPRESSION:\n 1. There is a gradient in the degree of clearing of lungs with the lowest\n improvement at the bases and near complete resolution at the apeces. The\n differential includes ARDS and the acute exacerbation of the underlying\n interstitial lung disease.\n 2. Findings of background interstitial lung disease with traction\n bronchiectasis and subpleural lines. The recent pathology suggested UIP.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1017632, "text": " 4:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with respiratory distress s/p intubation and \n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Respiratory distress, status post intubation.\n\n CHEST:\n\n Comparison is made with the prior chest x-ray of . An endotracheal\n tube is in place in a satisfactory position lying 3 cm from the carinal angle.\n\n Diffuse interstitial is again seen with air bronchograms in the right\n lower lobe. These findings indicate an acute process in top of the chronic\n fibrotic changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-23 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1017675, "text": " 11:46 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: new right IJ CVL\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with ARDS\n REASON FOR THIS EXAMINATION:\n new right IJ CVL\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Right IJ line placed, check position.\n\n CHEST: The tip of the right IJ line lies just within the right atrium. Two\n feeding tubes are seen within the stomach, one of which has sideholes within\n the esophagus. The position of the endotracheal tube is satisfactory.\n Diffuse interstitial is again seen, not significantly changed since the\n prior chest x-ray. The lung volumes are slightly better.\n\n IMPRESSION: Tip of IJ line in right atrium.\n\n" }, { "category": "Radiology", "chartdate": "2148-06-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018023, "text": " 6:23 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: swan repositioned\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with ARDS\n REASON FOR THIS EXAMINATION:\n swan repositioned\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:35 .\n\n HISTORY: ARDS. Swan-Ganz catheter repositioned.\n\n IMPRESSION: AP chest compared to :\n\n Tip of the Swan-Ganz catheter projects over the origin of the right descending\n pulmonary artery, in standard placement. Mild generalized interstitial\n abnormality has improved consistent with resolving edema. Small right pleural\n effusion persists and the mediastinum and hilar enlargement are due to\n adenopathy demonstrated by recent chest CTA. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018215, "text": " 5:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with ARDS\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 2:13 PM\n No significant interval change.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: ARDS, assess for interval change.\n\n FINDINGS: AP single view of the chest obtained with patient in sitting\n semi-upright position is analyzed in direct comparison with a preceding\n similar study dated . The patient remains intubated, the ETT in\n unchanged position. The same holds for the previously described right\n internal jugular approach sheath that carries a Swan-Ganz catheter and an NG\n tube still reaching far below the level of the diaphragm. A wide bore NG tube\n has been removed during the interval. The previously identified bilateral\n disseminated confluenting parenchymal densities persist. There is a\n suggestion that the right-sided pleural effusion has increased somewhat\n further, but quantification is difficult on this bedside examination. No\n pneumothorax has developed.\n\n IMPRESSION: No gross interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018216, "text": ", P. TSURG SICU-A 5:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with ARDS\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n PFI REPORT\n No significant interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018419, "text": " 4:04 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: rule out worsening of consolidations, effusions\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with UIP now with resp failure ARDS.\n REASON FOR THIS EXAMINATION:\n rule out worsening of consolidations, effusions\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: and a chest CT from .\n\n HISTORY: 58-year-old woman with UIP, now with respiratory failure. Rule out\n ARDS.\n\n FINDINGS:\n\n The small right pleural effusion has decreased. Small present left pleural\n effusion is stable. The heart size is normal. Mild-to-moderate pulmonary\n edema is seen in both lungs. The endotracheal tube, feeding tube, sheath of\n right internal jugular line are stable in satisfactory location.\n\n IMPRESSION:\n 1. Persistent mild-to-moderate pulmonary edema.\n 2. Improvement of the small right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018433, "text": " 8:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with chronic interstitial lung diease and ARDS\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: at 05:39.\n\n HISTORY: 58-year-old woman with chronic interstitial lung disease and ARDS.\n Evaluate for interval change.\n\n FINDINGS:\n\n In the interim, there is no change in the status of mild-to-moderate bilateral\n pulmonary edema and small right pleural effusion. Heart size is top normal.\n Lines, tubes and catheters are in expected locations.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018603, "text": " 3:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with interstitial lung disease, s/p VATS/wedge resection,\n intubated w/ARDS\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: ARDS.\n\n Pulmonary opacification has markedly progressed, with widespread airspace\n opacities now involving both lungs diffusely, slightly more severe on the left\n than the right. Indwelling devices remain in standard position. Probable\n bilateral layering pleural effusions are evident as well as questionable\n ascites and anasarca.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1019052, "text": " 4:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval changes\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman s/p VATS, UIP, persistent vent need\n REASON FOR THIS EXAMINATION:\n please evaluate for interval changes\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MEz TUE 1:08 PM\n PFI: Patient is status post VATS, UIP, with persistent ventilatory need.\n Evaluate for changes. Stable pulmonary edema, left more than right.\n Unchanged location of endotracheal tube and new left internal jugular line\n terminating at the caval/brachiocephalic junction.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: and chest CT on .\n\n HISTORY: Patient with UIP, status post VATS, evaluate for interval change.\n\n FINDINGS: The moderate left pulmonary edema and the mild right pulmonary\n edema are stable. Small bibasilar pleural effusions are stable. The heart\n size is top normal. The right internal jugular sheath has been removed with\n no pneumothorax. An endotracheal tube tip is 3 cm from the carina. A newly\n placed left internal jugular line terminates at the caval/brachiocephalic\n junction.\n\n IMPRESSION:\n 1. Stable bilateral pulmonary edema and stable small pleural effusions.\n 2. New left internal jugular line in satisfactory location.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-10 00:00:00.000", "description": "BILAT UP EXT VEINS US", "row_id": 1020456, "text": " 11:00 AM\n BILAT UP EXT VEINS US Clip # \n Reason: ?dvt\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with persistent fevers, bedbound, picc recently in ue\n REASON FOR THIS EXAMINATION:\n ?dvt\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KLMn WED 1:12 PM\n No DVT. Internal jugular veins could not be evaluated.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old woman with persistent fevers, PICC line in place.\n\n BILATERAL UPPER EXTREMITY ULTRASOUND: Given technical limitations, the\n internal jugular veins could not be accessed for evaluation. Grayscale and\n color Doppler son of the left and right subclavian, axillary, brachial,\n and basilic veins were performed. There was normal flow, augmentation,\n compressibility, and waveforms demonstrated. No intraluminal thrombus is\n identified. PICC line was seen in the right axillary vein.\n\n IMPRESSION: No evidence of upper extremity deep vein thrombosis. Unable to\n evaluate the internal jugular veins.\n\n" }, { "category": "Radiology", "chartdate": "2148-07-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1020610, "text": " 3:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval progression\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with persistent respiratory failure\n REASON FOR THIS EXAMINATION:\n evaluate for interval progression\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 10:28 AM\n No appreciable change compared to the prior study.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Persistent respiratory failure.\n\n Portable AP chest radiograph was compared to .\n\n There is no change in the bilateral lung consolidations predominantly in the\n bases that may represent bilateral pneumonia or persistent edema. The mild\n pulmonary edema involving the upper lungs is unchanged as well. The\n cardiomegaly is moderate. There is no change in the mediastinal configuration\n that might represent either vascular engorgement or adenopathy. Tracheostomy\n is in unchanged position. No appreciable pleural effusion is demonstrated.\n The right PICC line tip is in mid portion of the right subclavian vein.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018813, "text": ", D. MED SICU-A 4:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval changes\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with UIP currently intubated for respiratory failure s/p\n VATS\n REASON FOR THIS EXAMINATION:\n interval changes\n ______________________________________________________________________________\n PFI REPORT\n Worsening opacities within the left lung likely representing pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2148-07-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1019347, "text": " 7:23 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval. s/p trach\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with trach\n REASON FOR THIS EXAMINATION:\n Eval. s/p trach\n ______________________________________________________________________________\n WET READ: RSRc WED 8:40 PM\n Tracheostomy tube in apparently satisfactory position. Bilateral pleural\n effusions and pulmonary edema unchanged. -\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post tracheostomy tube placement.\n\n COMPARISON: .\n\n UPRIGHT CHEST RADIOGRAPH: There has been removal of a nasogastric tube and\n endotracheal tube. A tracheostomy tube has been placed and is appropriately\n positioned. A Dobbhoff tube lies within the stomach. A left-sided internal\n jugular central venous line is appropriately positioned. Accounting for\n differences in technique mild pulmonary edema and small pleural effusions on a\n background of interstitial disease are unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1020167, "text": ", D. MED SICU-A 3:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ICU transfer\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with h/o interstitial lung dz s/p VATS w/ RML/ \n resection and UIP in ICU hypoxic respiratory failure.\n REASON FOR THIS EXAMINATION:\n s/p ICU transfer\n ______________________________________________________________________________\n PFI REPORT\n Compared to prior exam from , there is no appreciable change in\n extent of pulmonary edema or bibasilar opacities. The left IJ central venous\n catheter has been removed, however, the newly placed right PICC has migrated\n proximally and now terminates within the brachiocephalic vein.\n\n" }, { "category": "Radiology", "chartdate": "2148-07-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1020382, "text": " 3:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls evaluate for interval progression\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with IPF, intubated\n REASON FOR THIS EXAMINATION:\n pls evaluate for interval progression\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3:20 A.M. :\n\n HISTORY: Pulmonary fibrosis. Intubated. Assess progression.\n\n IMPRESSION: AP chest compared to through :\n\n Lung volumes have improved since . Consolidation persists at both lung\n bases, and could be due to bilateral pneumonia or persistent edema. Mild\n edema is present in the upper lungs superimposed on pulmonary fibrosis. Heart\n is moderately enlarged unchanged and the configuration of the mediastinum\n suggests continued vascular engorgement as well as adenopathy. Tracheostomy\n tube in standard placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1020611, "text": ", P. MED MICU-7 3:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval progression\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with persistent respiratory failure\n REASON FOR THIS EXAMINATION:\n evaluate for interval progression\n ______________________________________________________________________________\n PFI REPORT\n No appreciable change compared to the prior study.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1019595, "text": " 4:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o interval progression of infiltrates, consolidations\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with UIP intubated for resp failure.\n REASON FOR THIS EXAMINATION:\n r/o interval progression of infiltrates, consolidations\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old female with UIP. Intubated for respiratory failure.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: All lines and tubes are in unchanged positions.\n Bilateral pleural effusions and moderate pulmonary edema persists. Left\n retrocardiac opacity with air bronchograms raise the possibility of\n consolidation.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-10 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1020447, "text": " 10:43 AM\n PORTABLE ABDOMEN Clip # \n Reason: ?obstruction\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with high residual tube feeds no BMs\n REASON FOR THIS EXAMINATION:\n ?obstruction\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc WED 3:07 PM\n No bowel dilatation to suggest obstruction. Residual contrast material in the\n colon.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old woman with no bowel movements and high tube feed\n residuals.\n\n COMPARISON: G-tube check of .\n\n SINGLE SUPINE VIEW OF THE ABDOMEN AT 10:55 a.m.: A PEG tube overlies the left\n upper quadrant. Contrast material is present in the colon to the rectum,\n likely residual from the recent G-tube check. There are no dilated loops of\n small or large bowel. Evaluation for free intra-abdominal air is limited.\n Bony structures are unremarkable.\n\n IMPRESSION: No evidence of bowel obstruction. Residual contrast material in\n the colon.\n\n" }, { "category": "Radiology", "chartdate": "2148-07-10 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1020448, "text": ", P. MED MICU-7 10:43 AM\n PORTABLE ABDOMEN Clip # \n Reason: ?obstruction\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with high residual tube feeds no BMs\n REASON FOR THIS EXAMINATION:\n ?obstruction\n ______________________________________________________________________________\n PFI REPORT\n No bowel dilatation to suggest obstruction. Residual contrast material in the\n colon.\n\n" }, { "category": "Radiology", "chartdate": "2148-07-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018812, "text": " 4:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval changes\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with UIP currently intubated for respiratory failure s/p\n VATS\n REASON FOR THIS EXAMINATION:\n interval changes\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JWK MON 12:13 PM\n Worsening opacities within the left lung likely representing pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old female with UIP currently intubated for respiratory\n failure status post VATS. Evaluate for interval changes.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: All lines and tubes are in unchanged position.\n Of note, the left internal jugular central venous catheter appears laterally\n directed in the superior vena cava. The cardiomediastinal silhouette is\n unchanged. Hazy opacities have increased, particularly within the left lung,\n representing pulmonary edema. There are persistent small bilateral pleural\n effusions.\n\n IMPRESSION:\n 1. Mild increase in pulmonary edema.\n 2. Stable small pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1021055, "text": " 10:11 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: check pneumo\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with R Pneumo s/p R CT\n REASON FOR THIS EXAMINATION:\n check pneumo\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: , 4:32 a.m.\n\n FINDINGS: In the interval, a right-sided chest tube has been inserted. The\n extent of the right-sided pneumothorax has slightly decreased, the\n pneumothorax, however, is still clearly visible. There is no more lateral\n deviation of the mediastinum. Otherwise, the radiograph is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1019404, "text": " 4:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check placement of new trach, r/o worsening infiltrates, con\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with UIP intubated for resp failure.\n REASON FOR THIS EXAMINATION:\n check placement of new trach, r/o worsening infiltrates, consolidations\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: UIP with intubation for respiratory failure.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. The support and monitoring devices remain in position. Bilateral\n pleural effusions and moderate pulmonary edema persists. There may be\n developing bronchograms at the left base raising the possibility of\n consolidation in the retrocardiac region.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1020166, "text": " 3:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ICU transfer\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with h/o interstitial lung dz s/p VATS w/ RML/ \n resection and UIP in ICU hypoxic respiratory failure.\n REASON FOR THIS EXAMINATION:\n s/p ICU transfer\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KYg TUE 10:58 AM\n Compared to prior exam from , there is no appreciable change in\n extent of pulmonary edema or bibasilar opacities. The left IJ central venous\n catheter has been removed, however, the newly placed right PICC has migrated\n proximally and now terminates within the brachiocephalic vein.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 58-year-old female with interstitial lung disease, hypoxic,\n respiratory failure.\n\n Single AP chest radiograph compared to shows no change in the\n extent of pulmonary edema or bibasilar opacities. The partially obscured\n cardiomediastinal contour is not significantly changed. Since the last exam,\n the left IJ central venous catheter has been removed. Tracheostomy remains in\n place. Right PICC has been pulled out slightly and now terminates within the\n brachiocephalic vein. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2148-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1019755, "text": " 5:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval changes\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with trach for chronic respiratory failure in the setting of\n UIP\n REASON FOR THIS EXAMINATION:\n please evaluate for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Chronic respiratory failure, UIP.\n\n COMPARISON STUDY: .\n\n FINDINGS:\n\n A left IJ catheter terminates at the superior vena cava. Tracheostomy tube is\n present at the thoracic inlet. Since the prior study, there has been interval\n increased opacification of the left lung and the right lower lobe. There is\n continued mild pulmonary edema. There are small bilateral pleural effusions.\n\n IMPRESSION:\n\n 1. Interval worsening. Increased consolidation bilateral lower lobes. Small\n bilateral pleural effusions.\n\n 2. Mild congestive failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018715, "text": " 4:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tube placement interval change\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with intubation\n REASON FOR THIS EXAMINATION:\n tube placement interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, , 6:42 A.M.\n\n COMPARISON: , .\n\n INDICATION: Endotracheal tube assessment.\n\n Endotracheal tube remains in standard position terminating about 3 cm above\n the carina with the neck in a flexed position. Left internal jugular vascular\n catheter appears more laterally directed in the superior vena cava, but this\n could potentially be due to the effects of patient rotation rather than a true\n change in catheter position. Consider repeat non-rotated radiograph for more\n complete assessment. Right internal jugular catheter sheath has been removed\n with no pneumothorax. Worsening hazy and reticular opacities are present in\n the mid and lower lungs bilaterally, and there are persistent small bilateral\n pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1020731, "text": " 3:11 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval for proper line placement; r/o pneumothorax\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman s/p left IJ placement\n REASON FOR THIS EXAMINATION:\n eval for proper line placement; r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left IJ placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a left IJ catheter that extends to the brachiocephalic vein\n before its entry into the superior vena cava. The right PICC line again has\n its tip in the subclavian vein.\n\n Allowing for the poor inspiration and underpenetration of the image, there is\n probably little overall change in the appearance of the heart and lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1019053, "text": ", R. MED SICU-A 4:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval changes\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman s/p VATS, UIP, persistent vent need\n REASON FOR THIS EXAMINATION:\n please evaluate for interval changes\n ______________________________________________________________________________\n PFI REPORT\n PFI: Patient is status post VATS, UIP, with persistent ventilatory need.\n Evaluate for changes. Stable pulmonary edema, left more than right.\n Unchanged location of endotracheal tube and new left internal jugular line\n terminating at the caval/brachiocephalic junction.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1019859, "text": " 4:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change in infiltrates, consolidations\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with UIP trach'd for resp failure.\n REASON FOR THIS EXAMINATION:\n assess for interval change in infiltrates, consolidations\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: UIP, tracheostomy for respiratory failure.\n\n COMPARISON STUDY: \n\n FINDINGS:\n\n Tracheostomy is present in the midline at the thoracic inlet. Left IJ\n catheter terminates at the superior vena cava. There is essentially no change\n in the appearance of the chest since the prior study. There is diffuse\n consolidation of both lungs in the perihilar and left lower lobe region with\n air bronchograms. There is mild congestive failure. There are probable\n bilateral pleural effusions and mild cardiomegaly.\n\n IMPRESSION:\n 1. No change. Perihilar consolidation, left lower lobe consolidation with\n air bronchograms. Bilateral pleural effusions.\n 2. Mild congestive failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1018675, "text": " 7:00 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: ? line placement\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with new LIJ\n REASON FOR THIS EXAMINATION:\n ? line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, , AT \n\n COMPARISON: , at 0529.\n\n INDICATION: Line placement.\n\n New left internal jugular vascular catheter terminates in the mid superior\n vena cava, with no pneumothorax. Widespread alveolar opacities have markedly\n improved, favoring pulmonary edema as the most likely etiology. Otherwise, no\n substantial change since recent radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1019211, "text": " 5:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o worsening pleural effusions, consolidations, infiltrates\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with UIP intubated for ARDS.\n REASON FOR THIS EXAMINATION:\n r/o worsening pleural effusions, consolidations, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: UIP, intubated for ARDS.\n\n FINDINGS: In comparison with the study of , there is little change.\n Bilateral pleural effusions and moderate pulmonary edema persists in a patient\n with cardiac size at the upper limits of normal. Various tubes remain in\n place.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-10 00:00:00.000", "description": "BILAT UP EXT VEINS US", "row_id": 1020457, "text": ", P. MED MICU-7 11:00 AM\n BILAT UP EXT VEINS US Clip # \n Reason: ?dvt\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with persistent fevers, bedbound, picc recently in ue\n REASON FOR THIS EXAMINATION:\n ?dvt\n ______________________________________________________________________________\n PFI REPORT\n No DVT. Internal jugular veins could not be evaluated.\n\n" }, { "category": "Radiology", "chartdate": "2148-07-06 00:00:00.000", "description": "P G/GJ/GI TUBE CHECK PORT", "row_id": 1019795, "text": " 2:24 PM\n G/GJ/GI TUBE CHECK PORT Clip # \n Reason: Confirm placement of G tube in stomach\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with respiratory failure and new G-tube\n REASON FOR THIS EXAMINATION:\n Confirm placement of G tube in stomach\n ______________________________________________________________________________\n FINAL REPORT\n G-TUBE CHECK, \n\n CLINICAL INFORMATION: Respiratory failure with new G-tube.\n\n FINDINGS:\n\n Contrast has been instilled through an existing percutaneous gastric tube.\n Contrast is seen to outline the folds of the stomach and some contrast\n progresses into the duodenum. No extraluminal contrast is identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-08 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1020100, "text": " 2:45 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with chronic vent/trach, PEG, needs long term access for IVF;\n IV team failed\n REASON FOR THIS EXAMINATION:\n please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n\n PICC LINE PLACEMENT, .\n\n INDICATION: 58 year old female with chronic vent/trach, PEG, needs long term\n access for IVF.\n\n RADIOLOGIST: Dr. and Dr. performed the procedure. Dr.\n , the Attending Radiologist, was present and supervised the entire\n procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right brachial\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a double PICC line measuring 31 cm in length was then placed\n through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest. The peel-away sheath and guidewire were\n then removed. The catheter was secured to the skin, flushed, and a sterile\n dressing applied. The patient tolerated the procedure well. There were no\n immediate complications. Total fluoroscopy time was 1.2 minutes.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double lumen\n PICC line placement via the right brachial venous approach. Final internal\n length is 31 cm, with the tip positioned in upper SVC. The line is ready to\n use.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2148-07-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1020712, "text": " 1:42 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for pneumothorax\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman s/p left IJ attempt\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post left IJ attempt, to evaluate for pneumothorax.\n\n FINDINGS: In comparison with earlier study of this date, there is little\n overall change in the appearance of the heart and lungs. Specifically, no\n convincing evidence of left pneumothorax following the failed IJ attempt.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1017900, "text": " 4:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: RIGHT LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with ARDS\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: ARDS.\n\n COMPARISON: and .\n\n FINDINGS: Endotracheal tube, right IJ catheter, NG tube and esophageal probe\n remain in unchanged standard position. Worsening retrocardiac opacity\n obscuring the left hemidiaphragm most likely represents atelectasis. Diffuse\n bilateral airspace opacities noted on demonstrated interval\n improvement on and yet on current radiograph demonstrate similar\n appearance to that of initial radiograph. Differential includes worsening\n ARDS versus acute pulmonary edema upon improving ARDS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-07-11 00:00:00.000", "description": "Report", "row_id": 1642743, "text": "Nursing 1900-0700\n\nNeuro: no movement of extremeties, pt does not follow commands. PERLA 4mm/4mm brisk. Fentanyl at 120mcg and versed at 4.5mg. eyes opeing spontaneously with no tracking noted. Pt grimacing with sternal rub.\n\nCV: Pt AX temp is 97.5, NBP 120-130/60-70's with a mean 70-80's, ABP 120-130/60-70 with a mean 60-70's. No edema noted +PP. skin is warm and dry with episodes of pt being diaphoretic. Pt is currently on Neo at 0.7mcg from 1.2mcg. Hct is stable at 26.0, K 4.6, NA 141.\n\nRespiratory: Lung sounds clear in upper lobes and deminished at the bases. Pt suctioned frequently for small/moderate tan thick secretions. Pt on Pressure support at 0.70% FiO2. CXR was done this AM. With turing pt must have FiO2 increased to 100% 2/2 pt 2 drops quickly down to the 80's. Pt also requires long time to recuperate from any kind of movement.\n\nGI: HISS with fixed dose of lantus, abdomen is soft non-tender with bowel sounds in all quadrents. No TF high residual and lack of bowel movement for some time. Pt receiving reglan for obsorption PRN.\n\nGU: 80-120cc of clear yellow urine from foley. if urine output drops below 100 HO would olike to give another dose of 20mg of IV lasix. CREAT 0.5 and BUN 17.\n\nSkin/other: Fentanyl Patch on right shoulder that is do to be changed today, G-tube and A-line dressing changed, no phone calls overnight, ? CMO after meeting with family on MOnday.\n\nPlan: conitnue to ween neo and sedation medication as tolerated, provide emptional support to both pt and family, ? restart of TF, monitor for bowel movem,ent.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-11 00:00:00.000", "description": "Report", "row_id": 1642744, "text": "Respiratory Care:\n\nPt & sedated on spontaneous ventilation. We attempted to wean Fio2 to 60 %, back after repeated ABG. Pt's sats is still labile and requires time to recuperate after any movement. Bs are dim midly, more to bases bil. We are sxtn routinely for small/mod amt of thick tan secretions from ETT. Plan: Continue present iCU monitoring & attempt to wean sedation as tol. See Careview for further details.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-11 00:00:00.000", "description": "Report", "row_id": 1642745, "text": "Nursing 0645 addendum: At 0500 Pt HR started to slowly increase to the 130 ST sustained. At the highest point HR reached 152 that was questionable to be A-. HO was notified and ? of over diurised. Subsequently bolus of 250cc was given with no effect. During episode on telemetry ? of pt being in A-flutter. 2.5mg of IV lopressor was given with no effect. HR continued to hold in the 130-140's ST. Another 250cc bolus of NS was given also with no effect. ABG was drawn with no change from previous results. Pt receieved a ttotal of 50mcg bolus of fentanyl and GTT was increased to 130mcg. Also Pt received a total of 3.5mg bolus of versed and increased to 7mg/hr. At 0657 Hr continues to be 116-120's Pt does not appear to be in discomfort. awaiting for further team plan.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-11 00:00:00.000", "description": "Report", "row_id": 1642746, "text": "Events;Central line placement,EKG,ECHO,Xray,fluid bolus.\n\nResp;Received on CPAP+PS LS ronchi/dim at bases sats were maintianed >95%.ABG at noon was 7.40/60/100 Fio2 was taperred to 60% and PS to 15 ABG repeated after vent changes 7.41/58/69.Sats down to 93% uncomfortable and in distress while positioning and routine nsg care.Suctioned for mod/thick yellow secretions.Tracheostomy care given.\n\n\nNeuro;Pt was sedated with Fentanyl 130mcg/hr and Versed 7 mg at the beginning of the shift,at noon while attempting for central line pt became more awake,versed 3 mg and Fentanyl 100+100 mcg bolused and Versed infusion increased to 10 mg for the procedure and now back to previous rate.opens eyes for painful stimuli vague look doesnot track,pt did move upper the extrimities while the procedure was going on.Pt is blind in rt eye and lt pupil 3mm and brisk.\n\nCVS;HR 99-113 ST EKG was obtained (HR was 120-150 last night)did recieve250+ 250 ml fluid bolus.Recieved on NEO 0.7 mcg/kg/mt weaned off at 1700,ABP was maintained 100-120/58-67 --arterial waveforms are dampened,has good backflow,so following NBP now MAP >60 acceptable.Central line placed with difficulty,placement confirmed with Xray.PICC line removed and tip send for culture.Positive pedal pulses.ECHO done awaiting for results.Pt has swelling on both upper extrimities US was done and negative for DVT.\n\nGI;Abdomen softly distended positive bowel sounds,PEG tube in place/patent not on TF.Pt did not have bowel movement after admission on agressive bowel regimen.\n\nGU;Foley catheter in palce draining adequte amts,planning to keep her on even balance in view of her tachycardia.\n\nSkin;WNL On triadyne bed back care given Q4hr.\n\nID;Pt was afebrile today, in catheter tip started on fluconazole.Continued on vanco/meropenem.PICC line removed and tip send for Culture.\n\nSocial; brother and visited and updatd,Family wants to wait till monday to take desicion.\n\nPlan; Full code,ICU care at this time.\n Wean vent and sedations as tolerated\nhaemodinamic monitoring.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-07-11 00:00:00.000", "description": "Report", "row_id": 1642747, "text": "Respiratory care\nPt had lines placed and ultra sound this shift. Weaned /cpap to 15/12 fio2 weaned to 60% with resulting abg 741/58/69/38/9. Plan to slowly wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-24 00:00:00.000", "description": "Report", "row_id": 1642678, "text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient afebrile with WBC coming down while on vanco/cipro (vanco level due this evening). HR 60-70 NSR this morning in the afternoon rose to 80's at which time pt also noted to be breathing over the vent, paralytic increased and RR decreased to set rate of 25 and HR back to 70's. While breathing over the vent O2 sats dropped to low 90's and neo requirements increased. Once adequate paralysis attained oxygenation improved and neo requirements decreased. Only able to wean/titrate neo by .1mcg/kg/min SBP very sensitive. Titrating btwn 1 and 1.5mcg/kg/min. CVP has remained 11 all day. Making ~200cc/hr of urine and pt is -1200cc since midnight without any diuretic.\n Brother in to visit in the morning and spoke with pulmonologist. Still awaiting biopsy results. MD (brother) of probable need to keep pt intubated for at least 2-3 days.\n Skin intact. Frequent repositioning and utilizing \"swimmers position\" d/t ARDS. No secretions obtained with suctioning. No titration of sedation d/t paralytic. Allowing PCO2 to rise (baseline probably closer to 50). Small vent changes made. PEEP down to 8 (14) and RR down to 25 (32). ABG on these settings with FiO2 60% acceptable.\nPLAN:\n re-assess in am for possible stop of paralytic\n wean neo as tolerated\n pulmonary toilet\n ppf/fent for sedation\n Notify H.O. with any changes\n" }, { "category": "Nursing/other", "chartdate": "2148-06-28 00:00:00.000", "description": "Report", "row_id": 1642693, "text": "NURSING 7P-7A\n VSS OVERNIGHT. NSR- SINUS TACHYCARDIA. REMAINS ON NEO TO MAINTAIN MAP>65. CURRENTLY ON .56 OF NEO, NO TITRATION OVERNIGHT. TEMPERATURE MAX 99.3.\n REMAINS ON PRESSURE CONTROLLED VENTILATION. FI02 INCREASED FROM 50 TO 60% THIS MORNING FOR PAO2 OF 78. REPEAT ABG PENDING. RATE REMAINS SET AT 26, 5 PEEP. SYNCHRONOUS WITH VENTILATOR, NO OVERBREATHING. LUNGS REMAIN CLEAR UPPER, DECREASED BASES. TOLERATED SIDE TO SIDE ROTATION ON TRIADYNE BED ABOUT 60% OF THE TIME. OCCASIONALLY HAD TO TURN ROTATION OFF FOR LOW O2 SATS. RESOLVED WITH SUPINE POSITION, SUCTIONING, AND LAVAGE. MODERATE AMOUNTS OF THICK WHITE SECRETIONS SUCTIONED OVERNIGHT. PERCUSSION TURNED ON ONCE PER HOUR OVERNIGHT, TOLERATED WELL. ETT NOT ROTATED YEATERDAY DUE TO BROKEN DOWN AREA OF UPPER AND LOWER LIP RIGHT SIDE OF MOUTH. CONTINUE ON FENTANYL 200 MCG'S AND VERSED 3 MG FOR SEDATION. OPENS EYES TO PAINFUL STIMULI. PUPILS EQUAL AND REACTIVE.\n GLUCOSE LEVELS CONTINUE TO BE IN THE 200'S. SLIDING SCALE ADMINISTERED Q6/HOURS. CORTISOL STIM TEST COMPLETED. WBC'S INCREASED AGAIN TODAY, CURRENTLY 18.3. CULTURES FROM THE 19TH STILL PENDING.\n FULL STRENGTH REPLETE WITH FIBER AT GOAL. RESIDUALS LESS THAN 50 EACH CHECK. ABDOMEN SOFT, HYPOACTIVE BOWEL SOUNDS. NO STOOL OUT SINCE ADMIT. FOLEY WITH AMBER URINE, SOME SEDIMENT. QS AMOUNTS OF URINE OUT OVERNIGHT. REMAINS ON JUST KVO IVF'S AND AMOUNTS GIVEN VIA GTTS. ALL GTTS AT MAXIMUM CONCENTRATION.\n CONTINUE TO MONITER HEMODYNAMICS, NEURO STATUS, SEDATION LEVELS, AND RESPIRATORY STATUS. FREQUENT ABG'S, AGGRESSIVE PULMONARY TOILET, PERCUSSION Q/HOUR. FOLLOW GLUCOSE LEVELS CLOSELY, ADMINISTER INSULIN AS NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-28 00:00:00.000", "description": "Report", "row_id": 1642694, "text": "Resp Care\n\nPt continues having episodic decrease in Spo2, Fio2 was increased to 60%. Pt has been sx regularly, sometimes for copious amts of thk yellow secretions. Paralytics stopped yesterday, pt is capable of spontaneous breathing, brief RSBI this morning was 83. ABG 7.38,54,78.\non PCV with driving pressure of 28, RR of 26, 60% Fio2.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-24 00:00:00.000", "description": "Report", "row_id": 1642679, "text": "Respiratory Care Note\nPt received on AC as noted. BS are clear with good aeration. Pt suctioned for small amts thick secretions. PEEP weaned from 14cm to 10cm and vent rate weaned from 32-25 as noted. ABG on 400x25 +10cmpeep and 60% reveals a compensated respiratory alkalosis with good oxygenation. Ptp range -2.2 to -8.2 and Pes 16.9-17.6. Plan to continue on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-24 00:00:00.000", "description": "Report", "row_id": 1642680, "text": "Respiratory Care Note\nVT weaned secondary to increase in PIP 41-42cm and rate increased to maintain MV.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-10 00:00:00.000", "description": "Report", "row_id": 1642738, "text": "NPN 7p-7a\nEVENTS: Pt has had issues with oxygenation and desatting with turning and other NSG care. Pt will become very tachypneic, dysynchronous with vent and appearing extremely uncomfortable. PIPs as high as 50 at times, with poor Tvs and RR 40s. Pt would require several mg boluses of Versed with poor effect and subsequent increase of Neo to support BP. Multpile vent changes made during these times with poor effect. Pt was on AC for short period, but ultimately appeared more comfortable on CPAP. Pt transfered to triadyne bed as pt unable to tolerate frequent turning.\n\nNEURO: Pt is now sedated on 9.0mg/hr of Versed and 125mcg/hr Fentanyl. Pt will open her eyes to pain, with blank stare, does not track or blink to threat. Pt does not follow commands, no spontaneous movements. Pt is blind in right eye, left pupil 3mm, brisk.\n\nRESP: Pt is , currently on CPAP+PS fio2 was as high as 100%, now weaned down to 70%. Vent settings currently PS 70%/17/12 TV 350-400s. RR 20s-30. Sats mid 90s. LS coarse t/o. Suctioning for thick tan secretions in small amounts mostly, but did lavage x1 for copious sticky secretions. ABGs per careview.\n\nCV: HR 80s-100s in NSR. BP 90s-100s/60s-80s supported by Neo gtt MAP >60. Pt has easily palpabel pulses. Pt diaphoretic at times.\n\nGI/GU: ABD is softly distended, +BS, TFs held briefly for high residuals. Will resume after Reglan is started. No BM this shift. U/O adequate, foley draining clear yellow urine.\n\nID: Tmax 100.2, given 650mg Tylenol. Pt covered on Cipro, vanco and meropenem. Cultures pending.\n\nSOCIAL: No contacts over night.\n\nPLAN: Cont to wean vent as tolerated\n Wean sedation as tolerated.\n Wean Neo as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-10 00:00:00.000", "description": "Report", "row_id": 1642739, "text": "Respiratory Care:\n\nPt on spontaneous ventilation, requiring heavy sedation. We had a profound desats with dysynchronious resp & hypotension with a bed turn, tried vent support, she could not tolerate any mode except PSV. FI02 increased to 100%, weaned slowly o/n. Bs are coarse bil. We are sxtn earlier for mod amt of thick tan secretions. Plan: wean vent & sedation as tol. See Careview for further details..\n" }, { "category": "Nursing/other", "chartdate": "2148-07-10 00:00:00.000", "description": "Report", "row_id": 1642740, "text": "Respiratory Care\npatient remains on ventilatory support, all settings documented in carevue. No changes made this shift. Desaturation noted to upper 70's by nursing when patient turned from one side to the other. Prolonged period of time for recovery to original hemodynamic measurements.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-10 00:00:00.000", "description": "Report", "row_id": 1642741, "text": "Nursing Progress notes from 0700 to 1900 mhrs.\nThis 58 Y/O F with H/O Interstitial lung disease, Pulmonary fibrosis, S/P VATS procedure, RML & RLL wedge resection . Patient was transferred from SICU to MICU 7 for ARDS, hypoxic resp failure, & ongoing fever. CT neg for PE, but did show pulm edema & ARDS. Patient has had persistent fever, trach & PEG placed & has been on/off pressors.\n\nNeuro : Received on Versed @ 8 mg/hr, Fentanyl gtt @ 125 mcg/hr. Titrated down versed gtt to 6 mg/hr for couple of hours, became tachypnic, Versed gtt back to 8 mg/hr. opens eyes during turning/suctioning but does not track/blink . No movement noted at bilateral upper & lower extremities. Midaz bolus 2 mg X1 with no therapeutic effect for tachypnea. Rt eye blind from detouched retina, lt pupil 3 mm & brisk.\n\nResp : #7 trach in place. Recieved on vent PS/17/+12/0.70. Last ABG 7.42/57/94/9. patient seems to be dependent on this vent settins as she failed other vent settings earlier. She is dysynchronous with vent. RR 24 to 38's. Becomes tachypnic at times, desats to mid 70's during turning, takes several minutes to come up. Satting mostly at mid 90's to 100's. Lungs are coarse throughout. Tracheal suctioning for white/tan thick secrtions. Oral suctioning for white thick secretion. Uses accessory muscles for breathing mostly.\n\nC/V : NSR mostly. Sinus tachy, heart rate up to 130's at times\n. 12 lead EKG done. Rare ectopics noted at times. Prominent S1 /S2. Dependent on Pressors. SBP dropped to 70's during turning / neo bag change. Settle out with increasing demand of NEO. Neo @ 1.4 mcg on flow to keep MAP >60. SBP otherwise ranges from 80-110's, & MAp 60-78's. Rt A-line , in place, Positional, able to draw lab. A -wave dampen. Doubple lumen PICC line in place at R upper arm. Both lumens are patent. Abdominal X ray done today. US @ BIlateral upper extremities done to R/O DVT. Impaired cough & gag reflexes. Pedal pulses pos. Multi Pod /CSI on. lasix 20 mg IV given. PM electolytes checked, WNL. Started on steroids from today.\n\nGI/GU : Abdomen sofft, distended, Bowel sounds pos at all quadrants. Lactulose, colace, Biscodyl, senna given for bowel movement. So far no bowel movement noted. Stool to be sent for C. Diff. Tube feeding being held for high residual. Will restart after BM. reglan given on PRN basis. PEG tube in place. Lasix 20 mg IV given. Goal is negative 500 ml balance. Urine output ranges from 60 to 400 ml/hr. Indwelling urinary cath in place, draining yellow/clear urine.\n\nID : T max : 101.8, Tylenol 650 mg given with therapeutic effect. Patient is diaphoretic. Discontinued Cipro ? drug allergy as evidenced from lab results. Will continue on meropenam, Vancomycin.\n\nSkin : Intact. small red blister at right corner of mouth and close approximated incission at right thoracic region. See flowsheet for details.\n\nED : FSBS q 6 hrly. No coverage required.\n\nPlan/ Dispo : Full code. Brother visited the patient today, updated the status by doctor. Updated her boyfriend. to wean neo as tolerated if possible\n" }, { "category": "Nursing/other", "chartdate": "2148-07-10 00:00:00.000", "description": "Report", "row_id": 1642742, "text": "Nursing Progress notes from 0700 to 1900 mhrs.\n(Continued)\n. maintain 500 ml negative balance. Will continue on Steroids. Stool to be sent for C-diff. Will continue monitoring closely her resp status & vital signs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-06-28 00:00:00.000", "description": "Report", "row_id": 1642695, "text": "NEURO; PT DOES NOT OPEN EYES TO VOICE OR FOLLOW COMMANDS, PERL #3 AND BRISK, POSITIVE CORNEALS, WEAK GAG ELICITED ON SUCTIONING, DOES NOT WITHDDRAW EXTREMITIES TO NAILBED PRESSURE-MICU AND PULMONARY TEAMS INFORMED, SEDATION OF VERSED AND FENTANYL BEING DECREASED TO ALLOW PT TO BE MORE ACTIVE YET CONGRUENT WITH VENTILATOR,\n\nCARDIOVASCULAR; HR 090'S-LOW 100'S, SR-ST, NEO WEANED TO 0.56 MCG/KG/MIN TO KEEP MAP > 65, TEMP MAX 99.3, EXTREMITIES PALE BUT WARM, PEDAL AND PT PULSES \n\nRESPIRATORY; REMAINS ON PC/V, FIO2 AT 60%, SUCTIONED FOR SMALL AMTS THICK YELLOW SECRETIONS, ABGS THIS PM SHOW PERSISTENT RESPIR ACIDOSIS WITH METAB ALKALOSIS, PC02 DOWN TO 49 FROM 51, 02 SATS 95%, ROTATION AND PERCUSSION MODES ON TRIADYNE BED UTILIZED,\n\nENDOCRINE; INSULIN GTT , PT ON SLIDING SCALE Q 4 HRS, RANGE 150'S, ORDER FROM RESIDENT TO START D5W AT 100CC/HR, DISCUSSED WITH MICU ATTENDING AND ORDER FOR D5W TO BE DC'D (NOT HUNG),\n\nRENAL; UK/O > 30CC/HR, YELLOW AND SL CLOUDY BUT MORE CLEAR THAN YESTERDAY,\n\nPLAN; WEAN SEDATION AS POSSIBLE TO KEEP PT COMFORTABLE BUT ALLOW TO BE MORE INTERACTIVE, PULMONARY TOILETING WITH ROTATION, PERCUSSION AND VAP PRECAUTIONS, ? EXTUBATION OVER WEEKEND, OR POSSIBLE TRACH, EMOTIONAL SUPPORT TO SIGNIFICANT PARTNER AND RELATIVES,\n" }, { "category": "Nursing/other", "chartdate": "2148-07-13 00:00:00.000", "description": "Report", "row_id": 1642755, "text": "MICU NPN 0700-1900\nEvents: Pt continues with poor toleration of turning and poor oxygenation. Pt preoxygenated with 100% FiO2 prior to turning, tolerated turn, but unable to wean FiO2 to 70%. Presently pt is on FiO2 80% with O2 sat 90-91%.\n\nNeuro: Pt remains sedated on Fentanyl 135mcg/hour and versed 5mg/hour. No spont movement noted and no response to stimuli. Pupils reactive. Rt pupil irregularly shaped, seen by ophthalmology yesterday who say that it is not related to an infection. Pt opens eyes with stimulation, but does not track.\n\nCV: HR 70's-80's prior to turning, up to 100's after turn and slowly trending back down. BP this am 120's-130's/60's, after turn up to 160's/70's-80's. MD aware. HCT down to 21.8 this am. Repeat pending. Will transfuse for HCT <21. Art line changed to left radial artery with improved waveform. Na 150 this am, up from 145. Receiving D5W at 150cc/hr for 1L.\n\nResp: LS's clear anteriorly, very diminished posteriorly. Remains vented on PCV, insp press 24, PEEP 10, FiO2 80%, RR 28, TV 300's. Ventilation improving slightly by ABG. Will repeat this eve. Suctioned for small amount of blood tinged secretions.\n\nGI: Abd softly distended with postive BS's. PEG tube in place, clamped, TF's on hold due to high residuals overnight. Aspirated approx 30cc coffee ground material this am, guaiac + and pH 1. TF's to remain off. Reglan changed to standing q6hours and started on protonix IV. Remains on bowel meds, no BM this shift.\n\nGU: Foley draining 35-85cc/hour clear yellow urine.\n\nSkin: Very small rash noted to coccyx, antifungal ointment applied. On Triadyne bed, currently not rotating. Pt does not tolerate turning well.\n\nSocial: Pt's SO visiting this afternoon. Updated on pt's condition and need for increased ventilatory support.\n\nPlan: Cont to monitor resp status and ability to wean FiO2. Monitor neuro status and wean sedation as able. Monitor labs. Provide emotional support to family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-07-13 00:00:00.000", "description": "Report", "row_id": 1642756, "text": "Respiratory Care\n\n\n Pt continues on PCV 02 sat labile. No changes made on ventilation. B/S diminished. Sx'd sm/mod thick blood tinged secretions. MDI's as ordered. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-23 00:00:00.000", "description": "Report", "row_id": 1642674, "text": "NEURO SEDATED ON PROPOFOL FENTANYL PARALYZED NIMBEX\n\nC/V NSR NO ECT B/P STABLE WITH NEO. SKIN WARM\n\nRESP VERY HIGH RR AND PIPS IN AM. ABG POOR. PARALIZED NIMBEX WITH IMPROVED VOLUMES CONTINUED ABG WITH PCO2 >100. VENT ADJUSTMENTS WITH EVENTUAL IMPROVEMENT IN ABG SAT 98% ESOPH BALOON IN TO MONITOR ACURATE PEEP. ADJUSTED AS NEEDED TO MAINTAIN ACCEPTABLE O2/VENT. SEE RESP FLOW SHEET FOR ADJUSTMENTS. CURRENT ON A/C 70% RR 32 14 PEEP. TOL WELL SUCTIONED FOR SCANT THICK.\n\nGU/GI OG PLACED WITH SMALL AMTS GREEN DRAINAGE. ADEQUATE URINE OUT ABSENT BOWEL SOUNDS\n\nPLAN CONTINUE TO CLOSELY MONITOR RESP STATUS AND HEMODYNAMICS\n" }, { "category": "Nursing/other", "chartdate": "2148-06-23 00:00:00.000", "description": "Report", "row_id": 1642675, "text": "Resp Care: Pt remains intubated paralyzed/sedated. Esophageal balloon inserted. PEEP adjusted accordingly. ABG revealed resp acidosis. RR ^'d to 32 w/ gd effect. Most recent ABG WNL. Plan: cont vent support. Please see carevue for further vent inquiries.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-27 00:00:00.000", "description": "Report", "row_id": 1642690, "text": "NURSING 7P-7A\n STABLE OVERNIGHT. CONTINUES IN NSR, NO ECTOPY. REMAINS ON NEO AT .8 TO KEEP MAPS>65. TEMP MAX 99.3. PAN CULTURED FOR INCREASED WBC'S PER PRIMARY TEAM. POTASSIUM LOW THIS AM, REPLETED WITH 40 KCL. A-LINE DAMPENED AND BECAME DIFFICULT TO DRAW FROM, LINE RESTARTED BY DR. IN LEFT RADIAL ARTERY. CARDIAC OUTPUTS REMAINED WNL. CVP'S . SEE CARE VUE FOR FULL ASSESSMENT.\n MINOR VENT CHANGES OVERNIGHT. PRESSURE DECREASED THIS AM TO 28. ABG'S TRENDING MORE TOWARDS NORMAL. SEE CARE VUE FOR FULL ASSESSMENT. CONTINUES TO DERECRUIT WHEN TURNED AND RESPOSTIONED. DID NOT TOLERATE SWIMMER'S POSITION LAST NIGHT. O2 SATS DROPPED WITH DECREASES IN PAO2 TO THE 50'S TAKING >1 HOUR TO RECOVER TO BASELINE. TURNED AND REPOSITIONED SIDE TO SIDE WITH JUST PILLOWS PLACED LIGHTLY UNDER BACK. LUNGS REMAIN CLEAR TO AUSCULTATION BILATERALLY WITH THE EXCEPTION OF DECREASED BREATH SOUNDS RIGHT BASE. SVO2'S REMAIN 68-75 OVERNIGHT.BIS MONITER WITH VALUES 30-40 OVERNIGHT. AT 0230 WHEN TURNED BIS VALUE BECAME GREATER THAN 60, FENTANYL AT THAT TIME WAS AT 100 MCG'S, INCREASED TO 150 MCG'S. REMAINS ON VERSED AT 3 MG/HOUR AND PARALYZED WITH CISTATRICURIUM AT .18. 1 THUMB TWITCH AT THAT DOSE, SYNCHRONOUS WITH THE VENT.\n ABDOMEN SOFTLY DISTENDED, POSITIVE BOWEL SOUNDS. TUBE FEEDS ARE CURRENTLY AT 60. RESIDUALS HAVE BEEN LEFT THAN 50, CHECKED Q 4 HOURS. FOLEY WITH ADEQUATE URINE OUTPUT.\n DRESSING OVER THORACOTOMY SITE DRY AND INTACT. PUNCTURE WOUNDS CLEAN AND DRY. SKIN GENERALLY INTACT. OLD IV SITE LEFT ANTECUBITAL STILL WITH ERYTHEMA, SCABBED OVER. LEFT OPEN TO AIR.\n CONTINUE TO MONITER HEMODYNAMICS, RESPIRATORY STATUS. FREQUENT ABG'S. MONITER BIS LEVELS. RECHECK ELECTROLYTES THIS AFTERNOON.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-06-24 00:00:00.000", "description": "Report", "row_id": 1642676, "text": "Respiratory note:\nPt remains intubated, paralysed. Peep was ^^ based on esophageal ballon inserted yesterday. Adequate oxygenation revealed ABG , FiO2 decreased to 60%. Pt remained on PRVC. Sx for small amt of thick white secretions. MDI's given as ordered. Plan to wean peep as tol. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-24 00:00:00.000", "description": "Report", "row_id": 1642677, "text": "B SHIFT NPN\nLITTLE CHANGE OVER SHIFT\nSEE FLOWSHEET FOR OBJECTIVE AND TREND INFO\n\nNEURO: CHEMICALLY PARALYZED ON 0.13MG/KG/HR CISATRACURIUM AND SEDATED ON FENTANYL/PPF GTTS. 4 TWITCHES NOTED ON TOF, NOT OVERBREATHING VENT.\nMULTIPODUS BOOTS ORDERED AND APPLIED FOR FOOT DROP. UNABLE TO ASSESS NEURO STATUS FURTHER.\nCV: SR, NO VEA. SBP MAINTAINED ON 1.5MCG/KG/MIN PHENYLEPHRINE, UNABLE TO WEAN IN SPITE OF TRYING TO DO SO.\nRESP: ABG IMPROVING, FI02 DECREASED TO 60% REMAINS ON PRVC RR 32, LAST ABG SENT AT 0630 RESULTS PENDING.\nGI: NGT TO LCWS WITH 300CC GREEN BILIOUS DRG. BS HYPOACTIVE, NO BM.\nRENAL: AUTODIURESING WITH HUO >200CC/HR.\nPLAN: WEAN FI02 AND CHANGE VENTILATOR SETTINGS TO A/C, WEAN PHENYLEPHRINE GTT AS TOLERATED AND KEEP FAMILY UPDATED ON PLAN OF CARE.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-07-08 00:00:00.000", "description": "Report", "row_id": 1642731, "text": "NURSING NOTE\nASSESSMENT:\n PATIENT ON FENTANYL & VERSED GTTS, OCCASIONALLY ABLE TO OPEN EYES AND FOLLOW COMMANDS. MOVING ALL EXTREMITIES. SOMETIMES ABLE TO COMMUNICATE BY MOUTHING WORDS AND NODDING \"YES/NO\". APPROX 11PM, PATIENT GETTING INCREASINGLY TACHYPNEIC TO 40 (VERSED HAD PREVIOUSLY BEEN DROPPED TO BY 0.5 MG/HOUR). SUCTIONED AND GIVEN INHALERS WITH MINIMAL IMPROVEMENT, RESP THERAPY & MICU INTERN PRESENT. PATIENT DID NOT APPEAR AGITATED OR IN PAIN @ THIS TIME. ATTEMPTED PATIENT ON ASSIST CONTROL AND PRESS SUPPORT WITH NO IMPROVEMENT, RETURNED TO PRESSURE CONTROL. CXR DONE & ABG SENT (BASELINE). PATIENT RECOVERED AFTER APPROX 1 HOUR AND RESP RATE NOW DOWN TO 30.\n FEBRILE TO 102 (CULTURED YESTERDAY). TACHYCARDIC 90-120 & SBP 100-130'S, NEO GTT OFF. CVP ~ 10, MAKING ADEQUATE HOURLY URINE. LUNG SOUNDS OCCASIONALLY COARSE, BUT SUCTIONED FOR MIMINAL SECRETIONS. PATIENT COUGHING FREQUENTLY, GIVEN LIDOCAINE DOWN ET TUBE AND AWAITING EFFECT. ABDOMEN SOFT, NONDISTENDED. TOLERATING REPLETE WITH FIBER @ GOAL RATE OF 50 CC/HOURLY THRU G-TUBE. NO STOOL OVERNIGHT.\nPLAN:\n A-LINE TO BE PLACED LATER TODAY. CONTINUE WITH CURRENT MONITORING AND TREATMENT. PROVIDE SUPPORT. ? PICC LINE PLACEMENT TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-08 00:00:00.000", "description": "Report", "row_id": 1642732, "text": "Respiratory Care:\n\nPatient with 7.0 Portex. Air added due to small leak. Cuff pressure 27cm/H20. Pt. sedated. Period where patient waking up, dysynchrony with vent,coughing episodes, and desating to 88%. Vols decreasing to 300's from 400's with RR ^ 40's. Fio2 ^ briefly to 100%. Attempted PSV and A/c modes for more comfort but RR ^ 45-50. PCV best mode at this time. Sedation ^ via RN. BS unchanged(coarse bilaterally). Sx'd for sm amounts of thick white secretions. Lidocaine 1/% given 1cc via trach x 1. Tolerated well. Coughing resolved. Fio2 weaned back to 60% with PCV 24, Rate 20 and Peep ^ 8 this shift. CXR done. ABG revealed compensated resp acidosis. Fluid positive. No further changes made.\nPlan: Continue with PCV and wean Fio2/PCV rate as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-27 00:00:00.000", "description": "Report", "row_id": 1642691, "text": "resp care\nremains intub/vented in pcv mode. paralytic turned off and so far ventilation is stable. goal pao2 >55. sxned as charted. well sedated. bronchodilators given q4h. refer to flow sheet for further data.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-27 00:00:00.000", "description": "Report", "row_id": 1642692, "text": "NEURO; CISATRACURIUM DC'D THIS AM, JFOUR THUMB TWITCHES ONE HR AFTER , PT DOES NOT OPEN EYES TO VOICE OR FOLLOW COMMANDS, DOES NOT WITHDRAW TO NAILBED STIMULI AT PRESENT, VERSED AND FENT GTTS INCREASED TO KEEP PT IN SYNCH WITH VENT, NEO GTT TITRATED TO KEEP MAP > 65\n\nCARDIOVASCULAR; AFEBRILE, HR 90'S-LOW 100'S, SR-ST, PA LINE PULLED AND CORDIS CAPPED,\n\nRESPIR; LUNGS CLEAR, SUCTIONED FOR SMALL AMTS THICK YELLOW -LIGHT TAN SECRETIONS, ABGS REFLECT RESPIR ACIDOSIS AND METAB ALKALOSIS, I/E RATION CHANGED SIGHTLY BUT NO OTHER MAJOR CHANGES, PT PLACED ON TRIADYNE BED WITH ROTATION AND PERCUSSION, 02 SATS PRESENTLY 94-95%, PT DID EARLIER THIS PM TO 88, SUCTIONED FOR SMALL AMT THICK YELLOW MUCOUS AND SATS IMPROVED,\nBIS MONITOR DC'D TODAY AFTER PARALYTICS, RANGE 30-40'S\nENDOCRINE; PT ON INSULIN GTT WITH RANGE 92-190'S, EARLIER, PRESENTLY 125, INSULIN GTT DC'D PER MICU AND PT WILL BE ON SLIDING SCALE,\n\n\nPLAN; PT NEED TRACH IN FUTURE, KEEP PT ON TUBE FEEDS AT PRESENT, TRIADYNE BED WITH ROTATION AND PERCUSSION, AGGRESSIVE PULMONARY TOILETING,\nPT NOW ON MICU SERVICE,\n" }, { "category": "Nursing/other", "chartdate": "2148-07-13 00:00:00.000", "description": "Report", "row_id": 1642753, "text": "MICU NPN 1900-0700\nEvents: Requiring increased sedation, vent changes, Temp spike-> cultured.\n\nResp: Initially on PSV with 12 Peep, O2 sats had been 90-91% with RR of 14. Sat down to 89%, TV's in the 300's. Able to obtain an ABG: pO2 87, CO2 106. pH 7.14. After multiple changes and adjustments, the pt was placed on PCV 28, TV 400, Fio2 70%, 10 Peep. ABG improved with CO2 72, and pH 7.22. Will recheck an additional ABG ~0600. Pt received additional bolus' of versed and fentanyl for further sedation control. If she does not show signs of improvement, she may require paralysis.\n\nCV: HR has been in the 120's, after vent manipulation and further sedation, HR has been in the 80's SR. No hypotension, Neo remains off.\n\nNeuro: No improvement noted. Does not follow commands, has not moved extremities independently. Opening eyes only to tactile stimulation.\n\nGI: Unable to tolerate TF's. Residuals have been 140-150cc's the entire shift. TF's were stopped ~. Aspirates have been re-fed and reglan was administered. Hypoactive BS, no stool. Cont's to received colace and senna.\n\nGU: Urine output averaging 80cc/hr.\n\nID: Tmax 100.5 AX. Blood cultures times 2 (periperal and CL) obtained and sent. Urine culture also sent.\n\nSocial: No contact with family overnight.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-07-13 00:00:00.000", "description": "Report", "row_id": 1642754, "text": "Respiratory therapy\npt presents on PSV. 0200 Pt noted to have a significant resp acidosis. After multiple vent changes and sedation, placed on PC A/C with good effect. Despite dysynchrony, abg's improved. MDI's as ordered. Plan: continue ventilatory support.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-08 00:00:00.000", "description": "Report", "row_id": 1642733, "text": "Resp Care\n\nPt remains with a #7 Portex and currently vented on PCV Pinsp 24 RR 20 PEEP 8 with Vt ranging from 300-400ml and MV 10-12L. PT consistently overbreathing set rate with total RR in the mid to high 30s with agitation. No changes made to parameter settings this shift. Pt transported to and from angio without any incident. Bronchodilators given x3 with good aeration noted. WIll cont with vent support and wean accordingly.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-09 00:00:00.000", "description": "Report", "row_id": 1642734, "text": "NPN 7p-7a\nPt is a 58y/o with h/o interstitial lung disease, pulmonary fibrosis s/p VATS/RML and RLL wedge resection . Pt was transfered from SICU (on MICU ) yesterday for hypoxic resp failure and ARDS, and fever. Pt has had complicated course, initially admitted for VATS which went without immediate complications. Pt had increased O2 requirements on the floor and then fell while ambulating to the bathroom. Pt then triggered for RR 40s-50s and sats 50-60% on 6.0L NC. Pt was put on bipap and then intubated for worsening resp distress. CTA neg for PE, but did show pulm edema/ARDS. Pt has since had persistent fevers and failure to wean, trach and PEG placed and has been on/off pressors.\n\nOVERNIGHT EVENTS: Pt spiked temp to 101.2, pancultured and given 650mg Tylenol. Pt was transiently dropping sats to 90%, ABG showing PaO2 59. Multiple vent changes made, see careview.\n\nNEURO: Pt was received on 5mg/hr Versed which was increased on pt arrival to unit from 1.5mg/hr as pt very agitated and tachypneic to 40s and dysynchronous with vent. Pt also on 125mcg/hr Fentanyl. Pt opens her eyes to stimuli, does not follow commands, but will withdraw to pain. Moves upper extrems on bed. Pt has detached retina in right eye and is legally blind.\n\nRESP: Pt , currently on CPAP. Awaiting f/u ABG. RR 20s-30s. Sats 96-100%. LS coarse t/o. Suctioning for thick tan/white secretions. Pt will occas have coughing epsiodes and become tachypneic and . Pt will settle out with boluses of sedation.\n\nCV: HR initially 100s in ST. Now 80s-90s, NSR. BP 90s-100s/50s supported by Neo at 1mcg/kg/min. Pt has easily palpable pulses. LENIS r/o DVT.\n\nGI/GU: ABD is soft, +BS, No BM this shift. TFs runnig at goal 50cc/hr via PEG. U/O ample, foley draining >100cc/hr.\n\nID: Tmax 101.2, covered on meropenem, vanco, cipro. Cultures pending.\n\nSOCIAL: No contacts overnight.\n\nPLAN: Cont to monitor resp status, wean as tolerated. Pt needs Aline.\n Wean sedation as tolerated.\n Monitor fever curve, f/u with pending cultures.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-09 00:00:00.000", "description": "Report", "row_id": 1642735, "text": "Respiratory Care:\nPatient desaturated and became dysynchronous with the ventilator. Switched to CPAP/PSV. Less dysynchrony noted. ABG results were essentially unchanged, although the SPO2 read 100%. PEEP increased to 10 cm. Repeat abg results to follow.\n\nNo RSBI measured due to the patient's current high FIO2.\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\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\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-07-09 00:00:00.000", "description": "Report", "row_id": 1642736, "text": "Nursing progress notes from 0700 to 1900 hrs.\nAlx : PCN, Codeine.\nCode : Full code.\nAccess lines : PICC at rt upper arm, Rt RAd A-line.\n\nSignificant events : A-line placement.\n Vent parameters changed to keep Sat > 90% & RR at\n 20 -30 bpm.\n Titarting Neo up & down to keep MAP >60.\n\nNeuro : Sedated on versed @ 5 mg/hr, fentanyl@125 mcg/hr. Opens eyes during turning/mouth care. Does not respond to any painful stimuli or any verbal stimuli or neither track to follow any commands. No movements at the upper & lower extremities noted. RT eye blindness from retinal detouchment. Left pupil 3 mm/ brisk. Versed 1 mg X1 bolus given for tachypnea without therapeutic effect.\n\nResp : Trach # . recieved on vent with parameters CPAP/0.70/15/+10. vent parameters changed to keep saturation above 90's. ABG at 1500 hrs : 7.37//61/85/7. Recent vent setting : PSV/0.60/17/ +12. Maintaining sats at mid 90's. Tachypnic mostly, RR ranges from 24 -40 bpm. Lungs are coarse throughout the fields. Suctioned for small, tan secretion. Uses accessory muscle for breathing mostly.\n\nC/V : NSR mostly, no ectopic beats noted. Heart rate between 80-110's. SBP 80 to 120's. MAP 55-70's. received on neo 1 mcg, titrated down & up to keep MAP >60. Lasix 20 mg IV given & MAP down to 50's. Increased neo to 1.2 mcg to keep MAP>60. Now Neo @ 1 mcg/kg. Goal MAP >60. A-line at rt rad artery done at 1430 hrs. Rt A line positional, able to draw ABG & other labs. Plan to wean neo as tolerated if possible. No edema noted. Multi boots on . PICC @ RUA patent. PM Electrolye checked, WNL. Profuse sweating noted (afebrile at this time), notified to MD.\n\nGI/GU : PEG tube in place. Tube feeding held for few hours as residual was >150 ml. Resumed tube feeding @ 30 ml/hr (goal rate @ 50 ml/hr). Lasix 20 mg IV given for diuresis with good outcome. Goal to maintain I & O balance negative 500 ml. urine output ranges from 50 to 300 ml/hr. Indwelling urinary cath in place, draining yellow/clear urine. Positive bowel sounds at all quadrants. No BM at this shift.\n\nID: Febrile, T max : 101.8. Tylenol 650 mg PR given with therapeutic effect. F/U with culture. Stool to be sent for C-diff. Will continue on vanco, meropenam, cipro.\n\nSkin : Intact. Blister at rt corner of mouth & Close approximated incission at rt thoracic cavity. Repositioned frequently & back care given.\n\nPlan/Dispo : Full code. Family updated about the status. Goal to keep MAP>60 mm of hg, Sat >90%. Plan to wean neo as tolerated if possible. Will continue on sedation. ? CT head & sinus in future. Goal to keep 500 ml negative balance. Stool for C-diff to be sent. Will closely monitor her resp status, neuro status.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-09 00:00:00.000", "description": "Report", "row_id": 1642737, "text": "pt required PEEP and sedation increase early in shift due to desaturation, improved through shift and sx'd for moderate amount of thick secretions. plan to be revaluated in AM rounds.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-26 00:00:00.000", "description": "Report", "row_id": 1642687, "text": "Condition Update\nPlease see carevue flowsheet for specifics:\n\n Remains paralyzed on cisat @0.18 mcg, kept at the same dose but after change in sedation meds obtaining twitches with less mA. Noninvasive BIS monitor placed by anesthesia resident to pt's forehead to monitor pt's sedation level while transitioning sedation from propofol to midazolam. Instructed by anesthesia resident to keep BIS number between 40-60 for adequate sedation. Propofol weaned off, midazolam @3mg, fent titrated to 125mcg, Pt adequately sedated per BIS number, not breathing over vent. Lungs clear, dim in LLL. O2 sat 94-99% Suctioned for scant pale yellow secretions. Freq ABG's draw mode of ventilation changed and small changes made in RR and I:E ratio. Attempting at this time to back off on aggressive permissive hypercapnea but do not want to completely normalize abg's at this time per sicu attending.\n Nsr- ST at times 80's to 100's with occ pvc's and pac's noted .SBP 80's -120's neo tirated to keep sbp greater than 90, 0.5-2.0mcg requirements decreasing throughout shift. A-line dsg changed wave sharp and correlating with cuff pressure. CO fluctuating throughout day from mid 5's to 8's independantly of any med changes. 1 unit prbc's given for volume purposes, with no changes noted to hemodynamics.CVP stable through out day . BS hypoactive. Tube feed started after propofol off. Replete w/ fiber @ 20 cc/hr. CBG @10 am 328, sliding scale tightened, recieved 22 units reg at that time, repeat cbg @1600 247, covered accordingly. Skin intact, flush & diaphoretic, but remains afebrile. Ionized calcium 1.06, recieved 2gm's calcium gluconate as ordered. Family in at bedside. Social worker met with brother today.\nPLAN:\nContinue to monitor hemodynamics.\nDue for vanco trough prior to am dose.\nWean neo and sedation as needed\n" }, { "category": "Nursing/other", "chartdate": "2148-06-26 00:00:00.000", "description": "Report", "row_id": 1642688, "text": "Respiratory Care Note\nPt received on AC as noted. BS essentially clear throughout and diminished in LLL. Pt suctioned for minimal secretions. ABG's this am reveal a respiratory acidosis with a pH of 7.26 and PaCO2 of 67. Mode of ventilation switched to PCV secondary to PIP's and PEEP weaned to 5cm. Pt tolerated well with VT range 390-440. Esophageal balloon discontinued. ABG at 4pm was within normal limits. Vent rate weaned from 28 to 24. Sats are 91% after rate change - will obtain ABG and adjust settings accordingly. Plan to continue with PCV ventilation at this time.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-27 00:00:00.000", "description": "Report", "row_id": 1642689, "text": "Respiratory Care:\n\nPatient intubated on mechanical support. Vent settings unchanged. PCV 30cm, Peep 5, Fio2 50% and rate 26. 1:E ratio 1:1.6. Auto peep 0-1. BS clear bilaterally. Sx'd for sm amount of thick yellow secretions. Sputum cx sent. Vols 400-430. MV 11.2-11.5. Albuterol/Atrovent MDI's given Q4hr, Flovent . Vols improving from 370 to 430. Last ABG on above settings 7.43, 45, 76, 29. PaCO2 decreasing from 59 to 45 over course of shift. Pt. remains paralyzed/sedated.\nPlan: Continue with mechanical support and wean PCV level as tolerated. Allowing for Permissive Hypercapnea.\n" }, { "category": "Echo", "chartdate": "2148-07-11 00:00:00.000", "description": "Report", "row_id": 84908, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Chronic lung disease.\nHeight: (in) 63\nWeight (lb): 185\nBSA (m2): 1.87 m2\nBP (mm Hg): 108/63\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 15:45\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: 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: No masses or vegetations on aortic valve.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve. Mild PA 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. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%) Right\nventricular chamber size and free wall motion are normal. No masses or\nvegetations are seen on the aortic valve. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. No mass or vegetation is seen on\nthe mitral valve. Mild (1+) mitral regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: No valvular vegetations seen. Normal global and regional\nbiventricular systolic function. Mild pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , pulmonary\nhypertension is identified.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-07-12 00:00:00.000", "description": "Report", "row_id": 1642750, "text": "Events;Fluid bolus 1L,Neo weaned off,Versed gtt taperred to 5 mg,PEEP down to 10.\n\nCVS;HR 105-110 ST started to trend down after fluid bolus, CVP 8-10 ABP positional,following NBP--received with NEO gtt 0.25 mcg weaned off and blood pressures are maintained MAP >60 since then.Positive pedal pulses,LIJ and A-Line for access.\n\nNuero;Sedated with Fentanyl 135 mcg and Versed 5 mg,opens eyes for deep painful stimuli with vague look doesnot follow commands or move extrimities.Pupils--rt side iredectomy as per records and lt 3mm and brisk.\n\nResp; Ls are clear/dim on bases On CPAP+PS PEEP was changed as mentioned above no other vent changes.ABG as per careve.Pt was comfortable with breathing today,sats are maintained >95%.Planning to continue same vent settings for today.On methylprednisolone 3rd day.\n\nGI;Abdomen soft positive bowel sounds TF replete w/fiber started with 10 ml/hr pt had 180 ml residuals prior starting feeds,reglan prn dose was given with good effect.Bowel meds continued as prescribed and no more bowel movements noted.Blood sugar required coverage as per sliding scale,scale was revised today since pt is on methylprednisolone\n\nGU;Adequate output via foley catheter.\n\nSkin WNL\n\nSocial;Visited by multiple family members and updated.\n\nID;Low grade temp continued,Tylenol prn given.On Fluconazole,Vancomycin and Meropenem/Iv.Opthalmology was consulted to R/O possible FUNGAL ENDOPHTHALMITIS\n\nPlan;Full code for now\nFluid bolus/prn for hypotension\nWean sedation and vent as tolerated.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-07-12 00:00:00.000", "description": "Report", "row_id": 1642751, "text": "Addendum........\n\n 1700-- Pt desats to 87% after position and care,HR 130's afebrile NBP was stable,MD was notified,unable to obtain ABG due to poor access.APRV was tried with no improvement in sats,PEEP increased back to 12.CVP 14,NS 500 ml bolused.planning to insert new A-Line later.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-12 00:00:00.000", "description": "Report", "row_id": 1642752, "text": "Resp Care\nPt remains on PSV via trach. Stable shift, able to wean peep initially. End of shift pt to 87% following turn/care, tried recruitment x 2 on APRV, required ^ in settings. Plan to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-25 00:00:00.000", "description": "Report", "row_id": 1642684, "text": "Respiratory Care Note\nPt received on AC as noted. BS coarse throughout especially on L side with crackles in RLL - LLL is diminished. Pt suctioned for small to moderate amts thick, white secretions. PEEP and FiO2 weaned according to ABG's. ABG reveals a partially compensated respiratory acidosis with good oxygenation. Plan to continue on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-26 00:00:00.000", "description": "Report", "row_id": 1642685, "text": "Please See Carevue for Specifics.\n\nPt remains adequately paralyzed and sedated on 0.18mg/kg/hr of Cisatracurium with 65mcg Propofol/kg/min and 150mcg/hr of Fentanyl. Pupils are unequal (right and left ) but are both reactive to light accomadation. Right pupil has known detached retina and pt is legally blind in right eye. NSR-ST, no ectopy. MAP >65 maintained on Neo gtt. When Neo decreased pt SBP decreased to 60. CI 2.8-3.3, CO , SVR 800-1200. Lungs are diminished at bases, clear upper lobes. PaO2 60-90's with FiO2's. PF ratio at start of shift was 124 and towards end of shift it is was 134. Pt side to side every two hours in swimmers position. Abd is soft, obese, hypoactive bsx4. TF dc'd due to nutrition note indicating pt receiving enough KCal through Propofol. No stool this shift. Decreased urine output towards morning requiring 500cc NS bolus. Right thoracotomy site is CDI, no dressing.\n\nPOC: Wean vent as tolerates, continue to closely monitor hemodynamics. Continue side to side swimmers position and monitor PF ratio trends. Continue fentanyl and propofol to keep adequately sedated while on Cisatracurium. ?Family meeting in near future to discuss pt prognosis. Continue to offer pt and pt family emotional support throughout hospital stay.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-26 00:00:00.000", "description": "Report", "row_id": 1642686, "text": "Respiratory Care\nPt Device: Pt remains orally intubated on full ventilatory support. No changes made to vent t/o the noc. Pt tol vent well with NARN. No RSBI this AM. Pt is paralyzed and sedated.\n\nChest: BBS diminished in the bases. sx for thick white secretions. MDIs given as ordered.\n\nGas Exchange: ABG shows a respiratory acidosis. pt is afebrile, TBB is negative.\n\nPlan: monitor and support, wean as tolerated.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-06-25 00:00:00.000", "description": "Report", "row_id": 1642681, "text": "NURSING\n VSS OVERNIGHT. REMAINS IN NSR, NO ECTOPY. CONTINUES ON NEO AT 1.3, ALL ATTEMPTS TO TITRATE DOWN INEFFECTIVE. TEMPERATURE MAX 99.2. CVP 8-10. ELECTROLYTES WNL, NO REPLETIONS NECESSARY THIS AM. GLUCOSE LEVELS TREATED PER SLIDING SCALE.\n MINIMAL VENT CHANGES OVERNIGHT. ABG'S REMAINED GOOD OVERNIGHT. DOES NOT TOLERATE LARGE TURNS SIDE TO SIDE, DID NOT TOLERATE SWIMMERS POSITION OVERNIGHT. DESATS TO 88-90% WITH ANY TURNS SIDE TO SIDE. O2 SATS INCREASE SLOWLY AFTER TURNS TAKING ABOUT 45 MINUTES TO SETTLE BACK INTO THE 95-97% RANGE AT 0600 SUDDENLY DESAT TO 90-91 WITHOUT ANY PRECIPITATING EVENTS... WAS NOT TURNED, MOVED OR SUCTIONED PRIOR TO THAT TIME. LUNGS WERE CLEAR WITH SOME COARSE BREATH SOUNDS BASES. LAVAGED X3, SUCTIONED WITH MINIMAL SECRETIONS. MDI'S GIVEN PER RESPIRATORY THERAPY. PEEP INCREASED TO 10 WITHOUT ANY EFFECT THUS FAR. O2 SATS CURRENTLY STILL 90-91%. WILL NOT MAKE ANY FURTHER CHANGES AT THIS TIME. ABG TO BE CHECKED IN 20 MINUTES AT 0630. REASSESS VENT SETTINGS AFTER RESULTS OF ABG PER DR.. REMAINS ON PROPOFOL AT 75 MCG'S, FENTANYL AT 150 MCG'S, AND PARALYZED WITH CISTATRICURIUM AT 0.18 MCG/KG. O TWITCHES RIGHT ULNAR AT 60. PUPILS EQUAL AND REACTIVE.\n FOLEY REMAINS INTACT DRAINING LARGE AMOUNTS CLEAR YELLOW URINE. OGT TO LWS DRAINING BILIOUS DRAINAGE, 300 THIS SHIFT. BOWEL SOUNDS PRESENT BUT HYPOACTIVE, NO STOOL SINCE ADMIT TO ICU.\n DRESSING REMAINS INTACT OVER THORACOTOMY SITE. PUNCTURE WOUNDS FROM VATS OTA WITH EDGES APPROXIMATED. NO ERYTHEMA AT SITE. LEFT PIV ANTECUBITAL SITE HEALING WITH LESS ERYTHEMA, NO DRAINAGE. MULTIPODUS SPLINTS REMAINED ON OVERNIGHT TO PREVENT FOOT DROP.\n CONTINUE TO MONITER HEMODYNAMICS, RESPIRATORY STATUS. REEVALUATE VENT SETTINGS WITH RESULTS OF ABG AT 0630. USE CAUTION WITH TURNING SIDE TO SIDE. FREQUENT ABG CHECKS WITH ANY CHANGES IN O2 SATS, CHANGES IN LUNG SOUNDS.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-25 00:00:00.000", "description": "Report", "row_id": 1642682, "text": "RESPIRATORY CARE:\n\nPt remains intubated, fully vent supported on AC mode. Pulm status slightly worsened overnight; BS's more coarse, oxygenation slightly decreased, CXR worse. Sxing small amts thick white secretions. Administering Albuterol and Atrovent MDI's in line with vent. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-25 00:00:00.000", "description": "Report", "row_id": 1642683, "text": "SEE FLOWSHEET FOR SPECIFICS.\n AFEBRILE, CONTINUES ON NIMBEX. TOF ON RT ULNAR 1 TWITCH @ 60 AT TIMES.FENTANYL @150 AND PROPOFOL @75. NEO TITRATED AS NEEDED THROUGHOUT SHIFT. 1.2-2.0 MCG'S. SBP 80'S-90'S AS LOW AS 60'S AT ONE POINT PER RIGHT RADIAL A-LINE. VERY SENSITIVE TO SLIGHT CHANGES ON NEO. REMAINS NSR W/ RARE PAC NOTED. CCO SWAN INSERTED @ ~1400 PLACEMENT CONFIRMED. DSD D&I. LS COURSE ON LEFT, CRACKLES ON RIGHT , DM BIBASILAR. O2 SAT 95-100% OCC DESATS WHEN T&R. ESPECIALLY ON RIGHT SIDE. PEEP DOWN TO 8. SUCTIONED FOR MIN AMT OF THICK PALE YELLOW. FC DRAINING LIGHT YELLOW URINE. ABD SNT +HYPOACTIVE BS. NO BM THIS SHIFT. TF STARTED @1500 REPLETE W/ FIBER @20 CC. SKIN INTACT. THOROCOTOMY SITES CLEAN . DIAPHORETIC AT TIMES.\nCONTINUE TO MONITOR HEMODYNAMICS, T&R, ABG'S WITH ANY RESP CHANGES. WILL REASSESS IN AM.\n , RN\n" }, { "category": "Nursing/other", "chartdate": "2148-07-12 00:00:00.000", "description": "Report", "row_id": 1642748, "text": "MICU NPN 1900-0700\nSystem Review:\n\nCV: ~0400, pt's HR noted to be 130's, and quickly escalating to 150. EKG revealed ST. No drop in BP. Pt had been suctioned ~15 minutes prior to increased HR increase. Pt also noted to have a slightly elevated temp from earlier in shift, 99.2 ax. Received 2mg additional versed, 100 mcg fentanyl with no noticable change. At ~0500, pt given a one time dose of morphine, 2mg IV, and an additional dose of tylenol 650mg. Also received a 500cc NS bolus. By 0615 HR drifting slightly down to 130's.\n\nID: Cont' to receive IVABX, vanco level to be drawn between 0600-0800. Blood cultures times 2 drawn this am.\n\nHeme: Hct down to 23.9 from 26.0. Plan is to recheck labs a little later on this morning. Minimal aspirates via G-Tube, stool OB-.\n\nNeuro: Cont's sedated on fentanyl gtt at 130 mcg/hr and versed 7 mg/hr. No spontaneous movement of extremities assessed. She has opened her eyes to tactile stimuli. No tracking or following commands noted. Pupils ~3-4 mm in size, reaction; brisk.\n\nResp: Cont's and ventilated. On CPAP+PS 60% FiO2, 15 PS, 12 PEEP. LS CTA, diminished at right base, course in left base. Suctioned for small amt thick tan secretions. Pt pre-oxygenated with 100% FIO2 prior to any turning. ABG to be drawn in am.\n\nGI: +BS, abdomen soft, moderate stool, OB-, formed. F/U in am re: restarting TF's. Con'ts to receive colace and senna.\n\nGU: Voiding adequately via foley cath.\n\nSocial: No family contact this shift.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-12 00:00:00.000", "description": "Report", "row_id": 1642749, "text": "Respiratory Care:\n\nPt & sedated on spotaneous ventilation; PSV. No vent changes. Mdi's adm as ordered. We are sxtn for small amt of thck tan secretions. Plan: Continue present ICU monitoring. See Carevue for more details.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-01 00:00:00.000", "description": "Report", "row_id": 1642705, "text": "FOCUS: STATUS UPDATE\nDATA:\nPt. continues sedated on Fentanyl and Versed iv. Moves all extremities in bed but does not follow commands. Perl at 3-4mm, does not focus on speaker but does open eyes to speech at times.\n\nLungs bilaterally clear. Placed on PS20 with Peep5 with acceptable ABG but she became agitated and tachycardic with labored breathing. Returned to AC vent with better compliance. Sats 94-98% on 55%FIO2.\n\nStable BP, maintained >90sys and >60MAP off Neo. Aline positional but corrolates with NIBP when functioning properly and tracing is normal.\n\nTolerating tube feeds via OGT with no residuals. Sliding scale insulin coverage for elevated glucose levels, Glargine to start tonight.\n\nLasix x1 with good diuresing. I/O goal is even.\n\nPlan:\nFamily meeting between Dr. and Brother and sister regarding need for trach which will be planned within next couple of days after consulting with Thoracic.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-01 00:00:00.000", "description": "Report", "row_id": 1642706, "text": "RESPIRATORY CARE: PT REMAINS INTUBATED AND ON PCV IN THE AC MODE. PT BRIEFLY CHANGED TO PS 22/.55/5 PEEP THIS AM. ABG/VT/RR ... WERE STABLE BUT PT BECAME MORE TACHYCARDIC AND ANXIOUS.SO PLACED BACK ON PCV. RSBI ABOUT 70 AND MIP - 36 THIS AM. TRACH BEING DISCUSSED W/ FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-02 00:00:00.000", "description": "Report", "row_id": 1642707, "text": "NURSING PROGRESS NOTE\n\nSEE CAREVUE FOR DETAILS.\n\nNEURO: Sedated on Fentanyl & Versed however opening eyes to voice, not tracking. Does not follow commands. MAE on bed to nailbed pressure or with deep suctioning. Did become easily arousable on sedation MAE, opening eyes spontaneously & attempting to lift head w/out external stimuli; tachycardic into 120s during time, not settling >> sedation slightly increased to maintain pt comfort; Dr aware.\nCV: Aline dampened, SBP not correlating w/manual BP on same side (NBP on right side correlating w/manual on left), not drawing blood. Dr aware. MAPs correlating. Pt autoregulating maintaining SBP >90, MAP >65. Tachycardic HR 105-116, occasionally into 120s w/repositioning or stimulation. No viewed ectopy. CVP 5-10.\nRESP: No vent changes overnight. Sat's 94-98%. Suctioning for scant thick white secretions. Sm amt oral secretions. Lungs clear, slighlty dim in bases, R>L.\nGI: Abd soft. No BM. + BS. TF cont at goal w/no residuals.\nENDO: FBS tx per RISS checking every 4 hours, Glargine started.\nGU: Foley patent. Started twice daily lasix dose w/additional one time dose given for marginal u/o, Dr aware. Goal to maintain even to slightly negative fluid balance.\nSOCIAL: Boyfriend into visit.\n\nPOC: Monitor hemodynamics. Titrate Fentanyl & Versed to maintain pt comfort. Wean vent as tol. Plan to trach this week after Thoracic consult. Emotional support to family. Notify HO of any changes.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-02 00:00:00.000", "description": "Report", "row_id": 1642708, "text": "Resp Care\n\nPt on PCV with driving pressure of 24, peep 5, Fio2 of 55%. Pt gvn atrovent Q 4-6 hrs. Suctioned for moderate amts of thk white to yellow sputum, SpO2 mostly in mid 90's. No ABG tonight. RSBI as noted on flow sheet. Plan is for pt to go for trach in the next day or 2\n" }, { "category": "Nursing/other", "chartdate": "2148-07-05 00:00:00.000", "description": "Report", "row_id": 1642719, "text": "NURSING\n VSS OVERNIGHT. NSR-SINUS TACH. NO ECTOPY. CVP 6-10. ONE NS BOLUS 500 GIVEN FOR LOW BP, 80'S SYSTOLIC, AND DECREASED CVP. TEMP MAX 101.0, TYLENOL GIVEN. LAST TEMP 100.8. HCT DROP OF 4 POINTS, REPEAT HCT SENT, RESULTS PENDING. WBC'S STILL ELEVATED, CULTURES FROM THE 25TH PENDING.\n TUBE FEEDINGS STOPPED AT MIDNIGHT FOR OR TODAY. USUAL DOSE GLARGINE AND REGULAR INSULIN GIVEN AT HS MD. LACTULOSE STARTED FOR BOWEL REGIMEN, SMALL AMOUNTS STOOL OUT X2, FORMED. STOOL YESTERDAY WAS FIRST OUT SINCE ADMISSION. LACTULOSE TID UNTIL ADEQUATE STOOL OUTPUT.\n MORE AWAKE WITH DECREASED SEDATION. FENTANYL AT 125 MCG'S, VERSED AT 1.5 MG'S. WHEN UNCOMFORTABLE WILL OPEN EYES, MOVE UPPER EXTREMITIES, INCREASED BP AND HR. THE MAJORITY OF THE TIME NOT SYNCHRONOUS WITH THE VENT. OCCASIONALLY FOLLOWS COMMANDS. PUPILS EQUAL AND REACTIVE. OCCASIONAL MOUTHING OF WORDS. SMILING IN RESPONSE TO CONVERSATION.\n NO VENT CHANGES OVERNIGHT. REMAINS ON PSC AT 55%, 5 PEEP, RATE 20. LUNGS CTA BILATERALLY. SUCTIONED FOR SMALL AMOUNTS CLEAR WHITE SECRETIONS. ABG'S CONSISTENT WITH PREVIOUS VALUES. PLEASE SEE CAREVUE FOR SPECIFICS.\n REMAINS NPO FOR THE OPERATING ROOM TODAY FOR OPEN G-TUBE PLACEMENT. CONTINUE TO MONITER HEMODYANMICS. IF NOT CALLED FOR THE OR UNTIL AFTERNOON, REASSESS THE NEED FOR MAINTENANCE IVF'S. CONTINUE TO MONITER AND TREAT BLOOD SUGARS PER SLIDING SCALE. MONITER NEURO STATUS. CONTINUE BOWEL REGIMEN.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-07-05 00:00:00.000", "description": "Report", "row_id": 1642720, "text": "resp care - Pt is and on full vent support. Scant secretions were suctioned this shift, and BS were mostly clear. MDIs given as ordered. Pt went to OR this AM for insertion of G tube. Pt not able to do PSV trial. Plan is to do PSV trials as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-05 00:00:00.000", "description": "Report", "row_id": 1642721, "text": "NEURO; MORE AWAKE AND FOLLOWS SOME SIMPLE COMMANDS FAIRLY CONSISTENTLY, MAE, UKPPER EXTREMITIES MORE FORCEFULLY THAN LOWER,, PERL, #3 AND BRISK, PT TAKEN TO O.R FOR PLACEMENT OF G TUBE,(NOT REVERSED), LETHARGIC FOR SEVERAL HRS BUT HAS AWAKENED AND GIVEN ATIVAN AND MORPHINE FOR PROBABLE DISCOMFORT AND VENT CONTROL, (FENTANYL AND VERSED GTTS DC'D), PT ALSO RECEIVING FENTANYL PATCH,\n\nCARDIOVASCULAR; HR 100-120'S ST, MICU TEAM AWARE, TEMP M AX 101.2 THIS AM, MEDIC WITH TYLENOL AND PRESENTLY 99.8, A LINE POSITIONAL AND NOT ABLE TO DRAW ABGS (MICU TEAM INFORMED), BLOOD CULTURE ORDERED BUT UNSUCESSFUL ATTEMPT BY TWO NURSES, MICU INTERN INFORMED, PIC LINE ATTEMPTED BUT IV NURSE UNABLE TO INSERT BEYOND 33 CM, PT NEEDED TO GO TO INTERV RADIOLOGY FOR FURTHER GUIDED PLACEMENT BUT ORDER NOT PLACED ACCORDING TO IV NURSE (ALTHOUGH MICU RESIDENT INFORMED OF NEED FOR I.R. EARLIER), IV NURSE WILL PULL LINE\n\nGI; G TUBE PLACED IN O.R., PRESENTLY TO GRAVITY WITH DARK BILIOUS DGE,\nNOT TO BE USED UNTIL TOMORROW PER OKAY WITH TEAM, INCON SMALL AMT LIQUID STOOL X 1\nDOBOFF TUBE REMOVED IN O.R.\n\nPLAN; KEEP G TUBE TO GRAVITY TONOC, ? FUTURE DATE FOR PIC LINE, KEEP PT COMFORTABLE WITH PRN ANALGESIC AND ANXIOLYTICS, CONSISTENT CHEST PT, HCT 25 THIS PM, REPORTED TO INTERN,\n\n" }, { "category": "Nursing/other", "chartdate": "2148-07-05 00:00:00.000", "description": "Report", "row_id": 1642722, "text": "ADDENDUM; PT PLACED ON NEO FOR SEVERAL HRS POST-OP DUE TO SYS 80'S, MICU TEAM INFORMED, PT HAS SINCE BEEN WEANED OFF NEO\n" }, { "category": "Nursing/other", "chartdate": "2148-06-30 00:00:00.000", "description": "Report", "row_id": 1642700, "text": "NURSING PROGRESS NOTE\n\nSEE CAREVUE FOR DETAILS.\n\nNEURO: Sedated on Fent & Versed. No spontaneous movements. Withdrawing slightly to nailbed pressure moving extremeties on bed. Pupils brisk & reactive at 3mm.\nCV: Titrating Neo to maintain MAP >65, SBP >90. NSR/ST HR 90-116. Dr aware of pts inc HR, monitoring. No viewed ectopy. CVP 3-8.\nID: Afebrile. Right CVL removed by Dr , tip sent for culture. Second set of bld cx sent from new Left CVL.\nRESP: Lungs clr to coarse. Diminished at bases. Suctioning for scant white to yellow secretions. Sat's dropped to 88-89% w/repostitioning onto Left side. After multiple vent changes slightly increased FiO2 to 60% and PEEP to 7, ABG 7.41/59/70/39/9. Per Dr to wean PEEP first back down to 5 since pt maintaining sat's 95-96% currently. Goal PaO2 >60.\nGI: Abd soft. NT. ND. Hypoactive BS. No BM. TF currently on hold d/t residuals >100. To recheck & restart once residuals improved at rate of 50cc/hr.\nENDO: FBS check every 4 hrs; treating per RISS.\nGU: Foley patent making adequate CYU. Goal to maintain pt even to slightly negative. At MN pt +400cc, Dr aware >> 20mg IV lasix given at 2330 w/effect; currently pt -550cc.\nSOCIAL: No family called overnight.\n\nPOC: Titrate Neo for MAP >65, SBP >90. Wean vent maintaining PaO2>60; pulm toilet. Wean sedation as tolerates. F/u cultures. Fluid balance to even, ? need for additional Lasix in afternoon. Restart TF once residuals improve. Monitor FBS. Emotional support to family. HO aware of above, notify w/any changes.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-30 00:00:00.000", "description": "Report", "row_id": 1642701, "text": "Resp Care\n\nPt had some difficulty with oxygenation related to lying on left side. Peep and Fio2 temporerily adj up. Current settings are PCV 24/+5, 60%,\nRR 26. ABG 7.43,56,120. Sx for small amts of thck wht to yelloa secretions.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-30 00:00:00.000", "description": "Report", "row_id": 1642702, "text": "nursing progress note\nSedation lightened this am to midaz 1.5mg fent 100 mcg's. Pt became restless coughing/gagging on ett. Moving BUE's and head. Not purposeful or to command. MICU resident aware of intolerance to light sedation. Wants pt sedated and comfortable with no further weaning of sedation since the plan is to trach pt. Currently sedated with Midaz @ 2mg's and Fent @ 125mcg's. Withdraws to deep painful stimuli and becomes tachy/desats and bronchospastic with turning but settles down quickly.\nLungs Course with dim bases. O2 sat 92-98% on 60% FiO2. Baseline sat for pt is 88-92% per MICU reident. Suctioning scant thick pale yellow sputum from ett and thin clear orally. No vent changes made today d/t intolerance of small changes made yesterday/overnight planning to re-address plan to trach pt tomorrow.\nT-max 100.1 Remains on Vanco with no further troughs needed per MICU attending. MICU team D/C'd cipro and added meropenum for ? of VAP. Pt has uncertain PCN allergy MICU and ID aware Received first dose at 10 am without complication or reaction. Will continue meropenum. No results avail from yesterdays pan cx.\nNeo weaned off at 0900 SBP's 90's to 120's. HR up 130's-140's without ectopy. Resident attributing it to being dry and febrile (when temp climbs close to 101 HR noted to incr). Tylenol given for temp and pt became very diaphoretic. RR remained unchanged during period of tachycardia however CVP down to 4. As fluid balance becomes less negative CVP climbed to 7 and HR back down to 110-115. Currently +400's. Plan is to keep pt even to + 500 for fluid balance. Foley draining clear urine at 30-40cchr.\nAbd soft + bs. TF replete w/ fiber @ 50, residuals 30-60 today. Blood sugars checked Q4 to maintain tight control. No Bm this shift receiving colace . Skin warm continues to be diaphoretic.\nFamily in at bedside. Discussed with RN plans for trach.\nPOC\nKeep sedated and comfortable with lightest possible sedation.\nContinue to monitor sats and adjust per ABG's.\n? family meeting for trach and future poc in am\nContinue To monitor sats\n" }, { "category": "Nursing/other", "chartdate": "2148-07-01 00:00:00.000", "description": "Report", "row_id": 1642703, "text": "NURSING PROGRESS NOTE\n\nREFER TO CAREVUE FOR DETAILS.\n\nNEURO: Sedated on Fent & Versed; no adjustments made to sedation as pt plan to be trached in future. To maintain comfort w/lightest sedation possible. Withdrawing & grimacing to nail bed pressure. Becomes slightly tachycardic 114-120 w/respositioning, settles out within minutes. Pupils brisk & reactive. 3mm.\nRESP: Only vent change overnight was decreasing FiO2 from 60% to 55% (Goal PaO2 >65). ABG on new settings 7.42/47/118/32/5. Lungs clear, dim at bases. Suctioning for scant thick yellow/white secretions. Sm amt oral secretions. Sat's remain 95-98%.\nCV: Neo remains off, pt autoregulating maintaining SBP >90 and MAP >65. ST HR 102-112, increasingly tachycardic at times into 120s w/repostioning. CVP 8-14.\nID: Afebrile despite occassional diaphoresis. Cont Meropenum w/o reaction.\nGI: Abd soft. ND. + BS. No BM. TF cont at goal 50cc/hr w/min residuals.\nENDO: FBS checked & treated per RISS every 4 hrs.\nGU: Foley patent, >30cc CYU hourly. Goal to keep pt even to slightly positive (at MN pt +600cc. Currently +200cc, ? sm one time Lasix dose for day)\nSKIN: Old VAT site on right side of chest. Abrasion on lip cont to bld slightly during oral care.\n\nPOC: Cont light sedation; titrate to maintain pt comfort. Pulm toilet, wean vent as tolerates monitoring ABG/PaO2s. Monitor I&O; ? Lasix. Cont abx. Monitor hemodynamics. Family meeting today to discuss date of possible Trach. Notify HO of any changes.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-04 00:00:00.000", "description": "Report", "row_id": 1642715, "text": "NURSING 7P-7A\n VSS POST-OP. NSR-SINUS TACHYCARDIA, NO ECTOPY. HR INCREASES WITH DECREASED SEDATION AND INCREASED AWARENESS. TEMPERATURE MAX, 101.0. PAN CULTURED AT 2100 PRIOR TO RESTARTING ANTIBIOTICS. VANCOMYCIN AND MEROPENUM RESTART. LR AT 100/HOUR POST-OP. CVP 7-11. HCT STABLE OVERNIGHT.\n CONTINUES ON PSV, 55%FIO2, 5 PEEP, RATE 26. ABG'S ARE WHERE THEY HAVE BEEN FAIRLY CONSISTENTLY. SEE CARE VUE FOR FULL ASSESSMENT AND LAB VALUES. LUNGS CTA UPPER, DECREASED BASES. TRACH INTACT. SUCTIONED Q2-3 HOURS FOR WHITE THICK SPUTUM IN SMALL AMOUNTS. TRACH CARE Q6/HOURS. REMAINS ON FENTANYL AND VERSED GTTS FOR SEDATION. FENTANYL INCREASED AT 0300 WHEN VERY AWAKE AFTER BATH AND TURNING, HR INCREASED INTO THE 130'S AND BP INCREASED TO 150'S. ALSO AT THIS TIME MEDICATED WITH ATIVAN 1 MG WITH GOOD EFFECT, VS NORMALIZED.\n TUBE FEEDINGS RESTARTED AT 2200. START AT 20, INCREASE BY 15 Q6/HOURS TO GOAL OF 50. XRAY DONE POST-OP TO CONFIRM PLACEMENT OF POST-PYLORIC DOBOFF. OK'D TO USE PER MICU TEAM. FOLEY WITH ADEQUATE AMOUNTS URINE, 30-60/HOUR. POSITIVE BOWEL SOUNDS, NO STOOL OUT SINCE ADMIT. MILK OF MAGNESIA GIVEN AT 2200. 0200 DULCOLOX PR GIVEN. NO STOOL OUT YET.\n LABS WNL THIS AM. GLUCOSE LEVELS STILL RUNNING HIGH. GLARGINE AT HS GIVEN, ALL GLUCOSE LEVELS TREATED WITH SS REGULAR.\n NEURO INTACT. MOVING ALL EXTREMITIES, PUPILS EQUAL AND REACTIVE. AT TIMES OPENED EYES AND NODDED APPROPRIATELY TO QUESTIONS.\n CONTINUE TO MONITER HEMODYNAMICS, RESPIRATORY STATUS. CONTINUE PULMONARY TOILET. INCREASE TUBE FEEDS TO GOAL AT 1000. RECHECK ABG. FOLLOW GLUCOSE LEVELS AND TREAT WITH SLIDING SCALE.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-07-04 00:00:00.000", "description": "Report", "row_id": 1642716, "text": "resp care - Pt is with #7 Portex trach and is on full vent support. A PSV trial was successful for ~1H, ABG showing compensated resp acidosis. Coarse BS in upper lobes cleared on suction of small amounts of thick, white secretions. Continued weaning planned as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-04 00:00:00.000", "description": "Report", "row_id": 1642717, "text": "NEURO; LETHARGIC THIS AM, NOT WITHDRAWING TO NAILBED STIMULI AND NO SPONTANEOUS MOVEMENTS, FENT AND VERSED GTTS DECREASED, PT MORE AWAKE, OCCAS FOLLOWS SIMPLE COMMANDS OF ATTEMPTING HAND SQUEEZE, INCONSISTENTLY MOVES FEET TO COMMAND BUT RANDOMLY MOVING BOTH ARMS UKP SLIGHTLY OFF BED,, OCCAS TRACKS SPEAKER AND APPEARS TO ATTEMPT TO MOUTHE WORDS\n\nCARDIOVASCULAR; HR 115-130 ST, TEMP MAX 100.6, SYS 90'S-120'S, MAINTENANCE IV DC'D PER MICU TEAM\n\nRESPIR; SUCTIONED FOR SMALL-SCANT AMTS THICK YELLOW SECRETIONS, POSITIVE GAG AND COUGH, TRIALED ON PS FOR APPROX ONE HR BUT PT APPEARED UNCOMFORTABLE AND NODDED THAT SHE WAS DYSPNEIC, 02 SATS REMAINED 94 AND RESPIR RATE 30'S, PLACED BACK ON A/C, ABG HAD BEEN DDRAWN ON PS AND WAS STABLE\n\nGI; INCON SMALL AMT LIGHT BROWN STOOL X 2, TUBE FEEDS AT GOAL OF 50CC/HR, MAINTENANCE IV DC'D PER MICU TEAM,\n\nPLAN; ? G TUBE IN FUTURE, PULMONARY MD IN AND EXPLAINED THAT PEG PLACEMENT WAS NOT POSSIBLE AND HAD BEEN ATTEMPTED YESTERDAY, WILL NEED OPEN PROCEDURE IN O.R. AT FUTURE TIME, PULMONARY TOILETING WITH CHEST PT, ? FURTHER WEANING OF SEDATION BASED ON PT'S ANXIETY LEVEL AND RESPIR STATUS,\n" }, { "category": "Nursing/other", "chartdate": "2148-07-05 00:00:00.000", "description": "Report", "row_id": 1642718, "text": "RESP CARE NOTE\nPT REMAINS ON PCV 20/24/0.9/55%/+5. NO CHANGES MADE. LAST ABG 7.42/56/139/38. MDI'S GIVEN AS ORDERED. PLAN GO TO OR FOR G-TUBE TODAY. SX FOR SMALL AMOUTN OF YELLOW.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-07 00:00:00.000", "description": "Report", "row_id": 1642729, "text": "Resp Care\nPt remains with #7.0 portex on pcv fio2 increased this afternoon to 60% due to sats in the 80s. BLBS diminished suctioned for sm amt thick secretions. plan to continue on current vent settings as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2148-07-07 00:00:00.000", "description": "Report", "row_id": 1642730, "text": "Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: Cont with fentanyl and versed gtt,wasn't able to wean down as pt agitates and desats to 82-87%, following commands & moving all extrimities spont and withdraws to pain, PERL. denies pain.\n\nCV: NSR-ST, HR: 80-120, no ectopy noted, SBP 100-120, neo at 0.5mcg/kg/min,++PP, denies CP or discomfort.\n\nResp: Remains on vent, Fio2 ^ to 60% as desats to 80's and ABG with low pao2, Dr. aware.ls coarse all over and diminished at bases, Sxn thick white secretion, good cough, impaired gag. O2 sat 91-98%.\n\nGI: Abd soft, +BS, no BM. TF at goal, to send c diff if any stool according to Dr..\n\nGU: Foley cath patent with yellow clear urine adq amt.\n\nEndo: Bld sug q6h, WNL.\n\nID: T max 101.7, pan cx again, ciprofloxacin started today.\n\nAct: Turned and position changed, skin intact.\n\nSocial: Visited by pt's boyfriend, updated by Dr. and RN.called up brother aware of .\n\nPlan: Cont monitoring, pulm hygiene,wean sedation and neo as tolerates,support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-14 00:00:00.000", "description": "Report", "row_id": 1642759, "text": "MICU NPN 0700-1900\nEvents: AM CXR showed Rt PTX, thoracic surgery up to place CT. Pt with improved O2 sat after placement and FiO2 weaned to 80%.\n\nNeuro: Pt remains sedated on Fentanyl gtt at 150mcg/hr and versed gtt at 7mg/hr. She rec'd supplemental boluses for CT placement with good effect. Opening eyes to painful stimuli, no movement of extremities noted.\n\nCV: HR 100's-110's, SR/ST. BP 160's-170's/80's, no treatment ordered for persistent HTN. CVP 17 before CT and 12 after CT placed. Na 145, down from 150 yesterday after receiving 2L D5W yesterday. Generalized edema, pt is autodiuresing. Tmax 100.8, pan cultured.\n\nResp: LS's diminished throughout. Remains vented on PCV 24/10, FiO2 80%, RR 28 overbreathing by 2-4bpm. Suctioned for scant amount of thick tan secretions. ABG 7.32-75-78.\n\nGI: Abd softly distended with hypoactive bs's. TF's remain on hold. No BM. Rec'd dose of lactulose. No further episodes of coffee ground material from PEG tube.\n\nGU: Foley draining qs amounts clear yellow urine. Diuresis held as pt is autodiuresing.\n\nSkin: Pt turned minimally due to intolerance. Will attempt to turn this eve. Left radial aline and Left IJ TLCL with dressings and sites c/d/i.\n\nSocial: Pt's family in and spoke with Dr. regarding poor prognosis and plan of care. sister is flying in tomorrow and will be in in the afternoon. Family will discuss withdrawing care at that time\n\nPlan: Cont to monitor resp status and wean FiO2 as tolerated. Cont to monitor neuro status and increase as tolerated. Continue to provide emotional support to the family.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-14 00:00:00.000", "description": "Report", "row_id": 1642760, "text": "Respiratory care\n\n\n Pt continues on PCV no changes made today. B/S dim through out. MDI's as ordered. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-15 00:00:00.000", "description": "Report", "row_id": 1642761, "text": "Nursing Progress Note 1900-0700 hours:\n** FULL CODE\n\n** ALLERGY: PCN, CODEINE\n\n** ACCESS: LEFT RAD ALINE, LEFT IJ TLC\n\nIN BRIEF: HTN, HOME O2 (2L NC), BASELINE O2 SAT 88-92%, DESATS TO 70'S WHILE SLEEPING, INTERSTITIAL LUNG DX.\n\nS/P VATS WITH RML/RLL WEDGE RESECTION, PULM FIBROSIS, POST-OP ARDS FOUND TO HAVE PTX ; S/P CHEST TUBE PLACEMENT BY THORACICS. PT WITH IMPROVED O2 AFTER CT PLACEMENT AND FIO2 WEANED TO 80%.\n\nNEURO: SEDATED ON FENT 25OMCG/HR AND VERSED AT 9MG/HR. UNCLEAR AS TO WHETHER PT WAS EXPERIENCING PAIN AS BP WAS ELEVATED. PT WITH UNCOMFORTABLE APPEARING, DISYNCHRONOUS BREATHING (THOUGH ON PCV)-FENT AND VERSED GTTS INCREASED RESPECTIVELY. PEARL. DID OPEN EYES WITH SOME CARE GIVEN (EX. WHEN BOOSTED AND WITH TURN).\n\nCV: NSR-ST, NO ECTOPY. HR 93-105. 146-165/70-80, MAPS 98-110. CVP 24-31. DISCUSSED ELEV BP WITH MD-NO FURTHER INTERVENTION AT THIS TIME-MADE AWARE OF INCREASE TO PAIN MEDS TO ASSESS BETTER COMFORT. GENERALIZED EDEMA; CONT TO AUTODIURESE. HTN ALSO THOUGHT TO BE PRESUMABLY FROM PTX.\n\nRESP: 80%, PCV 24/ P10. TV'S HAVE BEEN 300-400. OCCASIONALLY OVB VENT BY FEW BREATHS. DYSYNCHRONOUS. SATS >94%. LUNGS CLEAR AND DIMINISHED IN BASES. SXN'D FOR SCANT AMT YELLOW/TAN SECRETIONS. CHEST TUBE SITE WITHOUT CREPITUS, + LEAK, +FLUC, SEROSANG. TOLERATING ROTATION WITH NO EPISODES OF DESATTING.\n\nGI: ABD SOFT, OBESE. HYPOACTIVE BS. TF'S REMAIN OFF COFFEE GROUND MATERIAL FROM PEG TUBE , HIGH RESIDUALS AND NO BM. PT LACTULOSE, SENNA, COLACE. NO FURTHER EPISODES OF COFFEE GROUND SEEN.\n\nGU: FOLEY WITH CLEAR, YELLOW URINE; 80-440CC/HR.\n\nID: LOW GRADE TEMPS WITH T MAX 99.9. PAN CX'D ON . FLUC FOR . COMPLETED MEROPENUM AND VANCO. (HAD COAG NEG STAPH IN LINE TIP).\n\nSKIN: INTACT. ON SPECIALTY ROTATING BED. AREAS OF REDNESS/FRAGILITY-MOISTURE CREAM APPLIED.\n\nSOCIAL: PT FAMILY SPOKE WITH DR RE: POOR PROGNOSIS AND . PT SISTER IS FLYING IN TODAY AND WILL BE HERE IN AFTERNOON. TO DISCUSS WITHDRAWAL OF CARE AT THIS TIME.\n\nPLAN: -CONT VENT SUPPORT, WEAN IS ABLE\n -MED GTTS AS APPROPRIATE FOR PAIN/DISCOMFORT\n -PT FAMILY WOULD LIKE PT TO HAVE ANNOINTING OF THE SICK\n (CHAPLAIN SAW YESTERDAY BUT THERE WAS NO CATHOLIC PRIEST AVAILABLE)\n -DISCUSS CODE STATUS CHANGE WITH FAMILY/MICU TEAM; OFFER SUPPORT\n -CONT MED REGIMEN AND ICU SUPPORTIVE CARE\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-07-15 00:00:00.000", "description": "Report", "row_id": 1642762, "text": "RESPIRATORY CARE NOTE\n\nPatient remains with Portex 7.0 DIC trach tube. Sxn for thick yellow secretions. No vent changes made during the night. ABG shows compensated respiratory acidosis.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2148-07-15 00:00:00.000", "description": "Report", "row_id": 1642763, "text": "BS few fine crackles; no change with MDI's. Suctioned for moderate amount thick yellow secretions. Pt is now CMO and vent support is being gradually withdrawn.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-15 00:00:00.000", "description": "Report", "row_id": 1642764, "text": "NSG NOTE\nPT CONT ON FULL VENT SETTINGS THRU THE DAY. HER STATUS WAS UNCHANGED. HER FAMILY HAS BEEN WITH HER THROUGHOUT THE DAY. SHE WAS VERY COMFORTABLE ON FENTANYL AND VERSED. AT 6PM, THE FAMILY WAS READY TO MAKE HER COMFORT CARE. THIS WAS DECIDED AFTER MULTIPLE DISCUSSIONS WITH THE HOUSE STAFF AND FAMILY MEMBERS OVER THE LAST SEVERAL DAYS WHERE IT WAS DETERMINED THAT SHE HAD A POOR PROGNOSIS. PT WAS SWITCHED TO MSO4 AND CONT ON VERSED. SHE PASSED AWAY AT 7P WITH FAMILY AT HER BEDSIDE. HOUSES STAFF NOTIFIED AND PRONOUNCED PT. SUPPORT GIVEN TO FAMILY THROUGH DAY.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-29 00:00:00.000", "description": "Report", "row_id": 1642696, "text": "NURSING UPDATE\nCV: HR SR, NO ECTOPY, SL TACHY AT TIMES. BP SUPPORTED ON NEO GTTS TO KEEP SBP>90 AND MAP>65. CVP 15-18.\nID: TMAX 100. VANCO LEVEL 12 IN PM, DOSED AS SCHEDULED.\nNEURO: SEDATED ON FENTANYL AND MIDAZ AGTTS. SLIGHTLY OPENING EYES THIS AM DUE TO DISCOMFORT DURING TRANSFER BED TO BED (BED FAILED), NO SPONTANEOUS MOVEMENT, NOT WITHDRAWING TO PAIN. PUPILS EQUAL IN SIZE AND REACTIVITY.\nENDO: REG INSULIN PER SLIDING SCALE, Q4H FINGERSTICK DONE.\nRESP: BREATH SOUNDS DIMINISHED @ BASES, SXN Q2-3H FOR SMALL THICK WHITE->YELLOW. PERCUSSION X3. ON ABG, PAO2 GOAL>60, FAILED FIO2 WEAN X1.\nGI: TUBE FEED INFUSING @ 50CC UNTIL 0500 WHEN GASTRIC RESIDUAL 110CC, TF STOPPED AT THIS TIME. SOFT, BOWEL SOUNDS PRESENT. NO BM.\nGU: URINE CLEAR YELLOW, ADEQUATE HUO.\nPLAN: WEAN AS TOLERATED.\nMAINTAIN BP WITHIN SET PARAMETERS.\nMAINTAIN ADEQUATE SEDATION AND COMFORT STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-29 00:00:00.000", "description": "Report", "row_id": 1642697, "text": "Resp Care\n\nPt sx for small to mod amts of thk wht secr. Pt is gvn flovent and alb and atrovent Q 4 hrs. She remains on PCV of 24/5 . Attempted to decrease FiO2 to 50% but pt was unable to sustain oxygenation and was returned to 60%.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-29 00:00:00.000", "description": "Report", "row_id": 1642698, "text": "Condition Update\nSee carevue for specifics.\nRemains sedated on 125 mcg of fentanyl and 2 mg of midazolam. Changed back to atmos bed secondary to Micu attending wanting to lighten sedation and not tolerating rotation while lighter. RR in the high 40's with fentanyl at 100 mcg's. Fentanyl bumped back up to 125 mcg's and midazolam unchanged @2mg's. No purposeful movements seen and does not follow any commands. Occ withdraws to suctioning and eye care. Neo titrated 0.5-1.0 mcg's throughout shift to keep sbp greater than 90 and map greater than 65. A-line positional at times, cuff pressure's correlating when there is a good waveform, so cycling NIBP. Sbp kept 90's to 120's. HR sr-st 90's -110's no ectopy noted HR more elevated when temp at tmax of 100.7 and during repositioning. Tylenol given and HR back down to 90's. Pt pan cultured per request of thoracic surgery, site of RIJ red with purulent drainage, line to be resited to Left IJ this afternoon by MICU team. Peripheral bld cx obtained, unable to draw off line for culture but will obtain 2nd set of bld cx off new line after resited. Tip to be sent for culture when changed.\n Lung sounds course with dim bases bilaterally. Abg's drawn pao2 86. Fio2 down to 55% from 60%. Suctioned for scant amount thick pale yellow secretions. Skin intact. Diaphoretic at times. Received 20 mg lasix d/t +fluid balance yesterday and poor cxr this am (per MICU team and thoracic surgery). Adequate diuresis and pt currently negative since midnight.\n TF restarted this am d/t residual improving btwn 50-70. Fingersticks Q4hr's to maintain tight control. No BM this admission.\n Siblings in to visit and updated by RN.\nPlan\nlighten sedation if possible\nTitrate/wean neo\nWean Fio2 per ABG's\nVanco trough prior to am dose\n" }, { "category": "Nursing/other", "chartdate": "2148-06-29 00:00:00.000", "description": "Report", "row_id": 1642699, "text": "RESPIRATORY CARE: PT REMAINS W/ A 7.5 ORAL ETT IN PLACE AND ON PCV AS PER CV. APPEARS COMFORTABLE W/ STABLE ABG AND PO2 86 ON AN FIO2 .60 SO FIO2 DECREASED TO .55. NO OTHER CHANGES TODAY. SX FOR YELLOW SPUTUM/ THICK. WILL C/W PCV AS TOLERATED AND ATTEMPT VCV OR POSSIBLY PSV IN AM.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-03 00:00:00.000", "description": "Report", "row_id": 1642711, "text": "Respiratory Therapy\nPt remains orally intubated on PCV. BS clear bilat. sx scant thick white secretions. ABG: 7.44/63/118/44. Plan:Trach in AM\n" }, { "category": "Nursing/other", "chartdate": "2148-07-03 00:00:00.000", "description": "Report", "row_id": 1642712, "text": "nursing progress note\nSee carevue for specifics\nSedated on fentanyl and midaz no changes made. Occasionally mae on bed to nailbed pressure or deep suctioning. Opens eyes, no movement purposeful or on command. T-max 100.8. Micu team aware. Pan cx from pending. Hr 110's no ectopy noted. A-line positional and slightly dampened. Nibp cuff on to correlate. SBP 80's -90's Maps remain greater than 65. 2 NS bolus', Total of 750cc, given per MICU team. With little change noted hemodynamically. CVP remains . U/O ~40cc/hr clear yellow.\nLS clear bilaterally dim in RLL. RR 26-38. O2 sat 97-98% on 55% FIO2,see resp note for specifics. No vent changes made. FBS 141 and 120 SSI coverage held since pt NPO for trach/ peg today. MICU team aware. ABD soft non-tender +BS. No BM this shift.\nBrother called in spoke with RN. Made aware of procedure delay. Will come in later.\nPOC\nContinue to monitor MAP And keep >65. Correlate w/NIBP\non call to OR for trach/peg.\ncontinue sedation to comfort\nProvide family support re: trach/peg.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-03 00:00:00.000", "description": "Report", "row_id": 1642713, "text": "Resp. Care Note\nPt received intubated and vented on PCV settings as charted on resp flowsheet. TV 350 range on PCV level of 24. Sats 98% on 55%. No vent changes were made this shift pending trache and peg in OR. Pt to OR around 17:00. Albuterol, Atrovent and Flovent MDIs as ordered. Reeval after trache for possible vent changes.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-04 00:00:00.000", "description": "Report", "row_id": 1642714, "text": "RESP CARE NOTE\nPT CONTINUES ON PCV 26/24/.. LAST ABG 7.43/58/133/40/12. PT IS NOW WITH A#7 PORTEX. MDI'S GIVEN AS ORDERED.RSBI NOT PERFORMED DUE TO HEMODYNAMICLY INSTABILITY. TIDAL VOLUMES AROUND 300. NO VENT CHANGES MADE.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-14 00:00:00.000", "description": "Report", "row_id": 1642757, "text": "Events;Pt was unsatble t/o sats dropped to 89%,Fio2 increased to 100%.\n\nResp; Pt was unstable on vent with poor oxygenation,not related to any procedures Recieved on PCV 80/28/10/24 ABG on this settings was 7.31/69/64 sats were 89%, MD informed and Fio2 changed to 100%,LS are clear/dim at base,Sats >95% after vent changes, minimal blood tinged secretions on suctioning.ABG after vent changes are 7.34/66/98.\n\nCVS;HR 97-110 did have one episode of SVT 130's after nsg care resolved back by itself.ABP 120-175/80-95, resident was notified about the high blood pressure,doesn't want to diures or start antihypertensive,positive pedal pulses.A-Line and LIJ for access.Please see carvue for AM labs.\n\nNuero;Sedated with Fenatnyl 135mcg and versed 5 mg,opens eyes for deep painful stimuli,doesnot follow commands,no movements noted for extrimities.Pt was bolused prior turning with good effect.Lt pupil 3mm and reacting.Not planning to paralyse the pt as per resident,pt will benefit from spontaneous breaths at this point as MD\n\nGI;Abdomen soft positive bowel sounds,PEG tube in situ, not on feeds.On bowel meds,no BM at this shift.Minimal residuals on regular dose of reglan.\n\nGU;Draining adequate amts Via foley catheter.\n\nSkin;WNL,redness at the back,on tryadine bed--rotation off since pt is unable to tolerate.\n\nID;T max 99.7 tylenol 650 mg given, PM dose of Vancomycin was given as by MD,Meropenem course completed.Fluconazole/IV to be continued.\n\nSocial;No contact from family over night\n\nPlan;Pending family discussions on code status\nICU care at this time.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-14 00:00:00.000", "description": "Report", "row_id": 1642758, "text": "RESP CARE: Pt remains /on vent on PCV. FI02 increased to 1.0 per Dr . No other interventions at this time. Breathing pattern disyncronous, team aware. Lungs coarse, only sxing small amts blood tinged sputum. No RSBI due to FI02 level.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-06 00:00:00.000", "description": "Report", "row_id": 1642723, "text": "NURSING NOTE\nASSESSMENT:\n PATIENT AGITATED AND RESTLESS @ BEGINNING OF THE SHIFT. TACHYPNEIC WITH RR UP TO 40 AND TACHYCARDIC WITH HR 130'S. PATIENT APPEARED UNCOMFORTABLE, GIVEN MORPHINE & ATIVAN WITH MINIMAL EFFECT. DR. AWARE AND EVALUATED PATIENT. PATIENT OPENING EYES, MOVING ALL EXTREMITIES, BUT MINIMALLY FOLLOWING COMMANDS. PATIENT ONLY APPEARED COMFORTABLE AFTER GIVEN 100 MCGS FENTANYL, NOW RESTING QUIETLY. HEART RATE 90'S NORMAL SINUS AND CUFF SBP ~ 100 (A-LINE DAMPEDED). FEBRILE TO 101.3, DR. AWARE AND RECTAL TYLENOL GIVEN. CVP MID-TEENS. PATIENT MAKING ADEQUATE AMOUNTS HOURLY URINE.\n PATIENT REMAINS ON PRESSURE CONTROL VENTILATION. UNABLE TO DRAW FROM A-LINE (DR AWARE), ABG SENT AND SLIGHTLY IMPROVED FROM PREVIOUS. SUCTIONED TWICE FOR SMALL AMOUNT THICK YELLOW SECRETIONS. LUNG SOUNDS CLEAR. SP02 MID 90'S.\n ABDOMEN SOFT, NONDISTENDED. G-TUBE TO GRAVITY WITH GREEN BILIOUS OUTPUT, NOT TO USE UNTIL LATER TODAY, PO MEDS HELD. GIVEN GLARGINE & HUMALOG FOR GLUCOSE > 150.\nPLAN:\n ? ATTEMPT PRESSURE SUPPORT THIS AM. PICC LINE MONDAY.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-06 00:00:00.000", "description": "Report", "row_id": 1642724, "text": "Resp Care,\nPt. remains on PCV overnoc. No vent changes this shift. Episode beginning of shift of desaturation to 90%, tachypnea RR 40. Sedated with good effect. RR high 20's rest of shift. ABG acceptable, RSBI 106 this am. Plan IPS trials as tol.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-06 00:00:00.000", "description": "Report", "row_id": 1642725, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT VERY AGITATED, TACHYPNEIC AND TACHYCARDIC THIS AM. RESTARTED ON FENT AND VERSED GTTS. PT NOW SEDATED AND COMPLIANT WITH VENT. WILL WEAN SEDATION AS TOL. PERRL. OPENS EYES TO PAIN. NO SPONT MOVEMENT NOTED BUT FLEXES TO PAIN.\n\nCV-WAS TACHY TO 110'S WHEN AGITATED, BUT NOW IN 90'S, NSR. SBP STABLE. ALINE D/C'D. SKIN W+D.+PP. PBOOTS ON.\n\nRESP-SAT DOWN TO 80'S WHEN AGITATED. SEE FLOWSHEET FOR VENT CHANGES. O2 SAT NOW 97%. LS COARSE. SXN FOR SCANT AMT THICK WHITE SPUTUM. PT DOES SEEM TO DROP SATS WHEN TURNED ON RIGHT SIDE.\n\nGI-ABD SOFT, NT/ND. +BS. HAD KUB WITH DYE. OK TO USE. WILL RESTART TF WHEN ORDERED.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nENDO-NO COVERAGE NEEDED.\n\nID-TEMP UP TO 101.2. PAN CX THIS AM.\n\nP-CON'T WITH CURRENT PLAN. MONITOR FOR CHANGES. WEAN VENT AND SEDATION AS TOL. RESTART TF. SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-06 00:00:00.000", "description": "Report", "row_id": 1642726, "text": "Resp Care\nPt remains with 7.0 portex vent settings weaned to PSV 18/5 late this afternoon vts ranging 350-400 rr 24-28. Pt had period of desaturation into the 80s around noon possibly ? due to aggitation or position on R side, pt suctioned for scant amt thick white secretions without improvement in sats so fio2 was increased to 60% and pt was reposition and given a sedation bolus, sats improved into the low 90s. plan to continue on PSV and wean fio2 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-02 00:00:00.000", "description": "Report", "row_id": 1642709, "text": "Focus: Status Update\nData:\nPt. has been more alert than yesterday. She opens eyes spontaneously but does not appear to track speaker. Perl at 3-4mm. She does follow commands on and off, not particularly related to lowered sedation but more so after being turned or repositioned. She has been agitated and restless at times and will lift and hold bilateral arms and purposefully attempt to grasp ETT. She attempts to move her legs but cannot lift them. Ativan given x1 with effect.\n\nBilaterally coarse lung sounds. Suctioned for thick yellow secretions but less than . PS with poor tolerance by pt-tachycardic, to 91-92 and labored breathing. Back to PCV with better tolerance. Tmax 100.6PR-->pan cultured.\n\nNegative fluid status-hold Lasix per medical team.\n\nPlan;\nNPO after MN for trach in am--on call to OR. Consent obtained from (brother). Continue Ativan as needed. Consult team re:restarting Abx.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-03 00:00:00.000", "description": "Report", "row_id": 1642710, "text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient afebrile tmax 100.0 WBC up from 14 to 18. Pt pan cultured last evening on (previous shift). Currently pt is off all antibiotics. MICU ordered evening dose of lasix to be given and pt diuresed to negative 800cc by midnight. HR sinus tach up to 125 for first couple hours d/w MICU team and small bollus given with small effect with rate down to 114. MICU also ordered EKG to r/o Aflutter, no formal but appears to be sinus tach with no ectopy. At the time of bollus unable to obtain CVP d/t pt's position. After bollus CVP ~9. Weight down 2kg.SBP high 80's to 90's MAPs maintained >65. Urine output adequate.\n Surgical resident phoned brother and obtained surgical consent for trach/peg which is on the OR schedule for 1330. TF turned off just after midnight. MICU team notified that pt received HS dose of glargine did not want to order any dextrose IV overnight. Bloodsugars checked frequently results >100. No BM.\n No vent changes made overnight. Sxn'd for scant secretions. Had difficulty passing sxn catheter down ETT d/t back teeth biting down on tube. ETT retaped and moved slightly more center. ABG with low paO2 at beginning of shift no changes made, rechecked and without any other changes in status paO2>100. Lungs clear and diminished in right base. No resp distress noted. Comfortably sedated on fent/midaz gtts not titrated overnight. While sedated opens eyes only to pain, inconsistently withdraws to pain sometimes only grimaces to nailbed pressure, not following any commands.\nPLAN:\n ?stop daily diuresis\n OR today for trach/peg\n Pulmonary toilet\n Follow bloodsugars closely while NPO\n Notify H.O. with any changes\n\n" }, { "category": "Nursing/other", "chartdate": "2148-06-23 00:00:00.000", "description": "Report", "row_id": 1642672, "text": "Respiratory note:\nPt s/p trigger/hypoxia. CTA done result pending. Mask ventilation started, pt remained SOB. Intubate (see care...for details). ABG on 400/16/5 revealed resp acid. Rate ^^ to 22. Adequate ventilation, plan to continue to monitor.No RSBI done, peep at 10.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-23 00:00:00.000", "description": "Report", "row_id": 1642673, "text": "NURSING\n ADMIT FROM F-7, S/P RIGHT VATS, WEDGE RESECTIONS, BIOPSIES OF NODES, AND FLEXIBLE BRONCHOSCOPY ON THE 13TH. HAD AN UNEVENTFUL POST-OP COURSE, WAS SCHEDULED FOR DISCHARGE YESTERDAY. PRIOR TO DISCHARGE FELL OFF TOILET IN BATHROOM, DID NOT HIT HEAD OR HAVE LOC. O2 SATS WERE FOUND TO BE IN THE 70'S. NON-REBREATHER PLACED ON WITHOUT MUCH IMPROVEMENT. SCHEDULED AND SENT FOR CHEST CT WITH INTERN, ADMIT TO SICU POST CHEST CT.\n ON ARRIVAL TO SICU VERY SOB, RESPIRATIONS IN THE 50'S TO 60. A-LINE PLACED. ATTEMPT MADE FOR CPAP, DECIDED TO INTUBATE. ANESTHESIA PAGED, INTUBATED WITHOUT INCIDENT. PLACED ON PROPOFOL. PROPOFOL TITRATED UP TO 75 MCG'S. FENTANYL GTT ADDED WHEN RESPIRATORY RATE DID NOT DECREASE ENOUGH. STARTED AT 100 MCG'S, INCREASED TO 150 MCG'S WITH REDUCTION IN RATE TO THE LOW 20'S. REMAINS ON 100% FIO2, ABG'S SLOWLY IMPROVING. SEE CARE VUE FOR FULL SPECIFICS. LUNGS DECREASED THROUGHOUT.\n PLACED ON NEO AFTER INTUBATION AS PROPOFOL TITRATED UP TO KEEP MAPS> 60-65. CURRENTLY ON 2 OF NEO. MAPS REMAIN >65. NSR-SINUS TACHYCARDIA. NO ECTOPY. TEMPERATURE MAX 101.0. RIGHT AXILLARY IV DC'D DUE TO INFILTRATED. PUS OOZED OUT OF SITEWHEN LINE DC'D, CATHETER SENT FOR CULTURE. AFTER SPIKE, PAN CULTURED WITH BLOOD CULTURE, CXR, UA/C&S, AND BRONCHIAL LAVAGE SENT FOR CULTURE.\n FOLEY IN PLACE DRAINING CLEAR YELLOW URINE IN LARGE QUANTITIES. U/O 1400 SINCE MIDNIGHT. RECIEVED LASIX PRIOR TO ADMIT TO SICU. NO STOOL OUT OVERNIGHT. NO NGT PLACED. ALL MEDS GIVEN VIA IV.\n DRESSING INTACT RIGHT FLANK. SKIN OTHERWISE INTACT.\n CONTINUE TO MONITER HEMODYNAMICS, RESP STATUS. FREQUENT ABG'S. MONITER AND MEDICATE FOR PAIN OR DISCOMFORT. REPEAT LYTES THIS AFTERNOON.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-07 00:00:00.000", "description": "Report", "row_id": 1642727, "text": "NURSING NOTE\nASSESSMENT:\n PATIENT ON FENTANYL & VERSED GTTS. OCCASIONALLY OPENING EYES AND MOVING EXTREMITIES, DOES NOT FOLLOW COMMANDS. HEART RATE 80-120 SINUS RHYTHYM. HYPOTENSIVE @ THE BEGINNING OF THE SHIFT WITH SBP 70-80'S (WHEN PATIENT ADEQUATELY SEDATED). ATTEMPTED TO WEAN SEDATION SLIGHTLY TO INCREASE BP, PATIENT BECOMING AGITATED. WHEN SEDATION DECREASED, PATIENT'S RESP RATE 40 & DESATS TO 80'S APPEARING VERY UNCOMFORTABLE. MICU TEAM NOTIFIED AND EVALUATED, FENT & VERSED GTT RESUMED @ 100 MCGS & 1.5 MG. NEO GTT STARTED FOR HYPOTENSION WITH GOOD EFFECT, SBP > 65. TMAX 101. MAKING ADEQUATE HOURLY URINE, FLUID BALANCE TODAY REMAINING EVEN (WEIGHT STILL UP APPROX 5 KGS).\n LUNG SOUNDS MOSTLY CLEAR, RESP RATE NOW 20'S. TOLERATED PRESSURE SUPPORT FOR APPROX 3 HRS LAST EVE AND RETURNED TO PRESSURE CONTROL VENT. ABDOMEN SOFT, TOLERATING REPLETE WITH FIBER @ GOAL RATE (MINIMAL RESIDUAL).\nPLAN:\n ? ATTEMPT PRESS SUPPORT AGAIN TODAY. AWAITING CULTURE RESULTS FROM YESTERDAY. CONTINUE WITH CURRENT MONITORING AND TREATMENT.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-07 00:00:00.000", "description": "Report", "row_id": 1642728, "text": "Resp care,\nPt. changed back to PCV overnoc. following episode of desaturation/tachypnea. Tol. IPS for 3 hours. RSBI 100 this am, plan IPS trial today as tol.\n" }, { "category": "Nursing/other", "chartdate": "2148-07-01 00:00:00.000", "description": "Report", "row_id": 1642704, "text": "Resp Care\n\nPt has good ABG showing mod resp acidosis that has compensated. Pt is going for a trach tube todayalb/atr Q 4-6 hrs.\n" }, { "category": "ECG", "chartdate": "2148-07-10 00:00:00.000", "description": "Report", "row_id": 216207, "text": "Regular supraventricular rhythm. P wave configuration is not typical of\nsinus and may represent ectopic atrial rhythm. On the previous tracing\nof there was sinus tachycardia present at a faster rate.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2148-07-02 00:00:00.000", "description": "Report", "row_id": 216208, "text": "Sinus tachycardia. Short P-R interval without evidence of pre-excitation.\nCompared to the previous tracing of the findings are similar.\n\n" }, { "category": "ECG", "chartdate": "2148-06-22 00:00:00.000", "description": "Report", "row_id": 216209, "text": "Artifact is present. Sinus tachycardia. The P-R interval is short without\nevidence of pre-excitation. Probable non-specific ST-T wave changes. Compared\nto the previous tracing ST-T wave changes are new.\n\n" }, { "category": "ECG", "chartdate": "2148-06-18 00:00:00.000", "description": "Report", "row_id": 216210, "text": "Sinus rhythm. Borderline short P-R interval, is non-specific and may be normal\nvariant. No previous tracing available for comparison.\n\n" }, { "category": "ECG", "chartdate": "2148-07-11 00:00:00.000", "description": "Report", "row_id": 216205, "text": "Sinus tachycardia. Since the previous tracing ST-T wave abnormalities have\nresolved at a slower rate.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2148-07-11 00:00:00.000", "description": "Report", "row_id": 216206, "text": "Sinus tachycardia at a rate of 140. Since the previous tracing of \nthe rate is faster and the P wave is more typical of a sinus mechanism and is\nthe same as that seen on . There are also now ST-T wave abnormalities.\nClinical correlation is suggested.\nTRACING #2\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2190-05-25 00:00:00.000", "description": "Report", "row_id": 1943149, "text": "NPN 07P-07A\n\n\nRESP\nCont. on NC 1L, Fio2 40-65%, increased to 90% with cares. LS\nclear and equal, cont. with subcoastal retractions. RR\n40-80. No spells, occ. slight drifts into 80's, QSR. Cont.\nmonitor resp. status.\nSepsis\nCont. on IV gent and ampicilling. and active with\ncares. In OAC, temps stable. BS 93.\nParents\nPOB @ bedside this pm. FOB held infant. Caring and loving.\nAsking appropriate questions. Cont. support and educate.\nG&D\nIn OAC, temps stable. & active with cares. Slightly\nirritable inbetween. Settless with pacifier. Fontanels soft,\nflat. Voiding, stooling. AGA. MAEs equally. Cont. assess for\ngrowth and developm. patterns.\nFEN\nTF 80 cc/kg/day. Weight 3890 (up 10). In pm appeared hungry\nand irritable. As MD feeds started. Bottled 30\ncc of 20. Tolerated well. Cont. with bottle feedings. No\nspits. IV heplocked. Cont. assess for po intake tolerance\nand weight gain.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-25 00:00:00.000", "description": "Report", "row_id": 1943150, "text": "Neonatology Attending Note\nDay 4\nPCA 38 4\n\nNC 1L, 40-60%. Inc w po feeds. RR40-80s. +SC rtxns. No murmur. Bili 11.1. HR 120-150s. Wt 3890, up 10 gms. TF min 80, po ad lib. 20. d/s 93. Nl voiding and stooling.\n139/6.3/103/23\nDay 4/7 amp/gent, LP pending.\nIn open crib.\n\nA/P:\nWean O2 as tol\ncomplete abx course\ncheck LP\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-25 00:00:00.000", "description": "Report", "row_id": 1943151, "text": "NPN\n\n\nResp: Infant remains in NCO2 1L. FIO2 ranges from 50-60%\nthis shift thus far. LS cl/=. Breathing 40-80s.Infant does\nhave mild sc retractions and increased WOB w/ po feeds. Req\nO2 increased w/ feeds. Attempted to wean o2 but not tol\nwell- to mid 70s. NO bradys. Will cont to monitor Resp\nstatus.\n\nSepsis: Infant is on day of ampi/gent. LP consent signed\ntoday-plan to do LP tomorrow due to increased RR. Will cont\nto monitor I/D status.\n\nSocial: Parents in for every care. Fed infant, took temp,\nchanged diaper. Asking appropriate questions. Concerned\nabout infants well being. Loving and involved. Updated at\nbedside by this RN regarding infants current condition and\nplan of care. Will cont to support and update as needed.\n\nG+D: Infant remains in OAC. Swaddled.Temps stable. A+A w/\ncares. Sucks on paci. AGA, AFOF. Will cont to monitor G+D.\n\nFEN: Infant is now ad lib demand w/ min of 80cc/ 20.\nInfant taking all po feeds 60-70cc per feed. Some increased\nWOB but tol well. Voiding and stooling. One trace positive\nstool-MD aware-will cont to monitor for heme pos stools. IV\nHL in R hand-flushes well. Will cont to monitor FEN.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-25 00:00:00.000", "description": "Report", "row_id": 1943152, "text": "NICU Fellow Note\nExam\ncomfortable in crib, slightly tachypneic. clear breath sounds with mild subcoastal retractions and respiratory rate in 50-60's\n" }, { "category": "Nursing/other", "chartdate": "2190-05-25 00:00:00.000", "description": "Report", "row_id": 1943153, "text": "NPN\nIV in R hand not flushing-replaced. No Left hand. Flushes very well.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-24 00:00:00.000", "description": "Report", "row_id": 1943144, "text": "Case Management Note\nChart has been reviewed & events noted. Have placed EIP & VNA lists in record. I will be providing clinical reviews to insurance. I will cont to follow and assist w/any d'c planning needs.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-24 00:00:00.000", "description": "Report", "row_id": 1943145, "text": "SOCIAL WORK\nMet with parents during their family meeting in which they were informed about infant's current status and care plan discussed. Provided info re: reduced parking and Room Away From Home Program as parents are interested in remaining close to hospital following mum's d/c tomorrow. Plan to check in with parents tomorrow and will persue if they would like. Parents appear to be adjusting well to NICU environment. Will remain available. Thank you.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-24 00:00:00.000", "description": "Report", "row_id": 1943146, "text": "NICU Fellow Note\nExam:\nGeneral-tachypneic on warmer\nHEENT-CPAP in place\nLungs-good air movement, mild subcoastal/intercoastal retractions with tachypnea\nCV-RRR, no murmur\nAbdomen-soft, nondistended\nSkin-slight jaundice\n" }, { "category": "Nursing/other", "chartdate": "2190-05-24 00:00:00.000", "description": "Report", "row_id": 1943147, "text": "Respiratory Care\nPt currently on prong CPAP. Fio2 .27-.35, bs clear, rr 50-80 with mild retractions. No spells noted. Plan to support as needed. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-24 00:00:00.000", "description": "Report", "row_id": 1943148, "text": "NPN\n\n\n#1 O: Baby remains tachypneic, RR40-90, BS\nclear and equal, remains on nasal prongs CPAP6 at\n27-35%FIO2. A: Stable on CPAP6, P: Attempt to wean, consider\nNC. Cont to monitor.\n#2 O: Baby remains on Gentamycin and Ampicillin. Blood\ncultures pending. Decision to treat baby for pneumonia for 7\ndays due to baby's symptoms. Gent level from were 0.9\nand 9.4 A: Stable on antibiotics. P; Cont antibiotics as\nordered. Cont to monitor, LP needed in future per team.\n#3 O: Parents in x3 and called also. Family meeting with Dr.\n and , LISW. Parents asked\n questions. Mother held baby bundled for about an hr.\nBaby calm. A: Invoved family. P: Cont to inform and support.\nMom to be discharged tomorrow. She is considering stay in\nfamily room.\n#4 O: Baby with care, periods of irritability resolved\nwith swaddling and giving pacifier. A: AGA, P: Cont \n interventions.\n#5 O: Baby remains NPO, TF increased to 80/K via D10W with\nNaCl and K. Nacl to decrease slightly with new iv solution.\nD/S 69. Baby appears hungry at times. A: Stable. P: Cont to\nmonitor, strict I&O, consider feeds when tachypnea improves.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-22 00:00:00.000", "description": "Report", "row_id": 1943134, "text": "Neonatology - NNP Progress Note\n\nInfant is active with good tone. AFOF. She is pink, well perfused, no murmur auscultated. She remains tachypneic on CPAP, fio2 35%. Breath sounds clear and equal. She remains on IV fluids via PIV. Abd soft, active bowel sounds, voidng and stooling. Stable temp on open warmer. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-23 00:00:00.000", "description": "Report", "row_id": 1943135, "text": "NPN 1900-0700\n\n\n#1: O: Infant remains on CPAP of 6, FiO2 mostly 38-40% this\nshift. Fio2 requirement did come down to 28% briefly at\nstart of shift. RR 80's-120's with int/sc retractions. LS\nc/=. Infant has had 2 this shift, one to 58 when out\nonto scale and one to 62 while crying. Both requiring O2 to\nbe increased to 100% to recover. P: Continue to monitor.\n\n#2: O: Continues on amp and gent for 48hr rule out. P:\nContinue to monitor for signs of sepsis and give antibiotics\nas ordered.\n\n#3: O: Parents in at start of shift. A: Loving parents. P:\nContinue to support parents in the care of their infant.\n\n#4: O: Temp stable on off warmer. Infant is and active\nwith cares, irritable at times. Brings hands to face for\ncomfort and calms with pacifier. Remains swaddled. A: AGA.\nP: Continue to support growth and development.\n\n#5: O: Weight tonight 3960g, down 85g. TF 60cc/kg/day of D10\nwith 2meq NaCl and 1meq of KCl running at 10.2cc/hr through\na PIV. Abdomen benign, voiding and passing meconium. Dstick\nthis shift was 95. Infant has had one spit and stomach was\nsuctioned for a moderate amount of clear-old blood tinged\nfluid. P: Continue to monitor I&O.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-23 00:00:00.000", "description": "Report", "row_id": 1943136, "text": "Respiratory Care Note\nPt. continues on 6cmH2O of nasal prong CPAP and 28-43% FIO2. BS clear. Pt. had 2 spells overnight. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-23 00:00:00.000", "description": "Report", "row_id": 1943137, "text": "NNP Physical Exam\nPE: pink, facial jaundice, AFOF, sutures apposed, nasal prong CPAp in place, breath sounds clear/equal with fair to good air entry, tachypnea, mild subcostal retracting, RRR, no murmur, normal pulses and perfusion, abd soft, non distended, + bowel sounds, active to irritable with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-23 00:00:00.000", "description": "Report", "row_id": 1943138, "text": "Neonatology Attending Note\nDOL# 2\nCGA 38 wk\n\nOn NCPAP 6, FIO2 28-45 %\nRR 80-100, now 70-90s\n\nP 130-140s\nMBP 49\n\nWt 3960 (down 85)\nTF 60 cc/kg of D10\nNPO\n\n141/4.4/102/26\nBili 8.6/0.3\n\nOn Amp and Gent\n\nA:\nNewborn infant with TTN vs pneumonia\n\nP:\nContinue supportive care, wean CPAP as tolerated.\nCOntinue NPO for now.\nRepeat CXR, determine course of antibiotics pending CXR results and clinical improvement.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-23 00:00:00.000", "description": "Report", "row_id": 1943139, "text": "NPN\n\n\n#1 O: Baby remains on nasal prong cpap6,\n30-48%FIO2, RR60-100, mild ic/sc retractions. BS clear and\nequal. A: Stable on cpap. P; Cont to monitor, maintain cpap,\nCXR ordered for pm.\n#2 O: Baby remains on antibiotics, cultures pending. Gent\nlevels pending. VSS. A: Sepsis suspect. P: Continue\nantibiotics as ordered. Follow cultures.\n#3 O: Parents in several times. Asking questions about plan\nof care. Spoke with , MD. A: Involved family. P:\nCont to inform and support.\n#4 O: Baby remains on open air warmer, swaddled and wearing\nt-shirt. Temp stable. Baby irritable at times but calms with\npacifier. A: AGA, P: Cont interventions, cluster\ncare, decrease stress.\n#5 O: Baby remains NPO, mother does plan to bottle feed. PIV\npresently in R hand and infusing well. D/S 59-89. D10 W with\nNACL and K infusing. Voiding 2cc/K/hr. Stooling transition.\nColor sl jaundice.A: Tol NPO status and fluids at 60K. P:\nStrict I&O, patent IV, D/S prn and with changes.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-23 00:00:00.000", "description": "Report", "row_id": 1943140, "text": "Respiratory Care\nPt received on nasal prong CPAP +6cm's with the fio2 34 to 45%. Pt's resp rates 60's to 90's. Plan is to follow on CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-24 00:00:00.000", "description": "Report", "row_id": 1943141, "text": "NPN 1900-0700\n\n\n#1 RESP S/O: Infant in CPAP nasal prong of 6. RR 50-100.\nHigher with exertion. FiO2 tonight 38-50%. Lungs sounds are\nclear with subcostal retractions. No spells tonight. CXR\ntonight showed a slight improvement. A: Stable P: Continue\nto monitor.\n\n#2 Sepsis S/O: Infant and active. Maintaining temps on\nan off warmer. IV infusing well. Getting IV amp and gent as\nordered. Will remain on antibiotics through today. A: R/O\nsepsis P: Continue to monitor for s/s of infection.\n\n#3 Parenting S/O: Mom and Dad in tonight. Asking appropriate\nquestions. Talking to infant. Mom called x1 for update on\nCXR. A: Involved, loving P: Continue to support and update.\n\n#4 DEV S/O: Infant maintaining temps on off warmer. \nand active with cares, sleeping well in between. Sucks on\npacifier. Brings hands to mouth. A: AGA P: Continue to\nsupport dev.\n\n#5 FEN S/O: TF 60cc/k/d. Infant NPO. IVF of D10 with 2NA and\n/hr infusing via right hand peripheral iv.\nAbdomen is benign, voiding and having mec stools. DS tonight\n60. Lytes drawn, results pending. A: Stable P: Continue to\nmonitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-24 00:00:00.000", "description": "Report", "row_id": 1943142, "text": "Respiratory Care\nBaby continues on prong CPAP 6 with 02 req 38-50% this shift. BS clear. RR 60-100 with SCR. CXR this eve reported to show slight improvement. Will cont to follow closely, support as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-24 00:00:00.000", "description": "Report", "row_id": 1943143, "text": "Neonatology Attending Note\nDay 3\nPCA 38 3\n\nCPAP Pr 6, 35%. RR60-80s. No A&Bs. No murmur. HR 120-140s. BP 82/42, 53. 141/4.6/102/26. Bili 11.1. Wt 3880, down 80 gms. TF 60 cc/k/day. d/s 60. Nl voiding and stooling. On amp/gent. On off warmer.\n\nA/P:\nRespiratory status slowly improving. however trend seems more unlikely for TTN and more concerning for pneumonia. CXR also has not completely cleared. Will treat for full course for pneumonia. Will need LP.\nInc TF to 80. Keep NPO while tachypneic.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-22 00:00:00.000", "description": "Report", "row_id": 1943128, "text": "RESPIRATORY CARE NOTE\nBaby received on Prong CPAP 6 FiO2 29-36%. At 11pm baby was taken off CPAP and placed on Nasal cannula @ 200cc FiO2 100% . Through the night the FiO2 has weaned to 30-50%. RR tachypneic at times. Stable on nasal cannula. Will cont to monitor for any increased work of breath of breathing and the need to go back on CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-22 00:00:00.000", "description": "Report", "row_id": 1943129, "text": "RESPIRATORY CARE NOTE\nBaby was placed back on bubble CPAP 6 via Prongs FiO2 35% @ 6am due to low sat . Will cont to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-22 00:00:00.000", "description": "Report", "row_id": 1943130, "text": "RESPIRATORY CARE NOTE\nBaby was placed back on bubble CPAP 6 via Prongs FiO2 35% @ 6am due to low sat . Will cont to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-22 00:00:00.000", "description": "Report", "row_id": 1943131, "text": "nursing progress note\n\n\n#1 O: Received baby in bubble CPAP of 6cm, 32% O2. Breath\nsounds equal & clear with mild IC/SC retractions &\ntachypnea. Occasional grunting after crying or cares. CBG\ndone. Baby electively placed in 200cc flow nasal cannula at\n11PM. O2 was 40-100%. Due to increasing desats requiring inc\nO2 to 100% & inc flow to 400cc, baby was placed back on 6cm\nCPAP at 5:30AM. Baby is presently in 38% O2, 6cm CPAP. No\ngrunting since CPAP resumed. A: Cont to have mild RDS. P:\nCont to assess.\n#2 O: Blood cultures pending. Remain son antibiotics. A:\nSepsis suspect. P: Antibiotics as ordered. Cont to assess.\n#3 O: Parents visited & Mom phoned X's 2 for updates. A:\nLoving family. P: Support.\n#4 O: Received baby on servo warmer. Warmer shut off & baby\nswaddle. stable. Irritable at times but calms with\nsucrose pacifier. A: Stable. P: Cont to assess.\n#5 O: Remains NPO. Wgt down 15 gms. PIV infusing at\n60cc/k/d. DS 102. UOP for this shift was 1.9cc/k/h. Baby\npassed small mec stool. A: Receiving fluids as ordered. P:\nCont to assess.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-22 00:00:00.000", "description": "Report", "row_id": 1943132, "text": "Neonatology Attending Note\nDay 1\nPCA 38 1\n\nCPAP6, 36-45%. RR70-100s. Evening gas 7.29/58. CXR c/w TTN. HR 130-140s. BP 75/43, 68. On amp/gent. Wt 4045, down 15. TF D10w at 60.\nNPO. Voiding 1.9. Passed stool. In open crib.\n136/5.0/101/23\nBili 6.2\n\nA/P:\nMaintain CPAP - likely TTN, however also consider pneumonia/infection\nKeep NPO\nKeep fluid restricted\nWill add lytes to fluid\nLytes, bili in am\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-22 00:00:00.000", "description": "Report", "row_id": 1943133, "text": "Nursing progress Notes.\n\n\n#1 O: Baby remains on prong CPAP 6, 36 to 45% oxygen at\nrest. Resp rates 88 to 140 at times. Breath sounds mostly\nclear and equal, mild retractions. Baby quickly if\nprongs fall out or baby cries. A: Remains tachypneic on\nCPAP. P: Continue to monitor and provide support as\nrequired.\n#2 O: Continues on IV antibiotics. A: On 48 hour rule out.\nP: Follow culture results.\n#3 O; Parents and grandparents up to visit several times\ntoday. A: Involved family. P: Continue to keep informed.\n#4 O: Temp stable on off warmer. BAby is and active\nwith cares and slept fairly well between cares. Occasional\nfussiness between cares. A: Appropriate for age. P:\nContinue to support development.\n#5 O: Total fluids remain at 60cc/kg/day via peripheral IV\nand changed to D10W with lytes this evening. Remains NPO.\nAbdomen soft, bowel sounds active, no loops. Voiding\n2.2cc/kg/hr and passing meconium. A: Remains NPO, P:\nContinue NPo and monitor intake and output.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-21 00:00:00.000", "description": "Report", "row_id": 1943124, "text": "Neonatology Attending\n38-1/7 week GA infant admitted with respiratory distress\n\nMaternal hx - 31 year old G2P1->2 woman with PMHx notable for adenocarcinoma (in situ). Prenatal screens were as follows: A positive, DAT negative, HBsAg negative, RPR non-reactive, rubella immune, GBS unknown.\n\nAntenatal Hx - for EGA 38-1/7 weeks. Pregnancy uncomplicated. Repeat cesarean section under spinal anesthesia. ROM at delivery yielded clear amniotic fluid. No intrapartum fever or other clinical evidence of chorioamnionitis.\n\nNeonatal course - NICU team not initially in attendance at delivery. Infnat was bulb suctioned and suctioned. NICU was called for grunting respirations. Apgars 8 at one minute, 9 at five minutes.\n\nPE\nBW 4060g OFC 37cm LN 53.3cm\non CPAP with SaO2 95% in 0.30 FiO2\nhr 124 rr 60-80 T 96.8 BP 66/36 (52)\nHEENT AFSF; non-dysmorphic; palate intact; neck/mouth normal; normocephalic; nasal CPAP in place\nCHEST mild intercostal retractions; good bs bilat; scattered coarse crackles\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; liver 1.5 cm BRCM; no splenomegaly; no masses; bs active; anus patent\nGU normal female genitalia\nCNS active, alert, resp to stim; tone normal and symm; MAE symm; suck/root/gag intact; grasp symm\nINTEG normal\nMSK normal spine/limbs/hips/clavicles\n\nINV\nCXR - lungs expanded to ribs bilaterally; diffuse mild opacification; fluid in major fissure\nWBC 16.8 (57 poly 0 bands) Hct 46.2 Plt 332\n\nIMPRESSION\n38-1/7 week GA infant with\n1. Respiratory distress, clinically most consistent with retained fetal lung fluid (given fluid in fissure and cesarean section). Differential diagnosis also includes pneumonia; surfactant deficiency (given low lung volumes and macrosomia). Cardiac examination is normal and the infant is hemodynamically stable.\n2. Macrosomia. There is no history of glucose intolerance in pregnancy and post-natal glucose is well-maintained\n3. Sepsis risk, based on respiratory symptoms and unknown maternal GBS colonization status. WBC is reassuring\n\nPLAN\n-Infant is currently on CPAP with well-controlled respiratory function. We will wean oxygen to maintain SaO2 94-98% given advanced gestational age. Obtain blood gas if fiO2 does not wean. If respiratory distress worsens or FiO2 increases significantly, will consider further respiratory support.\n-Monitor hemodynamic status and target mean BP > 45 mmHg\n-We will defer feeds until cardiorespiratory stability is established. In the interim, will provide maintenance D10W with usual monitoring of fluid status through serum electrolytes, weight and urine output\n-Blood cutlure has been drawn and CBC is reassuring. We have started broad spectrum antibiotic therapy for anticipated course of 48 hours pending culture results and clinical course.\n\nOB: Dr. \nPED; Dr. ()\n" }, { "category": "Nursing/other", "chartdate": "2190-05-21 00:00:00.000", "description": "Report", "row_id": 1943125, "text": "1 Term Respiratory Distress\n2 Infant with Potential Sepsis\n3 Parenting:\n4 Growth and Development\n\nREVISIONS TO PATHWAY:\n\n 1 Term Respiratory Distress; added\n Etiologies:\n Transient Tachypnea of the Newborn\n Meconium Aspiration\n Start date: \n 2 Infant with Potential Sepsis; added\n Start date: \n 3 Parenting:; added\n Start date: \n 4 Growth and Development; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-21 00:00:00.000", "description": "Report", "row_id": 1943126, "text": "5 FEN:\n\nREVISIONS TO PATHWAY:\n\n 5 FEN:; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-21 00:00:00.000", "description": "Report", "row_id": 1943127, "text": "Admission and NPN note:\nbaby girl was admitted from L&D OR s/p planned C/S. Infant noted to have GFR on arrival. Initial VS - temp 96.8 rectally, HR124, RR 64, with GFR. O2 sats 87%. BP 66/36 52. DStick 73. Infant continued with GFR, and drifting O2 sats to 80's, CPAP was initiated. CBC and BC obtained and then IV was placed and Ampicillin and gentamycin was started for r/o sepsis. Infant continues on prong bubble CPAP, in 24-38% FiO2. CXR obtained showing ribs expansion. Infants resp rate 40-100, with mild IC/SC retractions. Lungs are clear bilaterally. O2 sats 91-98%. Hr 90-140's, infant is pale pink well perfused, brisk cap refill, no murmur noted, normal peripheral pulses. BP means 52-55. Dsticks 84, and 132. IV fluids running via PIV at 60cc/k/d of D10w. Vit K and Erythromycin ointment given as ordered. will continue to monitor closely. Parents both have visited infant, updated at bedside by Rn and NNP today. Will continue to support and update family.\n" }, { "category": "Radiology", "chartdate": "2190-05-21 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 862799, "text": " 2:32 PM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: rds, lga 38 weeks, gfr, O2\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with\n REASON FOR THIS EXAMINATION:\n rds\n lga 38 weeks, gfr, O2\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Less than 1-day-old girl who was born at 38 weeks EGA and is large\n for gestational age. Respiratory distress.\n\n COMPARISON STUDIES: None are available.\n\n FINDINGS: The lungs are mildly hypo-aerated. Diffuse, bilateral interstitial\n opacities, which appear mildly granular. Thickening of the minor fissure and\n a small right pleural effusion are noted. The cardiothymic silhouette is\n remarkable for a prominent thymus. No gross bony abnormalities are\n identified. Visualized bowel gas pattern appears normal.\n\n IMPRESSION: Findings most consistent with transient tachypnea of the newborn\n although neonatal pneumonia might also have this appearance.\n\n\n" }, { "category": "Radiology", "chartdate": "2190-05-23 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 863011, "text": " 6:33 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate lung fields, R/O pneumonia\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with respiratory distress\n REASON FOR THIS EXAMINATION:\n evaluate lung fields, R/O pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n Examination of chest compared to .\n\n The heart and mediastinal structures are unchanged. The heart is within\n normal limits for size. There are still diffuse granular opacities in the\n lungs with some interval clearing at the left lung base since prior\n examination, with minimal improvement of diffuse lung disease. The proximal\n esophagus is remarkable for being quite distended with air, up to the level of\n T4.\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-28 00:00:00.000", "description": "Report", "row_id": 1943166, "text": "Neonatology Attending Note\nDay 7\nPCA 39\n\nNC 100cc, 13cc. RR40-70s. No murmur. HR 120-140s. Wt 3830, down 105. PO ad lib. TF 163. Photot off this am. Nl voiding and stooling. In off isolette (for photot).\nLast day of abx.\n\nA/P:\nSlowly progressing in the right direction. Continue to wean FiO2 as tol. Abx complete today. Check reb bili in am.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-28 00:00:00.000", "description": "Report", "row_id": 1943167, "text": "NPN 0700-1900\n\n\n#1Resp: Received pt. on NCO2 100% 25cc/min. pt.\noff @ noon. Currently, pt. in RA, RR 30-60's, sats > 94%.\nPt. has had occas drifts to high 80's w/ QSR. LS clear\nbilaterally w/ occas. mild SCR. P: cont to monitor off O2.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-28 00:00:00.000", "description": "Report", "row_id": 1943168, "text": "NPN 0700-1900\n#2Sepsis: Pt. completed 7 day course of ampi & gent. BLd cx NGTD. No s/s of infection. P: cont to monitor.\n\n#3Parenting: Parents in today for cares. Both asking approp questions. Updates given. Both independent w/ cares & feeding. Mom made pedi appt. for tues of next week. P: cont to support & update.\n\n#4G&D: Temps stable swaddled in off isolette. Pt. awake & for cares. Pt. waking for feedings. MAE. AFSF. Pt. settles well in between w/ pacifier. P: cont to support dev needs.\n\n#5FEN: Pt. adlib demand. Pt. waking Q 3-4 hrs & taking 105-120cc of 20. Pt. well coordinated w/ bottling. Tolerating feeds well, no spits. Abd soft & round, +BS. Pt. voiding & stooling, guaic neg. P: cont to monitor FEN.\n\n#6Hyperbili: Pt. sl jaundice, well perfused. Remains off phototherapy. P: check rebound in am.\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-28 00:00:00.000", "description": "Report", "row_id": 1943169, "text": "NICU Fellow Note\nExam: Patient breathing comfortably in RA in NAD. No retractions, no tachypnea, CTA b/l with no murmur. Abdomen benign. Ext-WWP\n" }, { "category": "Nursing/other", "chartdate": "2190-05-28 00:00:00.000", "description": "Report", "row_id": 1943170, "text": "SOCIAL WORK\nTouched base briefly with parents during their visit to the unit. Pleased with infant's status and like that she's been moved to the level two side of the floor. No questions/concerns noted. Will remain available.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-29 00:00:00.000", "description": "Report", "row_id": 1943171, "text": "2 Infant with Potential Sepsis\n\nREVISIONS TO PATHWAY:\n\n 2 Infant with Potential Sepsis; d/c'd\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-29 00:00:00.000", "description": "Report", "row_id": 1943172, "text": "NURSING SUPPORT NOTE\n\n\nRESP: In RA. Breathing 40-60's. Sats 90-100%. No spells or\n noted. Periodic breathing w/ occasional drifts. QSR.\nStable. P-Continue to monitor.\n\nPARENTS: Mom called and updated on daughter's status and\nimmediate plan by P-S. Loving and vested.\nP-Continue to support.\n\nG/D: Temp stable in OAC. Waking for feeds. and active.\nSlept throughout night. MAE. AF-flat. Likes her pacifier.\nAGA. P-Continue to support G/D.\n\nFEN: Current weight 3.820, -10gm. TF AD LIB. Total 24 hour\nintake 158cc/k. Infant is voiding, no stool. Active bowel\nsounds. Benign abdomen. No spits. Thriving. P-Continue to\nfollow current routine.\n\nHYPERBILI: Photo therapy remains D/C'd. Patient slightly\njaundice. Rebound bili sent, results pending.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-27 00:00:00.000", "description": "Report", "row_id": 1943162, "text": "Neonatology Attending Note\nDay 6\n\nNC 200cc, 35%. RR50-70s. Cl and =. No murmur. HR 150-160s. Bili 11.8/0.3. Under photot. Day 6/7 amp/gent. Wt 3935 up 65. PO ad lib. Tol well. Nl voiding and stooling. In open crib.\n\nA/P:\nWean O2\nAnother day of photot, follow bili levels\nFamily updated at bedside yesterday\n" }, { "category": "Nursing/other", "chartdate": "2190-05-26 00:00:00.000", "description": "Report", "row_id": 1943154, "text": "NPN 1900-0700\n\n\nRESP: Remains in NC 1 liter, FiO2 mostly 35-45%. LS C/=,\noccasional mild SCR.\n\nSEPSIS: Currently Day of Amp & Gent. Needs LP, consent\nsigned in chart.\n\nPARENTS: Mom in to visit x1, updated by this RN, asking\nappropriate questions. Has also called x1 thus far since\nreturning to room. Plans to be discharged today but stay in\nfamily room overnight.\n\nG/D: Temp stable swaddled in open crib. A&A w/cares, sleeps\nwell in between. Wakes for all feeds. Occasionally sucks on\npacifier, but otherwise hard to soothe.\n\nFEN: Tolerating all PO feeds on ad lib schedule well. Wakes\nfor all feeds. Abdomen soft/round, good bs, V&S (heme\nnegative).\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-27 00:00:00.000", "description": "Report", "row_id": 1943163, "text": "0700- NPN\n\n\nRESP: Infant remains in nasal cannula at this time. She was\nswitched from a blender at 200cc flow/30-40% fi02 to a\nlow-flow cannula and is currently in 150cc of flow (100%\nfi02). Flow rate is being weaned as tolerated. RR 40s-60s,\nmild SC retractions present. LS are clear and equal. No\nbradys, occasional quick drifts to high 80%s.\n\nSEPSIS: Day 6 out of a planned 7 day course of Ampicillin\nand Gentamicin, tx for presumed sepsis. VS stable per\nflowsheet.\n\nPARENTING: Parents have been visiting throughout the day and\nindependently change diaper and bottlefeed infant at care\ntimes. Parent packet and Back to Sleep brochure were given\nto parents today. They plan to take CPR sometime this\nevening. They are loving and invested.\n\nDEV: Temps stable in air control isolette. MAE, fontanels\nsoft and flat. and active with cares, sleeping between\ncares. Brings hands to face, sucks vigorously on pacifier.\nAGA.\n\nFEN: Remains on an adlib demand feeding schedule, receiving\nSimilac 20. Infant is bottling 100-130cc q3.5-4.5hrs today.\nOccasional small spits. Abdomen soft, round, no loops,\nactive BS. Voiding and stooling, guiac negative.\n\nBILI: Remains under double photothx at this time. Bili this\nmorning 11.8/0.3. Plan to D/C photothx tomorrow and check\nrebound bili the following day.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-27 00:00:00.000", "description": "Report", "row_id": 1943164, "text": "Nursing note\nParents attending CPR class. participating in and handout given. asking approp questions\n" }, { "category": "Nursing/other", "chartdate": "2190-05-28 00:00:00.000", "description": "Report", "row_id": 1943165, "text": "1. REsp: O: Infant is on O2 via low-flow nc, 100% FiO2 and\nin 25cc flow. No a/bs, no drifts. RR 50-70s, but\ncomfortable. She is not on caffeine. A: Stable in very\nlittle O2. P: Continue w/ plan. Wean as tol.\n\n2. Sepsis: O: Infant continues on her ampi and gent. She is\nactive w/ cares, bottles well, VSS. She is still in a tiny\nbit of O2. A: Generally well appearing but still with a tiny\nO2 need. P: Monitor. Wean O2 as tol. Antibx as ordered.\n\n3. Parents: O: Mom called for an update. She will be in\nlater today. A: Loving, involved Mom. P: Continue to\nsupport.\n\n4. G/d: O Temp is stable in a low heat isolette under\nphototx. She is very vigorous w/ cares and is sleeping well\ninbetween. She settles, after a feed, w/ a binkie. A/P:\nContinue to support infant needs.\n\n5. F/N: O: Infant is ad lib demand, waking @ q 4 hours and\nbottling formula, 20cal, well. She took in 163cc/k/d\nyesterday. She is voiding and stooling g- stools. No spits.\nShe lost 105g. A: Bottling well. P: Continue w/ plan.\n\n6. Bili: O: Infant continues under double phototx as ordered\nand will have it shut off at the next care time. She is\nstooling and bottling well. A: Hyperbilirubinemia. P: Shut\nphototx off at the next care time. Check a bili in 24 hours.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-26 00:00:00.000", "description": "Report", "row_id": 1943155, "text": "Neonatology Attending Note\nDay 5\nPCA 38 6\n\nNC 1L, 35-45%. RR40-60s. Inc w feedings. Cl and = BS. No murmur. HR 120-140s. Bili 11.1. Wt down 20 gms to 3870. TFI 121 w Sim20. Nl voiding and stooling. In open crib. Day 5/7 amp/gent.\n\nA/P:\nResolving presumed pneumonia. Complete abx. LP today. Cont close monitoring. Spoke to Dad at bedside yesterday.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-26 00:00:00.000", "description": "Report", "row_id": 1943156, "text": "NICU Fellow Note\nExam\nComfortable in crib with decreased respiratory rate, no retractions with clear breath sounds, no murmur, soft abdomen\n" }, { "category": "Nursing/other", "chartdate": "2190-05-26 00:00:00.000", "description": "Report", "row_id": 1943157, "text": "Nursing Progress Note\n\n\nResp: Infant is requiring 1L O2 at 30-40% FIO2 to keep sats\nin mid 90's. Attempted to wean flow to 800cc this am,\ninfant desated to 87. Infant is pink and well perfused.\nWill cont to support resp status.\n\nSepsis: Infant cont on Ampi and Gent as ordered. Resp\nstatus stable, no changes. Temp stable. Will cont to\nmonitor for s/s sepsis. Plan for LP.\n\nParents: Parents in throughout day. Independent with\ncares. Feeding infant throughout day. Parents loving and\ninvested.\n\nG/D: Temp stable in crib. Waking about Q3 hrs for\nfeedings. Infant is vigorous and crying for feedings.\nInfant sleeps wel between feedings. Will cont to support\ndev needs.\n\nFEN: PIV in L hand intact, flushed well with Heparin.\nInfant is waking for feedings Q3 hrs. Tolerating feedings.\nAbd exam benign. Voiding QS, passing yellow guiac neg\nstools. Will cont to monitor tolerance of feedings and abd\nexam.\nInfant is juandice. Will request bili check from MD.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-26 00:00:00.000", "description": "Report", "row_id": 1943158, "text": "Nursing Progress Note\nBili sent at 1500.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-26 00:00:00.000", "description": "Report", "row_id": 1943159, "text": "NICU Procedure Note\nLP performed under sterile conditions. Area prepped and draped. LP needle inserted in L4-5 space, 2.5 cc of xanthrochromic fluid obtained and sent for culture, cell counts and protein/glucose.\nNo complications with procedure\n" }, { "category": "Nursing/other", "chartdate": "2190-05-26 00:00:00.000", "description": "Report", "row_id": 1943160, "text": "NICU NPN\n\n1. O: Remains in NCO2 200-300cc flow, .30-.35%. BS are cl=\nto bases, mild ic retractions occas. RR is 50-80, no\nincreased WOB noted. PO Slight increase in FIO2 needed occas\nwith cares. No significant , no color changes. A:\nWeaning O2 slightly as tolerated. Resp status improving. P:\nWean o2 as toelrated, monitor for increased WOB.\n\n2. O: Continues on Ampi and Gent, VSS, active with\ncares. LP done by Fellow, procedure done without incident.\nToelrates all cares well. A: Pot for sepsis, antibiotic tx\nccontinues. P: Monitor s/s of infection.\n\n3. O: Mom and Dad in , asking appropriate questions,\nshowing loving concern. Both fed baby , handle infant\nwell. A: Loving, invested parents. P: Support and keep\ninformed.\n\n4. O: Stable, now in isolette because of phototherapy. Wakes\nfor feeds Q3-5 hrs, PO feeds excellent. Sleeps well between\ncares. A: AGA. P: Support developmental needs.\n\n5. O: Took in 130cc/k/d of Sim20cal today, PO feeding Q3-5\nhrs, taking ad lib amts. Voiding and stooling, weight is\n3935g, up 65g. Small spits x1. A: Gaining weight, PO feeding\nwell. P: Continue feeding ad lib amts as demanded.\n\n6. O: Bili: Infant jaundiced, bili sent. , active with\ncares, PO feeding well, Voiding nd stooling. Bili level\n17.3. DOuble photoherapy started, eye patches on. A:\nHyperbili treatment started. P: Monitor bili levels,\nactivity and intake.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-27 00:00:00.000", "description": "Report", "row_id": 1943161, "text": "Nursing Note\n\n\n1. Remians stable in NC 200-250cc FiO2 30-35%. Sats >95%, RR\nstable. Refer to flowsheet for RR. BLS c/=, No spells. WIl\ncont to wean O2 as tol today. See flowsheet for details of\nexams.\n2. Infant now d of abx for r/o sepsis. Presents without\ns/s sepsis. WIll cont to monitor.\n3. Mom here this AM for feeds at 0600. Independent with\ncares, asking approp quest. Updated at bedside. WIll spend\nmost of day with infant. States she is \"sad to leave without\nher.\" WIll cont to support fam. Cont to edu and plan for d/c\nteaching.\n4. Temps stable in air iso. Nested. AA with cares, sleeps\nwell between. MAE, AFOSF< PFOSF. AGA. Waking for cares\neagerly with rooting and crying. Brings hands to face, sucks\nfingers. Follows voice and sounds when awake. Very .\nCont to support and monitor dev milestones.\n5. WT=3935^65. TF=ad lib PO. Taking 90-120cc q3-5h.\nTOlerating well without spits, +bs, v/s heem neg. Abd exam\nis unremarkable. Cont to support FEN req.\n6. Infant jaundice in color. Last bili labs sent this AM\n0630. COnt under double photo. WIll cont to support and\nmonitor bili.\n\nSee flowsheet for details of all exams.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-29 00:00:00.000", "description": "Report", "row_id": 1943173, "text": "Nursing\n\nHave read note by and examined infant and agree with what is written. Infant did have a few very quick into the upper 80's accompanied by shallow breathing when she was sound asleep. I very comfortable breathing in room air. Mom called to check on daughter. level down from previous level off phototherapy.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-29 00:00:00.000", "description": "Report", "row_id": 1943174, "text": "Neo Attending Note by \n 8, now 39.2 pma\nRA since , SpO2 90-100%\nPeriodic breathing, no apnea, 30-50s, clear=BS.\nHR 140-150s. BP 80/53.\nSl jaundice. Rebound pending. 6.6, down from 11.\nWt 3820, down 10g\nad 20, 158 cc/kg/day, feeding well.\nabd wnl\nUOP and stooling\nVS stable. , active\nNeeds Hep B.\nPassed hearing screen.\nParents requested car seat test.\n\ns/p clinical pneumonia, blood cult neg, CXR c/w TTN/pneumonia, off supplemental O2 since .\nClinically ready. Discharge pending within next 24 hr if remains stable.\nWritten by \n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-29 00:00:00.000", "description": "Report", "row_id": 1943175, "text": "NPN Discharge\n\n\nInfants VSS and assessment benign; see flowsheet for\ndetails. Taking good bottles. Rebound today=\n6.6/0.2/6.4. Hep B vaccine given. Bath given. Passed\nhearing screen and car seat test. Newborn screen sent. VNA\nfaxed. Reviewed NICU D/C instruction form with parents.\nInfant D/C home in car seat with parents.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2170-07-24 00:00:00.000", "description": "Report", "row_id": 1341967, "text": "Pt cont's to be vented. Pt placed on PSV 10/Cpap 10 and 40%. VT's 350-450's. RR 18-22. 02 sats in high 90's. BS: Few scattered wheezing and rhonchi, clears some with suctioning. ALB/ATRO MDI given q4h with good effects. Plan is to wean on PSV/Cpap as tolerated and rest pt overnight on previous settings of A/C 18/500/40%/10p\n" }, { "category": "Nursing/other", "chartdate": "2170-07-25 00:00:00.000", "description": "Report", "row_id": 1341968, "text": "NURSING NOTE 1900HRS -0500HRS\n\n\nADMIT WITH ECAXERBATION OF COPD/PNEUMONIA EXTUBATED , RE-INTUBATED \n\n\n\nNEURO...LORAZEPAM FOR ANXIETY, DENIES PAIN [ CAN HAVE MORPHINE]. LETHAGIC BUT IS ABLE TO FOLLOW COMMNDS SLOWLY. DOES HAVE MOVEMENT IN ALL 4 LIMBS..LEFT PUPIL MIS-SHAPEN BUT BOTH REACT BRISKLY\n\n\n\nRESP ... P/S YESTERDAY BUT BACK TO A/C OVERNIGHT WITH SATISFACTORY ABG BUT THIS AM CLIMBING PCOC [ PREVIUOSLY EARLY 50'S NOW @ 58] BUTBACK TO P/S THIS AM , WILL RE-CHECK ABG..LUNGS CLEAR,\n SUCTIONED MINIMAL AMOUNT NEED SPUTUM SPECIMEN\n\n\nCVS...HYPETENSIVE WHEN STIMULATED / ANXIOUS 120-160 SYSTOLIC ...HR 85-95BPM...AFEBRILE ..B/S AS PER S/S...NA @ 145 LAST PM, AWAIT AM RESULTS\n\n\nGI...NO BOWEL MOTION FEED AT GOAL\n\n\nGU...POOR URINE OUTPUT , TEAM AWARE NO BOLUS ORDERED AS AVERAGING 30CC/HR...CATHETER CHANGED @ 0100HRS [ UNABLE TO DO WASHOUT] WITH SLIGHT IMPROVEMENT NOW MINIMAL AGAIN AWAITING REVIEW BY TEAM\n\n\nSKIN... INATCT\n\n\nLINES..PATENT\n\n\nSOCIAL..NO ENQUERIES\n\n\nPLAN..OBSERVE URINE OUTPUT, WEAN VENT ? ATTEMPT TO EXTUBATE GAIN TODAY\n" }, { "category": "Nursing/other", "chartdate": "2170-07-25 00:00:00.000", "description": "Report", "row_id": 1341969, "text": "Resp: pt on a/c 18/500/+10/40%. BS auscultated reveal bilateral clear. Suctioned for small amount of yellow secretions. MDI's administered Q4 hrs alb/atr/ . abg's (see careview) Vent changes to psv 10/10/35%,AM ABG's 7.39/56/126/35. VT's 500's. Plan to wean appropriately.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-25 00:00:00.000", "description": "Report", "row_id": 1341970, "text": "Respiratory Care\n\n Pt extubated without difficulty. Continuing albuterol and atrovent via HHN. B/S dim on R exp wheezes on L Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-25 00:00:00.000", "description": "Report", "row_id": 1341971, "text": "Micu Nursing Progress Notes\nEvents: Pt successfully extubated, placed on NTG gtt for very short time for HTN. Started PO anti-hypertensives due to increasing B/P. While taking meds became hypoxic, increased FiO2 and gave ativan.\n\nResp: Pt on PSV 10/ peep 10, FiO2 40% then slowly weaned to . She was extubated at 1245 and placed Face mask at 100%. O2 sats 97-98% so FiO2 dropped to 35% but dropped her sats to 92-93% and was uncomfortable so the FiO2 was increased to 40% and she was given a resp treatment. Her sats now are 97-98% RR 20-22 and she is comfortable.\n\nCardiac: B/P 140-150/60-66, HR 90-94. Prior to extubation she was given ativean .5mg and haldol 2.5mg IVP. She however did become hypertensive with extubation so was placed on IV NTG at 1.11 mcg/kg/min and her B/P fell from 176/80 to 140/62 so the NTG was quickly weaned to off, she was only on it for approx 15 min. Her B/p was 130-140/56-60 until she felt like she needed to have a BM then her B/P started to climb. At 1600 she was given lopressor 50mg and cozaar 50 mg PO due to a B/P 198/86, HR 116. She was also given ativan 1mg and her B/P was 114-120/50's (while asleep).\n\nGI: She was receiving promote with fiber at 60cc/hr which was stopped for extubation. She was given sips of water which she was able to swallow without difficulty. She was then able to take the pills easily. She has not had any stool today but did complain of the need. She was not able to get a dulcolax due to her hypertension then she was asleep.\n\nGU: foley draining clear yellow urine with U/O 40-60cc/hr.\n\nNeuro: Pt was awake alert and very anxious requiring ativan for sedation. She also received haldol 2.5mg prior to extubation. She was able to MAE and help with turning.\n\nSocial: Her two daughters came in prior to extubation and were with her until 1700 to help calm her following extubation with good success.\n\nPlan: carefully monitor her resp status overnight, possible call out tomorrow if she does well.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-25 00:00:00.000", "description": "Report", "row_id": 1341972, "text": "Micu Nursing Progress Notes\nAddendum: ABG drawn at 1615- 7.22/86/130 on FiO2 40% she was dropped to 30% and placed on BiPap.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-26 00:00:00.000", "description": "Report", "row_id": 1341973, "text": "RESP CARE: Pt placed on Bipap 10/5/.26 at start of shift due to detiorating ABGs, decreased mental status post extubation. Pt on/off bipap through the noc and given alb/atr nebs Q4 due to increased wheezing. By 4am pts ABGs had normalized with pt on 1.5lpm nasal 02 though pt had an increased WOB with use of accessory muscles noted. Pt placed back on Bipap at this time. Will evaluate again in am. Plan: Use Bipap intermittently with Hi flow nebs. Pt is now a DNR/DNI\n" }, { "category": "Nursing/other", "chartdate": "2170-07-26 00:00:00.000", "description": "Report", "row_id": 1341974, "text": "1900-0700 NPN\nNEURO: Pt. received somulent, incomprehensible words, unable to form sentences due to resp. status. moves bil. upper ext. , moves on bed bil. legs. Increase in mental status and participation in care in early am.\n\nCV: Sinus tach 100-130 through night. Hypertensive initial shift, restart nitro gtt for period of time. for maps 120-130. this occurs when pt. stressed. able to wean in am. skin warm to touch, Tmax 99.0, given lasix 80 mgm iv with 2 liter response. peripheral pulses weak\n\nRESP: pt. ph 7.22, pc02 in 70-80's. when pt. received on bipap. house office discussed options related to intubation vs non intubation. pt. prefers no intubation/ cough effort poor, secretions thick and tenacious, little product, rate 20-30. q 2 hr. breaks from bipap for oral care, alb/atrov nebs. bipap 24 % ps 10/5. tol mask well. improvement in mentation/ slight improvement of cough effort, pt. tires easily, begins use of accessory muscles for breathing. Did not give ativan/haldol this pm due to somulence. Did give MS 2 mgm iv x 2 in night for pain control, rest and preferred at this time over sedatives to assist pt. in tol bipap. Lung fields coarse to clear, diminished bibasilar until early am, then LLL diminished over right base. concerned regarding pocketing secretons post pharynx, will monitor.\n\nGU/GI: lasix 80 mgm iv x 1 with 2 liter diuresis, light yellow urine, abd soft non distended. npo for now. stool x 1 black soft mod amt.\n\nENDO: bs 142 no coverage at this time per sliding scale\n\nSKIN: dependant edema, prominent in bil upper ext.\n\nACCESS: aline positional, waveform wnl, multilumen cath intact.\n\nPAIN: pain in neck and back, ms 2 mgm iv given with good result.\n\nSOCIAL: family at bedside, long discussion with MD's regarding pt. status, decision for DNR/DNI with family, health care proxy and team. family supportive of pt., sleeping in waiting room for this night. Support and enc. pt. with cough/deep breath and eventually when fully awake teach incentive spirometer.\n\nPLAN: 1. pulm toilet, cont. bipap with rest periods @ 2 hr., alb/atrovent, chest PT, use of MS 2 mgm vs ativan/haldol.\n 2. support pt./family to allow to let pt. rest at intervals\n 3. enc. OOB to chair as soon as tol.\n\n" }, { "category": "Nursing/other", "chartdate": "2170-07-26 00:00:00.000", "description": "Report", "row_id": 1341975, "text": "Respiratory Care\n\n Pt remained off BiPaP today with good ABG's on two liters. Albuterol and Atrovent nebs given q4 via HHN. Plan return to BiPaP if wob/sob increases overnight. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-30 00:00:00.000", "description": "Report", "row_id": 1341983, "text": "Neuro:Pt. is A&O x3, cooperative with care. Denied any discomfort except for arms weakness and aches, no pain management required. Rt. had weakness persists, MAE, +PERRLA, intact cough/gag. Pt. slept comfortably most of night.\nResp: LS clear to diminished @ bases. Sats 94-96% on 2L NC. Continues on inhalors per orders. Nonproductive cough noted. RR 15-20s.\nCV: HR 60s-70s, NSR, no ectopy noted. BP 120s-140s/70s. Palpable pedal pulses, minimal bilat. arms edema noted.\nGI/GU: Tolerating house diet, did not take any food overnight, encouraged to drink fluids. Abd. soft, nontender, +BS, no BM, refused Colace due to BM's x2 yesterday. Foley found to be leaking, unsuccessfully attempted readvancing, changed to #16 fr. this AM with improvement in UO. Clear yellow urine with no sediment via foley.\nID: Afebrile. Remains on Clindamycin PO.\nSKin intact, turned and repositioned frequentlyl.\nSocial: Family visited in the evening.\nDispo: discharge to rehab this AM.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-21 00:00:00.000", "description": "Report", "row_id": 1341953, "text": "Events: Episode of hypotension to 75/30 post vent change at 0200. Fluid bolus 500cc and changing vent back to prior settings with resolution.\n\nNeuro: Remains sedated on 45mcg propofol, responsive to stimuli, follows no commands, PERRL bilat, propofol weaned back to 45mcg from 60 as pt more compliant with vent.\n\nResp: Current vent settings 400x20/30%/10. ABG 7.28/55/112/27. Had changed vent to increase RR when Ph 7.22 and CO2 in 60's but pt's b/p wouldnt tolerate. Lung sounds with little compliance. Coarse in uppper airways and decreased in bases. O2 sat in mid 90's. Suctioned x1 for scant amt of thick sputum. Sample sent.\n\nCardiac: Aforementioned hypotensive episode. SR with no ectopy on monitor. Current B/P 130-140's/90's. HR 70's. Peripheral pulses via doppler. R foot currently warm to touch and normal color.\n\nGI: ABD soft/disdended. hypoactive bowel sounds. Small amt of bilious contents suctioned via ngt. Very small Guiac-bm this shift. Sent for C Diff. Blood sugars unremarkable.\n\nGu: U/O labile. Seems to vary according to what position she's laying in. Urine is amber. Foley flushed/patent BUN/Cr 35/1.1\n\nDerm: Grossly intact. TLC site in L groin benign. R femoral cath site oozing/ covered with transparent dsg. seems unchanged from previously reported. Pedal pulses via doppler. PIV in L hand patent. PIV in R arm x2 clotted/ removed. Aline site benign.\n\nSocial: Daughter called for update.\n\nPlan: Continue with abx/steroids for COPD flare, monitor ABG (target CO2 is mid 50's). Wean vent as tolerated. Monitor hemodyanamic status and urine output closely.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-21 00:00:00.000", "description": "Report", "row_id": 1341954, "text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated on AC settings. BLBS are somewhat coarse and diminished. Sxn for thick yellow secretions.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2170-07-29 00:00:00.000", "description": "Report", "row_id": 1341981, "text": "1900-0700 NPN\nNEURO: intact. grip on right minimal, grip on left gross movement. mae\n\nCV: sinus, maps wnl, urine amber qs, tmax 98.2\n\nRESP: nasal cannual at 1.5 liters, desats to mid 80's on room air. cough effort substantial improved from prev. lung fields coarse to clear bil. without wheeze. left base diminished\n\nGU/GI: wnl. states had two stool this day. will hold stool soft per pt request. urine amber qs at min. no noted leakage around cath.\n\nENDO: bs wnl\n\nSKIN: intact. enc. pt. to do rom ankles and for hands/arms, grips and lifts while awake.\n\nPAIN: general body aches assist by tylenol, right hand ache.\n\nSOCIAL: calls from family taken in pm and am. pt. states she is anxious, looking forward to going to rehab but feels she is not progressing. no evidence to support this. I reviewed events last three days, discussed use of purse lip breathing when sob, energy conservation, rehab, use of ativan/sleeping meds. Pt. requested sleeping pill this night. I discussed with her why she would request sleeper when she by history falls asleep almost immediately and sleeps through night.\n\nPLAN: 1. increased activity\n 2. offer frequent sm. amts food. goal of 2 boosts per day. pt. needs assist with food/fluids due to decrease fine motor but enc the reach and grasp.\n 3. cont. coaching pt. on purse lip breathing, reassurance on progress, feedback on performance.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2170-07-29 00:00:00.000", "description": "Report", "row_id": 1341982, "text": "Nursing note (0700-1900) 17:00\n\nNeuro.\nNo change in neuro status during the shift, continues to need reassurance with all aspects of care and future in rehab. Pt with continued pain in R wrist, relieved with tylenol, still unable to move arm to any great extent, but has improved strength since yesterday.\n\n\nResp.\nPt continues on NC 1.5l/min, SpO2 92-95%, LS clear to coarse with diminished left base. Non-productive cough.\n\n\nCVS.\nStable, no periods of hypertension, once tachycardic due to pain, resolved to NSR with no ectopy.\n\n\nGI/GU.\nPt having small frequent aounts of food, only picks at main meals, needs snacks in between. Pt is reluctant to eat and needs lots of encouragement.\n+BS, no BM as yet today.\nGood response to Lasix via foley of clr/ylw urine.\n\n\nSkin.\npt's skin remains intact, some edema to arms, phlebitis to R arm being treated with Abx.\n\n\nSocial.\nVisited by daughters, asking to be contact by Case Manager with regard to details of transfer to rehab tomorrow.\n\nPLAN.\nContinue to provide emotional support to Pt about rehab.\nEncourage fluids and diet.\n\n" }, { "category": "Nursing/other", "chartdate": "2170-07-24 00:00:00.000", "description": "Report", "row_id": 1341965, "text": "Resp Care\nPt. remains intubated with no vent changes or abgs this shift.\nLabored breathing noted @ times, improves some with sedation.\nBs: coarse bilat. with occ. exp. wheezes.\nSxn'd x2 for sm- mod thick yellow.\nPlan: Cont. support.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-19 00:00:00.000", "description": "Report", "row_id": 1341947, "text": "NPN 7a-7p\n\nPt. admitted from cardiac cath lab with clean cath, presumed septic physiology. Presenting complaint- SOB w/ ischemic changes to Hospital sent here for emergent cardiac cath. Pls. see ICU Admission form for complete details.\n\nReview of Systems=\n\n Pt. arrived after receiving 2mg of Versed in the cath lab. Pt. was easily aroused, nodding to questions, mouthing words, following commands. Given an additional 2mg of Versed d/t dysynchrony with vent. Started on Propofol gtt at 12p for worsening acidosis and autopeeping. Titrated gtt up to 30mcg/kg/min. Pt. now sedate and only arousing to deep stimuli.\n\n Pt. received on A/C changed to PSV d/t autopeeping and subsequent inadequate ventilation/ hypotension. However, acidosis worsened and pt. transitioned back to A/C 400X25 PEEP 5 30%. Last ABG 7.19/53/159 (on 50%). Lactate 0.7. Sx'd for no secretions. Need a sample when available. CXR showing no obvious pna. Plan- possible bronch, possible CTA to r/o infection vs. PE, will maintain on A/C with sedation to counteract autopeep.\n\nCV- HR 80-90's, previously 100-110 on arrival. BP maintained with Dopamine and Vasopressin. Received pt. on 8.0mcg/kg/min of Dopamine and 0.02u/min of Vasopressin. Vasopressin increased to 0.04u/min and Dopamine has been titrated down. Currently, pt. on Dopamine at 2.0mcg/kg/min. Mg+ 1.6, repleted. PTT prolonged and pt. oozing from central line and old angio site. Angio site right fem with small hematoma, dopplerable pulses bilat. Intermittently, unable to detect DP pulse on right. Cardiology and team aware. Old PA catheter site next to angio site and is also oozing small amounts- dsg only required changing X1. PA numbers- PAP 35-45/20-30, wedge 32, CO 4.45, CVP 13-15. Swan d/c'd with sheath about 10:30am. Leg immoblizer d/c'd at 1630. Left triple lumen remains intact with some oozing. Troponin elevated- ? c/t code/ CPR, cont'd to cycle. Plan- decrease dopamine as tolerated, use vasopressin.\n\nGI- ABD soft. NGT in place. Slightly pink GI aspirates, minimal output. No stool. Need to send sample when available.\n\nGU- U/o 40-60cc/hr of yellow, clear urine. No IVF running d/t high wedge and hypercalemic acidosis. CREAT bumped to 1.2.\n\nID- Afebrile. Conts on triple abx vanco, levo, flagyl. ? pna as source of sepsis...\n\nSocial- Multiple family members in this am and updated by Green team resident and nursing. Dtr is health care proxy and lives with pt. Numbers listed on board and in ICU admission form.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-20 00:00:00.000", "description": "Report", "row_id": 1341948, "text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated on AC settings. Pip and Plateau pressures up during the noc at times. Be cautious with the inspiratory time. Now I Time on .75. Should not be any quicker. Pip's increase to 45-50 with faster I Time. Auto-peep at acceptable level of .\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2170-07-20 00:00:00.000", "description": "Report", "row_id": 1341949, "text": "MICU Nursing Note 1900-0700\nEvents: Occasional periods of labile BP especially with activity...BP responded well to fluid boluses.....Remains off Vasopressors. Remains intubated with episodes of increased airway pressures--treated with nebs and inhalers, continues to autopeep around 5cm. Sedated on Propofol. Increasing abdominal distention with pain on palpation..Stat KUB obtained and results pending. NGtube placed to intermittent LWS.\n\nNeuro: Remains sedated on IV propofol. Arouses to verbal stimulation and occasionally able to answer questions with head nods. Able to move all extremities with stimulation. PEARL. Requires boluses of Propofol before repositioning and suctioning. When physically stimulated and awake pt c/o anxiety when asked.\n\nCardiac: HR 80-90's SR with no ectopy noted. Left Radial Aline site C/D/I with good waveform and correlation to NBP. Small ecchymotic area noted over Left posterior hand...good from nailbed. BP 80-120's/40-60's with MAP= 50-70's. A few episodes of sBP to 80's---treated with 500 ml NS bolus x1 with good effect for 2 hrs with repeat hypotension treated with 1000ml of NS with good effect. Old Right Femoral Sheath site intially with small oozing and now with small ecchymotic area under transparent dsg. Left Femoral multi-lumen central line site with small ecchymotic area over insertion. + bilateral dopplerable pulses DP/PT. Right foot cool but pink and Left foot warm and pink. Remains off Vasopressors at present time.\n\nResp: Remains intubated with #7ETtube at lip=20cm. No vent changes thru night except increased inspiratory time. Current Vent Settings TV=400, FI02=30%, AC=25, Peep=10. Overbreathes vent by 5 breaths with stimulation. Suctioned for scant thick white. Bronchospastic with all activity. O2 Sats=93-98%. Lungs with expiratory wheeze and diminished at bilat. bases. This am ABG unchanged from prior =7.25-55-75-25.\n\nGI: Abd initially soft with + bowel sounds all quads---increased distention noted during noc---HO assessed---hypoactive bowel sounds and + flatus noted. Stat KUB obtained and results pending. NPO maintained. NGtube placement checked by auscultation. NGtube currently placed to low intermittent wall Sx.\n\nEndo: Remains on sliding scale insulin coverage---FS=126 at MN --no coverage needed.\n\nID: Tmax= 100.7...cultures still pending. medicated with Tylenol x1 with temp down to 99.4. WBC down to 17.9 this am. Remains on IV Flagyl, IV Vanco, and IV Levofloxacin.\n\nGU: Foley to CD draining clear yellow urine approx. 30-80ml/hr.\n\nSkin: intact. No open areas. Groin sites with no further oozing.\n\nPlan: Wean Vent as tolerated. Wean sedation as tolerated. ??? of Bronch today or CTA. Obtain results of KUB...continue supportive measures. pt and family. Continue to monitor abdominal status.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-20 00:00:00.000", "description": "Report", "row_id": 1341950, "text": "MICU Nursing Note Addendum\nNGtube placed to low wall suction...intially drained small amt of coffee grounds---Ngtube flushed with 60 cc NS with no further coffee gounds\n" }, { "category": "Nursing/other", "chartdate": "2170-07-20 00:00:00.000", "description": "Report", "row_id": 1341951, "text": "Respiratory Care Note:\n Patient with improving gas exchange noted. Attempt to wean to PSV not successful at this time with tidal volumes too small and sigificant decrease in minute ventilation. Attempts to wean PEEP reflected increased autopeep in circuit so it was left at 10cmH20. BS=bilat. Suctioned for med amounts of pale yellow sputum. She is receiving albuterol, atrovent, and flovent MDIs. See Carevue flowsheet for specifics.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-20 00:00:00.000", "description": "Report", "row_id": 1341952, "text": "NURSING NOTE 0700HRS -1700HRS\n\n\nADMIT WITH PEA ARREST ? CAUSE.. ? SEPTIC OR CARDIAC/EXCACERBATION OF COPD\n\n\n\n\nEVENTS..FAILED P/S TRIAL, PROPOFOL INCRESAE TO AID COMPLIANCE WITH VENT...NO SEPTIC SAUCE AS OF YET\n\n\n\n\nNEURO...APPARENTLY SOME WHAT INTERACTIVE WITH NIGHT STAFF AND NOT COMPLIANT WITH VENT THEREFORE BOLSED WITH SEDATION AND INCRESASED...PRESENTLY @ 55MCGS/KG...ONLY RECATIVE TO PAINFUL STIMULI ALTHOUGH NOTED THIS EVE IS REACTIVE [ RAISED EYE BROWS] TO NAME CALL WITH INCREASED B/P THEREFORE BOLUSED AND INCRESAED..PUPILS CONTINUE EQUAL /REACTIVE\n\n\n\nRESP... RECEIVED ON A/C WITH VERY HIGH PEAK AIRAWAY PRESSURES [ POOR ABG'S SINCE ADMISSION, SEE CAREVIEW] AC 25/400 PEEP 10...ABG REVIWED THIS AM AND 'TIMINGS' OF INHALATION/EXHALATION MANIPULATED BT RT WITH IMPROVED ABG.... BEACUSE OF KNOWN SEVERE COPD AIM FOR PCO2 MID 50\"S...AT TIMES LUNGS SOUND TIGHT /WHEEZY, INHALERS BY RT...REPEAT GAS PM SHOWS PCO2 < 50 THEREFORE RATE REDUCED TO 20 AND AWAITING REPEAT ABG... WAS TRIALED ON P/S BRIEFLY THIS AM BUT MV DROPPED SIGNIFICANTLY [ AS PER RT]\nSPUTUM SPEC STILL REQUIRED, VERY LITTLE SUCTIONED...CONTINUES ON HIGH DOSE STEROIDS\n\n\n\nCVS... CONTINUED OFF PRESSORS, SYATOLIC >110-120 THIS PM SYSTOLIC @ 160 THEREFORE BOLUSED WITH PROPOFOL [ NORMALLY ON HTN MEDS ? REVIEW LATER]...HR 75-85BPM\nBORDERLINE TEMP BUT BC SO FAR NEG...CONTINUES ON AB'S\nB/S STABLE\n\n\nGI/HAEM...NIGHT SATFF REPORTED PATIENT C/ PAIN, AREA SOFT BUT DISTENDED WITH DECRESAED B/S, KUB AT THAT TIME NEG AND N/G PUT TO SUCTION...UPON RECEIVING B/S EVIDENT BUT COFFEE GROUND IN CANNISTER HCT CHECKED AND STABLE FROM AM LABS..TEAM REVIWED AND MEDS HELD THIS AM AND PPI PUT TO B/D..CHECK HCT THIS PM SLIGHTLY LOWER ? RE-CHCK THIS EVE...UPON ASSESSSMENT @ 1600HRS B/S VERY FAINT TEAM INFORMED AND AWAIT REVIEW [ STILL REMAINS SOFT] AND OUTPUT FROM N/G IS NOW BILIOUS...\n\n\nGU...FLUCTUATING U/O , ON MAINTAINCE BUT REQUIRED BOLUS FOR LOW U/O THIS PM , ADEQUATE SINCE\n\n\nSKIN.. INTACT....PREVIOUS SWANN IN RT GROIN [ POST CATH YESTERDAY] RT FOOT CONTINUES COOL /PALE BUT PULSES DOPPLERABLE AND TEAM AWARE OF ON GOING CONDITION... CONTINUE TO OBSERVE....PUNCTURE SIGHT RT GROIN SATISFACTORY\n\n\nLINES... PATENT\n\n\nSOCIAL..X2 SONS/ DAUGHTERS AND UPDATE RE: CONDITION..REQUESTED THAT RINGS AN HER FINGERS BE CUT OF AS SWOLLEN\n\n\nPLAN...SLOW WEAN FROM VENT... CONTINUE TO INVEESTIGATE PEA ARRESST...FOLLOW ASSESSMENT\n\n" }, { "category": "Nursing/other", "chartdate": "2170-07-24 00:00:00.000", "description": "Report", "row_id": 1341966, "text": "NURSING PROGRESS NOTES\nREVIEW OF SYSTEMS:\n\nNEURO: PT ALERT AND ANXIOUS THIS AM. MOUTHING HER THROAT HURTS. ATIVAN 1MG IV GIVEN W/ LITTLE ANTIANXIETY EFFECT. MS 2-4MG IV Q 4HRS ORDERED AND 4MG IV GIVEN. PT RESTING COMFORTABLY, ABLE TO AWAKEN TO VOICE COMMANDS. LEFT PUPIL MISHAPEN-OVAL RIGHT PUPIL 3MM BOTH REACT BRISK\nTMAX 100.8 RECTALLY.\n\nRESP: PT VENTED AT PRESENT ON AC 18/500/40% 10PEEP. ABG ON THOSE SETTINGS 7.40/52/159/98%. PT NORMALLY HAS CO2 IN 50-60S. MICU TEAM WOULD LIKE TO TRY PSV, AWAITING RESP THERAPIST TO PLACE PT ON THOSE SETTINGS. LS THIS AM WHEN PT WAS EXP WHEEZES HEARD IN LEFT LUNG FIELDS, NOW THAT PT ARE CLEAR W/ DIMINISHED BASES. SUCTIONING THICK THIS AM BUT NOW ARE THIN WHITE SECRETIONS.\n\nCV: HRT SOUNDS DISTANT, TELE SR-ST 90-105 BP STABLE, PEDAL PULSES +2\nNA 147 D5W ORDERED X 1 LITER AND WILL RECHECK NA LEVEL AT 1700.\n\nGI: PT HAS NGT PROMOTE W/ FIBER AT GOAL RATE 60CC/HR ABD SOFT DISTENDED PASSING ALOT OF FLATUS. PT HAD ONE DARK BLACK SOFT STOOL THIS AM- GUIAC NEG. PT HAS FREE WATER FLUSHES 50CC QID.\n\nGU: PT HAS GREENISH/YELLOW URINE 22-80CC/HR.\n\nACCESS: PT HAS IN RIGHT IJ AND RIGHT ALINE.\n\nCODE: FULL\n\nENDO: BS QID 169/253 COVERED RISS. PT ON PREDNISONE.\n\nID: PT ON BC PENDING, URINE CS NEG, SPUTUM- FEW GRAM + COCCI, YEAST CONTAMINATED W/ ORAL FLORA, ANOTHER SPEC NEEDED.\n\nSOCIAL: PT HAS 3 CHILDREN. ONE OF HER 2 DAUGHTERS VISITED THIS AM AND WAS UPDATED.\n\nPLAN:\nTRY PSV THIS AFTERNOON. AND DRAW ABG ON SETTINGS AND PLACE BACK ON AC WHEN TIRES.\nCONT TO KEEP PT COMFORTABLE W/ ATIVAN AND MS\n AT 1700\nOBTAIN SPUTUM SPEC FOR C/S.\nDRAW ABG AND LABS IN AM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2170-07-27 00:00:00.000", "description": "Report", "row_id": 1341978, "text": "NPN 7a-7p\n\n Pt. remains on 1.5L NC and doing well. Has had 2 episodes of increased WOB r/t anxiety- given 1-1.5mg of Ativan which appears to calm pt. down. Eating a bit more than yesterday. OOB to chair/ waffle cushion X 4 hours. To go to rehab monday to .\nPlan- allow BIPAP as needed for rest, cont to get OOB work with PT tom'row, encourage nutrition.\n\nReview of Systems-\n\n Pt. intact. Requesting Ativan for anxiety r/t increased WOB. Severely deconditioned requiring lift for mobility.\n\nResp- LS- CTA, good airation. RT giving nebs. On 1.5L NC. To start on longer acting drug in Atrovent family in am (nebulized by RT- pls. pass on to RT dept.) Prednisone taper conts. BIPAP for rest overnoc if indicated.\n\nCV- HR 100 SR, BP 140-160's, down to 130's at rest. Art line d/c'd today. Right arm conts to be more swollen than left, will cont to monitor. Conts on daily lasix.\n\nGI- ABD soft, tolerating house diet. No stool.\n\nGU- U/o adequate with lasix given at 12p (20).\n\nID- Afebrile. Levoflox d/c'd today.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-28 00:00:00.000", "description": "Report", "row_id": 1341979, "text": "1900-0700 NPN\nNEURO: Intact, interactive, appropriate. full sentences in speech that is clear.\n\nCV: stable, sinus, afebrile, one episode of transient hypertension with maps in 100's with resolution without intervention.\n\nRESP: cont. alb/atrovent nebs with cough non prod., rhonchi, flapping secretions in right base. resp deep rate 16-22. oxygen 1.5 liters. improvement in exercise tolerance.\n\nGU/GI: abd soft, repeat senna with evening colace. no stool. foley drains min. amber urine. tol. po fluids and food, need freqent small meals/fluids.\n\nSKIN: intact\n\nENDO: bs wnl, will ask to dc sliding scale this day\n\nACCESS: multilumen cath in place and ports open. art line dc site cond. good.\n\nSOCIAL: family calls taken, pt. responsive to coaching, enc. by transfer to rehab facility early this week\n\nPLAN: increase activity and diet as tol. offer ensure for calories, freq snacks, advised pt. to have family bring in favorite snacks to be kept at bedside. reinforce use of purse lip breathing when anxious or SOB. offer emotional support and information regarding plan to transfer.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2170-07-28 00:00:00.000", "description": "Report", "row_id": 1341980, "text": "Nursing note (0700-1900) 16:45.\n\n\nNeuro.\nPt A+Ox3, follows commands, no apparent defecit from previous baseline. Lorazepam requested by pt x2 this shift for nerves, given with mild effect.\nPt with pain to R arm this am, coupled with weakness in the limb. Team informed, suspect phlebitis, started on Abx.\n\n\nResp.\nPt remains on N/C at 1.5l with SpO2 of 92-95%. LS clear to diminished at bases. Pt with laboured breathing at times, however pt feels breathing has returned to previous level and has no complaints.\n\n\nCVS.\nHR 80-100's NSR-ST with no ectopy seen.\nBP 140's-170's/60's-70's. Becomes hypertensive when turning, or when begins to feel anxious.\n\n\nGI/GU.\nPt encouraged to take diet with small success. pt becomes breathless when eating and remains reluctant to eat stating she has little appetite at the moment..\nPt has +BS and has stooled x3 of green formed stool, guiacc -ve, sample sent for C-Diff.\nGood response to Lasix of clear urine.\n\n\nSkin.\nPt's skin is in good condition with no areas of breakdown.\n\n\nPlan.\nContinue to support with nutrition.\nPt is for BIPAP overnight at teams request.\nPrepare for REHAB on Monday.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-22 00:00:00.000", "description": "Report", "row_id": 1341960, "text": "0700-1900 NPN\nSee carevue for subjective/objective data.\nNeuro: Received pt sedated on Propofol at 50mcg/kg/min however pt minimally responsive to painful stimuli therefore Propofol decreased to 30mcg/kg/min then off briefly. Pt slightly more responsive when Propofol off however breathing becoming more labored therefore Propofol restarted at 10mcg/kg/min until 1700 when Propofol off as MD orders. Pt is tolerating Propofol off although breathing is somewhat labored, pt taking very deep breaths, using accessory muscles at times. Pt minimally responding to nailbed pressure and sternal rub at this time (off of Propofol--pt furrows brows with painful stimuli). Pt does not follow commands. If mental status does not start to clear pt will travel to CT for CT of head.\n\nCV/Pulm: MP=NSR-ST, no ectopy noted. R rad A-line waveform sharp, zero'd and cal to monitor. Dsg D+I. Remains vented on PS , 30%. Pts TV 695-703 at this time. BS clear, diminished bil. Suctioned q3-4h for thick yel sec via ETT and thick clear orally.\n\nGI/GU: Abd soft, non-tender, bowel sounds present. TF on hold at this time as initially ?extubation, now ? traveling to CT for CT of head. U/O qs q1h. U/O brown, urine lytes sent.\n\nID/Integ/Endo: Tmax 100.0. No change in abx. Skin intact. Hand edematous, elevated on pillows. Multi-podis boots added to both feet as feet are ? developing foot drop. No coverage for fingersticks needed.\n\nPsychosocial/Plan: Daughters in to visit. Emotional support given to pt and fam. Plan is to monitor mental status and ? travel to CT of head is mental status does not clear. Cont vent support. Cont with current nursing/medical regime.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-23 00:00:00.000", "description": "Report", "row_id": 1341961, "text": "npn 7-7am\nNo changes overnight.\n\nneuro: No neurological changes overnight. Pt responds to painful. Does not exhibit any spontaneous movement. PERL @ 2mm. Propofol remains off.\n\nresp: PS 30%. LS clear. Suctioned for thick yellow sputum.\n\ncv: SR in the 90's, no ectopy. BP 150-160/70's.\n\naccess: R radial aline and R sc tlc.\n\ngi/gu: Abdomen is soft, +BS. NPO. Patent foley with adequate u/o.\n\nEndo: RISS.\n\nID: Afebrile. On levoflox.\n\nSkin: Intact.\n\nDispo: Full code.\n\nSocial: Daughter updated on phone last evening.\n\nPlan: ? head CT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2170-07-23 00:00:00.000", "description": "Report", "row_id": 1341962, "text": "Resp Care\nPt. continues to be intubated on PSV mode: spotn. vt's 600's with avg. MV 7-9lpm.\nBs: coarse, equal bilat. sxn'd x2 for thick yellow/moderate.\nabgs: compensated resp. acidosis. with adequate oxygenation.\nPlan: possible head CT since pt.has been off sedation x2days and continues to be unresponsive.\n\n" }, { "category": "Nursing/other", "chartdate": "2170-07-23 00:00:00.000", "description": "Report", "row_id": 1341963, "text": "0700-1900 NPN\nSee carevue for subjective/objective data.\nNeuro: At 0800 pt unresponsive, unable to elicit any response despite painful stimuli (nailbed pressure, sternal rub) or by loudly calling pt by name. PERL, L pupil irregular but brisk, reacts to light. Per family pt has suddently \"woken up\" in the past following intubation and sedation. At 0900 pt awake, mouthing words around ETT, MAE, following commands consistently. At this time pt is alert, follows commands, MAE ad lib, pupils unchanged.\n\nPulm/CV: Pt intubated in AM, RSBI 44.7, sats high 90's. Pt alert, cooperative therefore decision made by Dr. to extubate pt. Pt extubated at 1000, placed on 40% face mask. By 1100 pts BP 210/110, Insp/Exp wheezing noted with some stridor, diaphoretic, sats dropping. Pt reintubated by anesthesia with 7.5 ETT. BS coarse, rhonchi throughout. PCXR done. Pt had been started on NTG when hypertensive however NTG on for 15min only prior to intubation then DC'd. Pt rec'd 300mcg Fentanyl and 100mg Succs for intubation. Pt developed hypotension following meds and intubation, fluid resuscitated with BP returning to 100's/40's. Remains vented at this time with current settings AC18x500x40%x8peep. Will rpt ABG's at 1700 with PM labs. Suctioned for thick yel sec via ETT in lg-->copious amts. R rad A-line in place, R TLC patent. BS coarse at this time.\n\nGI/GU: Abd soft, pt did c/o some tenderness when extubated however has had two BM's since then. Stool dark but guaiac neg. Stool spec sent to lab for C-diff. TF restarted FS Promote with fiber, currently at 10ml/hr (goal rate is 60ml/hr). Bowel sounds present. U/O qs q1-2hrs, remains yellow-->brown tinged but more clear than 24hrs ago.\n\nID/Endo/Integ: Tmax 99.8 PO. No change in abx. No coverage for fingersticks required. Skin intact. Multi-podis boots on majority of day with ROM done to ankles when boots off.\n\nPsychosocial/Plan: Daughters in to visit, updated by Dr. . Plan is cont'd vent support, monitor labs, ABG's, I+O, VS, cont'd abx, TF.\nCont with current nursing/medical regime, cont to provide emotional support to pt and fam. Pt is full code.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-24 00:00:00.000", "description": "Report", "row_id": 1341964, "text": "neuro: Awake and mouthing words. Follows commands. slept in naps.\n\ncv/resp no vent changes. suctioned for thick yellow sputum. breath sounds very diminished. nsr no ectopy. bp stable.\n\ngi/gu tube feeds advanced to goal. residual 40cc max. Positive bowel sounds. foley marginal uop dk yellow urine. small oozing of black stools.Guiac -.\n\ninteg. bilat sm. groin dsgs changed for sm. amt serous drainage.\n\nplan: ? wean from vent attempts today. monitor mental status\nsecretion management. follow up on blood cx./ and this am labs.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-21 00:00:00.000", "description": "Report", "row_id": 1341955, "text": "NPN 7a-7p\n\nEvents- Femoral line changed to RIJ and femoral d/c'd. Pt. conts to be acidemic therefore a considering for weaning and extubation. ABG unchanged on PSV 10/5 from A/c settings. Bowel regimen initiated. TF to start this evening. Will use LR or Na+ HCO3 to bolus if needed- rec'd 500cc of LR for low u/o today with good response.\n\nReview of Systems-\n\nNeuro- Sedated on 50mcg/kg/min of Propofol. However, pt following commands, answer questions by nodding appropriately. Given 100mcg of Fentanyl during line change for pain. Moving all extremeties.\n\n Pt. conts to autopeep requiring vent adjusting. However, looking well with transition to PSV. ABG essentially unchanged from previous 7.27/57/82/26. Will tolerated PCO2 in 50-60 range given COPD hx. LS- diminished bilat. Sat's stable, dipping X 1 during coughing jag/ bronchospasm. Sx'd for minimal secretions. Conts on levoquin.\n\nCV- HR 80's BP 120'-170's. FB given X 1 of LR for low u/o. Steriod taper started. Skin intact. Labs ok. Line removed from left groin. Angio site and triple site oozing slightly.\n\nGI- ABD soft/ distended. Minimal NGT output compared to previous 24 hours. Conts to have coffee grounds, but minmal. TF to be started this evening- Promote with Fiber. Will need nutrition consult tom'row. No stool, started on Bowel regimen.\n\nGU- u/o marginal. Put out >200cc X 1 and then tapered off, now 40cc/hr. Will bolus as needed.\n\nID- Low grade temp, pt. feeling warm. Conts on levoquin.\n\nSocial- Multiple family members in today, updated by nursing.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-21 00:00:00.000", "description": "Report", "row_id": 1341956, "text": "Respiratory Care Note:\n Patient weaning on PSV of %. ABG= 7.27/54/82/26/-2. BS=bilat, diminished aeration. CXR with hyperinflated lungs. Suctioned for small-medium amounts of pale yellow tinged sputum. Plan to continue on PSV as tolerated. Above abgs acceptable to team.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-22 00:00:00.000", "description": "Report", "row_id": 1341957, "text": "NPN 1900 -0700\n\nNEURO: SEDATED ON PROPOFOL @ 50MCG/KG/MIN .AROUSES TO NOXIOUS STIM /SUCTIONING.WILL FOLLOW COMMANDS WHILE AWAKE.\n\nRESP:NOW ON CPAP 10/5 30% FIO2 W/ TV'S 350-400 RR 16-18. M ABG ON THESE SETTINGS 7.27/62/95. SUCTIONED FOR MIN AMTS SECRETIONS.NO EPISODES OF BRONCHOSPASM.LUNGS CONT TO BE COARSE AT APEXES AND DIM AT BASES.\n\nC/V: SR-ST NO VEA BP STABLE.\n\nF/E/N: TF OFF AT MN FOR POSSIBLE EXTUBATION THIS AM .UO 30-40CC/HR. ABD SOFTLY DISTENDED,NO STOOL OVER NOC, CONT ON BOWEL REGIMEN.\n\nPLAN: POSSIBLE EXTUBATION THIS AM, MONITOR HEMODYNAMICS, CONT AB TX.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-22 00:00:00.000", "description": "Report", "row_id": 1341958, "text": "RESPIRATORY CARE NOTE\n\n\nPt remains intubated and on PS ventilation all noc. Tolerated well. Decreased Peep this am to 5. ABG is consistent with previous. Plan to extubate this AM. BLBS are diminished and somewhat coarse. Sxn for thick yellow secretions.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2170-07-22 00:00:00.000", "description": "Report", "row_id": 1341959, "text": "Respiratory Care Note:\n Patient remains intubated and weaning on PSV. Propofol off and she remains asleep. Respirations appear slightly labored with # 7.0 ET tube in. BS=bilat, diminished. Suctioned for small to med amounts of thick yellow. Possible extubation today.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-26 00:00:00.000", "description": "Report", "row_id": 1341976, "text": "NPN 7a-7p\n\n Pt. off bipap this am about 8a and has been tolerating supplemental O2 since- stable ABG. Pt. anxious requiring 1mg of Ativan X 2 thus far per request. Family met with Dr. and nursing about communication concerns.\n\nReview of Systems-\n\n Pt. alert, oriented to person and place not time. Lethargic. However, pt. now speaking in word sentences. C/o of anxiety r/t to dyspnea and requested Ativan X 2, medicated iwth 1mg each time with fair relief. Conts on celexa.\n\n Pt. off bipap, on 3L NC with stable ABG/VBG- 7.44/58/68/41 and 7.41/63/37/41 venous. Pt. with increased WOB throughout the shift. However, more conversant now than this am. Anxiety and fear of exertion is a big concern for pt. which worsensing dyspnea. Pt. does tolerate moving in bed from side to side. Goal for tom'row would be to get pt. OOB. Pt. with strong, nonproductive cough. Conts on steriods 40mg daily. RT given nebx q4 hours.\n\nCV- HR 100-112 ST. BP 130's-150's on Enalapril q 6 hours, avoiding beta blockade given COPD concerns. Given lasix daily. Skin intact.\n\nGI- ABD soft, tolerated a slight advance in diet to soft solids. However, pt. scared to eat and feels like she is choking on large pills and solids. No stool this shift. However, little intake.\n\nGU- U/o adequate, put out 1L to lasix.\n\nID- Afebrile. Conts on levoquin without obvious source.\n\nSocial- 4 children in/out throughout the day, updated by medicine and nursing... appear comfortable and up to date on plan of care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2170-07-27 00:00:00.000", "description": "Report", "row_id": 1341977, "text": "1900-0600\nNEURO: lethargic, tired, increase in words per sentence, voice small.\n\nCV: sinus to sinus tach, maps at rest 80's, with increase in work effort, maps 140 transiently. urine out qs, mucous membranes dry. tmax 98.\n\nRESP: increase work of breathing with anxiety. pt. immed. asks for ativan. No ativan, coaching, reinforcing purse lip breathing, pt. hypervents., coach to slow successful. cough loose but not prod. cough effort improved. sats room air 88%, sats 1.5 liters low 90. placed on bipap for rest at 0000-0400. able to slept well, rr drops to 16, increase depth of resp. lung fields clear upper bil. diminished at bases bil. left greater than right. alb/atrovent x 2 in night.\n\nGU/GI: abd soft, BT active, smear drk green stool. senna given. pt. reluctant to take fluids food. some cough with thin liquids. able to take po meds slowly without prob. foley qs amber\n\nSKIN: intact. rom to lower ext, pt instructed to move about legs to increase strength, will get pt. up to chair this day.\n\nACCESS: art line with sharp pattern, able to draw labs without difficulty. left sub c line patent.\n\nENDO: BS 155, sliding scale coverage for same.\n\nSOCIAL: dtr. called to inquire re: status. update given. Pt. needs lots of coaching regarding breathing, increasing activity, increase po intake.\n\nPLAN: 1. Cont. 1.5 liter oxygen. accept sats 88% and above.\n 2. Pulm toilet, use bipap for rest periods when tired.\n 3. increase activity\n 4. coaching for anxiety and reinforce purse lip breathing techniques.\n 5. ensure adequate calories. determine best method to provide.\n 6. monitor bp, adjusting antihypertensives to need.\n\n\n\n" }, { "category": "Echo", "chartdate": "2170-07-19 00:00:00.000", "description": "Report", "row_id": 78849, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Left ventricular function. Myocardial infarction.\nHeight: (in) 65\nWeight (lb): 140\nBSA (m2): 1.70 m2\nBP (mm Hg): 100/50\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 07:10\nTest: Portable TTE (Focused views)\nDoppler: Limited doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. Lipomatous hypertrophy of the\ninteratrial septum.\n\nLEFT VENTRICLE: Severely depressed LVEF. No LV mass/thrombus.\n\nRIGHT VENTRICLE: Dilated RV cavity. Severe global RV free wall hypokinesis.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Physiologic MR (within normal limits). LV inflow pattern c/w\nrestrictive filling abnormality, with elevated LA pressure.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is dilated. The right atrium is dilated. Overall left\nventricular systolic function is severely depressed. No masses or thrombi are\nseen in the left ventricle. The right ventricular cavity is dilated. There is\nsevere global right ventricular free wall hypokinesis. The aortic valve\nleaflets are mildly thickened. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Physiologic mitral regurgitation is seen\nalthough singificant regurgitation cannot be excluded by this study. The left\nventricular inflow pattern suggests a restrictive filling abnormality, with\nelevated left atrial pressure. There is no pericardial effusion.\n\nIMPRESSION: Severe biventriculr systolic dysfunction. If clinically indicated,\na complete TTE is recommended for exclusion of significant valvular disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 869863, "text": " 11:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate ETT s/p intubation\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with chf, cardiogenic shock, unclear infectious source, new\n crackles on exam s/p Central line in right subclavian,\n REASON FOR THIS EXAMINATION:\n Evaluate ETT s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old woman with CHF and cardiogenic shock.\n\n AP PORTABLE SUPINE CHEST: Compared to the study of . Endotracheal\n tube, right-sided subclavian line, and NG tube unchanged in position. The\n heart remains normal size. The mediastinal and hilar contours are\n unremarkable. The lungs are clear without evidence of pneumonia or congestive\n heart failure. No pneumothorax is identified.\n\n IMPRESSION: No significant interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 869646, "text": " 12:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx, check for line placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with chf, cardiogenic shock, unclear infectious source, new\n crackles on exam s/p Central line in right subclavian,\n REASON FOR THIS EXAMINATION:\n r/o ptx, check for line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of CHF and cardiogenic shock, rule out pneumonia.\n\n AP PORTABLE UPRIGHT CHEST: Compared to film of two days prior. Endotracheal\n tube unchanged in position. Right-sided central line with its tip in the mid\n SVC. NG tube with its tip in the stomach. Heart size within normal limits.\n The mediastinal and hilar contours are unremarkable. The lungs are clear.\n There is no short interval change.\n\n IMPRESSION: No significant interval change. No evidence of congestive heart\n failure or pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 869336, "text": " 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with chf, cardiogenic shock\n REASON FOR THIS EXAMINATION:\n assess tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 72-year-old woman with CHF and cardiogenic shock for assessment\n of tube placement.\n\n CHEST, SUPINE AP PORTABLE: There are no prior studies available for\n comparison. There is a nasogastric tube passing into the stomach, whose tip\n positioning cannot be evaluated. There is an endotracheal tube situated\n beyond the thoracic inlet, approximately 6 cm above the carina. The cardiac\n and mediastinal contours appear normal. There is slight upper zone\n redistribution of the pulmonary vessels, and Kerley B lines. There is no\n pneumothorax or pleural effusion.\n\n IMPRESSION: Placement of endotracheal tube as described. Mild CHF.\n\n" }, { "category": "Radiology", "chartdate": "2170-07-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 869386, "text": " 10:59 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o infiltrates.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with chf, cardiogenic shock, unclear infectious source, new\n crackles on exam.\n REASON FOR THIS EXAMINATION:\n r/o infiltrates.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 72-year-old with history of CHF and cardiogenic shock, ?\n pneumonia.\n\n AP PORTABLE SEMI UPRIGHT CHEST: Compared to the study of six hours prior.\n Endotracheal tube and NG line unchanged in position. The cardiac,\n mediastinal, and hilar silhouettes are stable. The lungs are clear. There\n may be small bilateral pleural effusions. There is some prominence of the\n central pulmonary vasculature, with mild upper zone redistribution consistent\n with mild congestive heart failure, not significantly changed. No new\n pneumonia is identified.\n\n IMPRESSION: No significant short interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 870195, "text": " 10:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: COPD\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with CHF, COPD, s/p extubation, now wet sounding exam\n REASON FOR THIS EXAMINATION:\n eval infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old with CHF and COPD status post extubation, now\n sounding wet by exam, evaluate infiltrate or effusion.\n\n AP semi-upright chest compared to AP portable supine chest of 2 days prior.\n There has been interval extubation and removal of the NG line. The right IJ\n line remains unchanged in position. The heart size is unchanged. The\n mediastinal and hilar contours are unremarkable. Allowing for differences in\n technique, there is no significant interval change. There is no evidence of\n pneumonia or congestive heart failure.\n\n IMPRESSION: Status post extubation. Allowing for differences in technique,\n no other interval change. No evidence of congestive heart failure or\n pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-20 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 869471, "text": " 3:45 AM\n PORTABLE ABDOMEN Clip # \n Reason: assess distended bowel\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with distention, decreased BS\n REASON FOR THIS EXAMINATION:\n assess distended bowel\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal distention and decreased bowel sounds. Evaluate for\n distended bowel.\n\n No prior studies are available for comparison.\n\n SUPINE ABDOMEN: A nasogastric tube is in place, with the tip overlying the\n distal stomach. The stomach is quite distended with air. There is also air\n and stool noted within the colon. There is a left groin catheter in place.\n No free air is identified on this supine radiograph.\n\n IMPRESSION: Distended stomach. Otherwise, unremarkable abdominal radiograph.\n\n\n" }, { "category": "ECG", "chartdate": "2170-07-19 00:00:00.000", "description": "Report", "row_id": 211410, "text": "Right-sided chest leads show no evidence of acute injury. No previous tracing\navailable for comparison.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2170-07-19 00:00:00.000", "description": "Report", "row_id": 211411, "text": "Sinus rhythm. Since the previous tracing of the rate is slower,\nP waves are less peaked and ST-T wave abnormalities are resolved.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2170-07-19 00:00:00.000", "description": "Report", "row_id": 211412, "text": "Sinus tachycardia. Question P pulmonale. Non-specific ST-T wave abnormalities\nwhich may be due in part, to the rapid rate. No previous tracing available for\ncomparison.\nTRACING #1\n\n" } ]

[ { "category": "Echo", "chartdate": "2143-08-27 00:00:00.000", "description": "Report", "row_id": 76873, "text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Left ventricular function.\nHeight: (in) 64\nWeight (lb): 105\nBSA (m2): 1.49 m2\nBP (mm Hg): 90/50\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 11:27\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\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 normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). Regional left ventricular wall motion is\nnormal.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. The estimated pulmonary artery systolic pressure is\nnormal.\n\nPERICARDIUM: There is a trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: The patient is tachycardic (HR>100bpm). Based on AHA\nendocarditis prophylaxis recommendations, the echo findings indicate a low\nrisk (prophylaxis not recommended). Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is normal in size. 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. The estimated pulmonary artery systolic pressure is normal.\nThere is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Normal study. Preserved global and regional left ventricular\nsystolic function.\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": "Nursing/other", "chartdate": "2143-09-17 00:00:00.000", "description": "Report", "row_id": 1366425, "text": "CCU NPN admit\nO:\n\n42 yo female with hx ETOH, admitted to with abd distension, diarrhea, jaundiced. by report, has hx alchoholism x5yrs.\nw/u included diagnostic and therapeutic paracentesis x2-3. last tap was for 3L off. required FFP for elevated INR.\nliver bx showing no evidence of autoimmune disease.\nCXR showing bilat. pleural effusions. completed course of levo and zosyn for elevated WBC (12 on admit-> 23 on ). blood cx negative to date. afeb. this admit. also on prednisone which may also inc. WBC.\n\nby report: HR 1teens to 120 ST and BP 110/60. sats good on RA.\ndobhoff for meds and TF: deliver at 40cc/hr. on lactulose and was stooling freq., abd distended and c/o abd pain. stool neg. for c.diff.\n\nover past week, NA dropping to 119-120. lasix d/c'd. 1L FR.\nneuro: by report pt. has been more confused, drowsy over last 2 days.\n\n: pt. more weak, did not get OOB.. Ox3. u/o dropping last few days : 700cc and 450cc . only 100cc since 12am. pt. also with inc. confusion/lethargy overnight. sats dropping to 86% on RA. placed on FM. ABG 7.45/42/180. HCT also drop from 26-22 this AM.\n\ntransferred to CCU for closer monitoring, octreotide and neuro checks/blood transfusion.\n\nArrived to CCU at 0600. pt. lethargic, opens eyes to name, Ox2-3- mumbles, difficult to understand.\nHR 120ST. BP 108/48.\nsats 92% on face mask 6L. changed to cool mist face tent 70%, sats 97%. RR shallow 16-26.\n- foley draining 25cc conc. urine.\n- blood transfusion up at 0600. afeb.\nvenous access team called to place PIV. only able to find anticub. Resident aware of access difficulty and plan to place Central line and aline today possibly today.\nHowever, resident states need to speak with husband and for family meeting to discuss treatment options with liver team.\n\nA/P: start lactulose again via dobhoff, start octreotide sc . if Central line needed will need FFP prior. follow lytes, HCT. monitor neuro status. family meeting/support.\n" }, { "category": "Nursing/other", "chartdate": "2143-09-17 00:00:00.000", "description": "Report", "row_id": 1366426, "text": "Please see admit data, MD notes/orders. Neuro: Lethargic, wakes to verbal stimuli, carries on appropriate converstaion. PERRL. CV: ST no ectopy, sbp 1teens/40-50's. Pulm: 02 currently via 4L nc with sats in low to mid 90's. Does better with hob >45. Switches between cool mist mask and cannula. Lungs are clear, decreased at right base. GU: Bun/Cr rising, uo 5-35cc/hr concentrated amber. GI: Tube feeds resumed via doboff tube at 40cc/hr. Free water fluid restriction of 750cc maintained. Pt is able to take sow with no dysphagia noted. Mushroom catheter in place, pt had loose stool x2, recieves lactulose tid. Abd with +ascites causing some discomfort relieved with oxycodone x1. Paracentesis per previous note done on . Skin: Surfaces intact, perianal area excoriated. Had had trouble with hemmoroids per her husband. She is malnourished in appearence with 3+ pitting edema from trunk to feet. Peripheral pulses palpble, extremities warm. Endo: noon glucose 95. Soc: Has very supportive family who have met with Liver team this morning. P: Will continue full support at present. The pts brother in law is a gastroenterologist. He will be coming in from out of town this evening. The family would like to wait until he is present to discuss future plan of care, code status etc.\n" }, { "category": "Radiology", "chartdate": "2143-09-09 00:00:00.000", "description": "R UNILAT LOWER EXT VEINS RIGHT", "row_id": 842319, "text": " 3:20 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: RT LEG SWELLING, R/O DVT\n Admitting Diagnosis: CIRRHOSIS;NEW ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with alcoholic liver disease with u/l leg swelling.\n\n REASON FOR THIS EXAMINATION:\n r/o dvt\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 49 year-old woman with alcoholic liver disease and right leg\n swelling. Evaluate for DVT.\n\n scale and Doppler son of the right common femoral, superficial\n femoral, and popliteal veins were performed. Normal flow, augmentation,\n compressibility, and wave forms are demonstrated. Intraluminal thrombus is\n not identified.\n\n IMPRESSION: No evidence of DVT.\n\n" }, { "category": "Radiology", "chartdate": "2143-09-01 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 841395, "text": " 12:55 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: Please mark site for a therapeutic paracentesis.\n Admitting Diagnosis: CIRRHOSIS;NEW ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with ?alcoholic cirrhosis presents with new onset ascites\n and diffuse abdominal pain.\n REASON FOR THIS EXAMINATION:\n Please mark site for a therapeutic paracentesis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Alcoholic cirrhosis with new onset ascites and diffuse abdominal\n pain. Please mark site for therapeutic paracentesis.\n\n LIMITED ABDOMINAL ULTRASOUND: Imaging within four abdominal quadrants shows a\n mild-to-moderate amount of ascites. The largest amount of fluid is identified\n within the right lower quadrant. A mark was made for paracentesis to be\n performed by the clinical staff on the floor.\n\n\n" }, { "category": "Radiology", "chartdate": "2143-09-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 841396, "text": " 12:56 PM\n CHEST (PA & LAT) Clip # \n Reason: PNA?\n Admitting Diagnosis: CIRRHOSIS;NEW ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with acute liver failure etoh hepatitis, now with cough,\n increasing sob and rising WBC.\n REASON FOR THIS EXAMINATION:\n PNA?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 49 y/o woman with acute liver failure secondary to alcoholic\n hepatitis, now with cough and increasing shortness of breath. ? pneumonia.\n\n PA AND LATERAL CHEST: Comparison is made to prior study on . There\n has been interval placement of a tube that appears to descend through the\n esphagus into the stomach. Its tip is below the level of the end of the film\n and so the location of the tip can't be determined. As before, there are\n bilateral pleural effusions which may be slightly larger. The heart is normal\n size. There are increased interstitial markings but these have not changed\n from prior study. Retrocardiac density may be a result to the pleural\n effusion but I can't rule out an infiltrate.\n\n IMPRESSION:\n\n Retrocardiac density and bilateral pleural effusions. Acute infiltrate can't\n be excluded. The exact nature and location of a long tube that appears to\n descend the esophagus and enter the stomach can't be determined.\n\n" }, { "category": "Radiology", "chartdate": "2143-09-17 00:00:00.000", "description": "R UNILAT LOWER EXT VEINS RIGHT", "row_id": 843122, "text": " 11:03 AM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: WORSENING RT LEG EDEMA,EVALUATE FOR DVT, AGAIN\n Admitting Diagnosis: CIRRHOSIS;NEW ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with alcoholic liver disease with u/l leg swelling. One\n prior negative US but would like a repeat as one us is inadequate to exclude\n DVT.\n REASON FOR THIS EXAMINATION:\n please evaluate for DVT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Worsening right lower extremity edema.\n\n FINDINGS: Both -scale and Doppler color/waveform images of the right\n common femoral, superficial femoral, deep femoral, popliteal and calf veins\n were performed. Normal augmentation, waveform, flow and compressibility was\n identified in all the aforementioned veins. No intraluminal thrombus.\n\n IMPRESSION:\n\n No DVT of the right lower extremity.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2143-09-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 841427, "text": " 11:41 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: r/o effusions, edema, infiltrates\n Admitting Diagnosis: CIRRHOSIS;NEW ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with cirrhosis who became acutely hypoxic\n REASON FOR THIS EXAMINATION:\n r/o effusions, edema, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 49-year-old woman with cirrhosis and acute hypoxemia with\n question of effusion, edema, or infiltrate.\n\n COMPARISON: Chest x-ray PA and lateral of .\n\n TECHNIQUE: Portable AP chest x-ray.\n\n FINDINGS: The nasogastric tube passes into the stomach, as before, although\n the tip is not visualized. There is slight unchanged cardiomegaly. Since the\n prior study, there has been an interval increase in the size of the bilateral\n pleural effusions, increased bibasilar atelectasis with somewhat decreased\n lung volumes, and some upper zone vascular redistribution. The osseous\n structures and soft tissues appear unremarkable.\n\n IMPRESSION: Evidence of worsening congestive heart failure with increased\n bilateral pleural effusions and bibasilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2143-08-24 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 840436, "text": " 10:13 AM\n US ABD LIMIT, SINGLE ORGAN; DUPLEX DOPP ABD/PEL Clip # \n Reason: Please evaluate liver dopplers, gall bladder and mark for as\n Admitting Diagnosis: CIRRHOSIS;NEW ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with ?alcoholic cirrhosis presents with new onset ascites.\n REASON FOR THIS EXAMINATION:\n Please evaluate liver dopplers, gall bladder and mark for ascites tap.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old woman with alcoholic cirrhosis. Now presenting with\n new onset of ascites.\n\n COMPARISONS: No comparisons are available.\n\n ULTRASOUND of the LIVER: There are no focal lesions in the liver. All the\n vascular branches in the liver are patent\n including the hepatic veins, hepatic arteries, and main portal vein branches.\n\n The common bile duct is normal, and measures 3 mm. The gallbladder was not\n identified in this study, probably due to technical problems.\n\n There is a small-to-moderate amount of free fluid in the abdomen.\n\n A spot for paracentesis was marked in the left lower quadrant.\n\n IMPRESSION\n\n 1. Small amount of ascitis.\n 2. Spot for paracentesis was marked in the left lower quadrant.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2143-08-29 00:00:00.000", "description": "2ND ORDER OR> VENOUS SYSTEM", "row_id": 841027, "text": " 7:40 AM\n TRANSJUG LIVER BX Clip # \n Reason: Trans jugular biopsy of the liver please. Thank you.\n Admitting Diagnosis: CIRRHOSIS;NEW ASCITES\n Contrast: OPTIRAY Amt: 15\n ********************************* CPT Codes ********************************\n * 2ND ORDER OR> VENOUS SYSTEM TRANSCATHETER BIOPSY *\n * -51 MULTI-PROCEDURE SAME DAY HEPATIC VENOGRAM WITH PRESSURE *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATHETER BIOPSY *\n * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF *\n * INT/SHTH EP FXD CURVE NOT PEEL AW C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with alcoholic cirrhosis complicated by positive autoimmune\n titers. Pt with ascites and encephalopathy.\n REASON FOR THIS EXAMINATION:\n Trans jugular biopsy of the liver please. Thank you.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49 year old female with alcoholic cirrhosis complicated by\n autoimmune hepatitis. Please perform transjugular liver biopsy.\n\n PROCEDURE/FINDINGS: The procedure was performed by Drs. ,\n , and . Dr. , the staff radiologist, was\n present and supervising throughout. After the risks and benefits of the\n procedure were discussed with the patient and informed consent was obtained,\n the patient was placed supine on the angiography table. Her right neck was\n prepped and draped in the standard sterile fashion. The skin and subcutaneous\n tissues in the right neck were anesthetized with 10 cc of 1% lidocaine. Using\n ultrasound guidance, the right internal jugular vein was accessed using a 21\n gauge micropuncture needle. A .018 guidewire was advanced through the access\n needle into the superior vena cava under fluoroscopy. The skin entry site was\n incised with a #11 blade scalpel. The access needle was exchanged for a 5 FR\n micropuncture sheath with inner dilator. The inner dilator and guidewire were\n removed. A .035 wire was advanced through the micropuncture sheath into\n the inferior vena cava. The micropuncture sheath was removed. The tract was\n sequentially dilated with #7 FR and #10 FR dilators. A 9 FR bright tip sheath\n with inner dilator was then advanced over the wire into the inferior\n vena cava. The inner dilator was removed and the angiographic sheath was\n assembled to a continuous side arm flush. A 5 FR C2 Cobra catheter was then\n advanced over the wire and with this combination, the right hepatic vein\n was successfully entered. The guidewire was removed and a hepatic venogram\n was performed via hand injection of nonionic contrast. This demonstrated\n patency of the right hepatic vein along the inferior vena cava. The catheter\n was then successfully wedged in a peripheral branch of the right hepatic vein.\n The wedged right hepatic venous pressure was then measured as being 40 mm of\n Hg. The catheter was then withdrawn into the central portion of the vein\n where the free right hepatic venous pressure was measured as being 23 mm of\n Hg. The hepatic venous pressure gradient was 17 mm of Hg. The .035 \n wire was then advanced through the 5 FR C2 Cobra catheter into a peripheral\n branch of the right hepatic vein. The Cobra catheter was removed. A 7 FR\n sheath with metallic stiffener was then advanced through the 9 FR\n (Over)\n\n 7:40 AM\n TRANSJUG LIVER BX Clip # \n Reason: Trans jugular biopsy of the liver please. Thank you.\n Admitting Diagnosis: CIRRHOSIS;NEW ASCITES\n Contrast: OPTIRAY Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n sheath into the right hepatic vein. The sheath was rotated 90 degrees\n anteriorly and 4 passes were made with the Cook biopsy system in order to\n obtain 1 tissue sample for pathologic interpretation. The specimen was\n immediately sent to Pathology. Following this, the biopsy system was removed,\n followed by the 7 FR biopsy sheath with metallic stiffener. The 9 FR\n angiogrraphic sheath was then removed and manual pressure was held until\n hemostasis was achieved.\n\n COMPLICATIONS: There were no immediate post procedural complications.\n\n MEDICATIONS: 1% lidocaine. 0.5 mg of Versed were administered by the nursing\n staff with continuous monitoring of vital signs.\n\n CONTRAST: 25 cc of nonionic contrast.\n\n IMPRESSION: Successful transjugular liver biopsy performed via a branch of\n the right hepatic vein. Portal pressures were obtained with a hepatic venous\n pressure gradient of 17 mm of Hg, consistent with portal hypertension.\n\n" }, { "category": "Radiology", "chartdate": "2143-08-31 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 841310, "text": " 11:01 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: pt has persistantly high bili and elevated wbc count with di\n Admitting Diagnosis: CIRRHOSIS;NEW ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with ?alcoholic cirrhosis presents with new onset ascites.\n Prior US did not image gall bladder. Pt has continued abdominal pain.\n REASON FOR THIS EXAMINATION:\n pt has persistantly high bili and elevated wbc count with diffuse abdominal\n pain\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old woman with alcoholic cirrhosis and new onset ascites.\n Persistent abdominal pain, elevated white count, and elevated bilirubin.\n\n FINDINGS: Limited right upper quadrant ultrasound demonstrates a contracted\n gallbladder without intra- or extrahepatic ductal dilatation. The common duct\n measures 4 mm at the level of the hepatic artery. Real-time imaging\n demonstrates a markedly enlarged liver and a moderate-to-large amount of\n ascites.\n\n IMPRESSION: Contracted gallbladder. No evidence of cholecystitis or\n obstruction.\n\n\n" }, { "category": "Radiology", "chartdate": "2143-08-27 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 840807, "text": "\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: Please place post pyloric feeding tube in pt with alcoholic\n Admitting Diagnosis: CIRRHOSIS;NEW ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with alcoholic cirrhosis, poor PO intake and N/v.\n REASON FOR THIS EXAMINATION:\n Please place post pyloric feeding tube in pt with alcoholic cirhhosis, poor PO\n and n/v\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49 y/o woman with alcoholic cirrhosis, nausea, vomiting, and poor\n oral intake. She presents for placement for a post pyloric feeding tube.\n COMPARISON: None.\n\n TECHNIQUE: Placement of post pyloric feeding tube.\n\n FINDINGS: The feeding tube was placed beyond the pylorus, in the immediate\n proximal duodenum. From this point, it was not possible to advance the tube\n further into the jejunum with several attempts.\n\n IMPRESSION:\n\n Placement of feeding tube in the immediate proximal duodenum, shortly beyond\n the pylorus. Site of tube placement was discussed with Dr. shortly\n following the procedure.\n\n" }, { "category": "Radiology", "chartdate": "2143-09-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 842926, "text": " 2:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia v. effusion\n Admitting Diagnosis: CIRRHOSIS;NEW ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with cirrhosis with SOB, rll decreased breath sounds\n REASON FOR THIS EXAMINATION:\n pneumonia v. effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 49 y/o with cirrhosis and shortness of breath and decreased breath\n sounds, evaluate for pneumonia and/or effusion.\n\n The study shows an NG tube in place, tip is not included on the film. There is\n bilateral pulmonary vascular congestion, bilateral pleural effusion and\n compression atelectasis of the lower lobes. cardiomegaly is noted.\n\n IMPRESSION: pleural effusions, associated bilateral pulmonary vascular\n congestion and compression atelectasis of lower lobes are noted.\n\n" }, { "category": "Radiology", "chartdate": "2143-09-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 843204, "text": " 7:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls assess interval change. Worsening hypoxemia, bandemia,\n Admitting Diagnosis: CIRRHOSIS;NEW ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with EtOH cirrhosis with SOB and increased work of\n breathing.\n REASON FOR THIS EXAMINATION:\n pls assess interval change. Worsening hypoxemia, bandemia, leukocytosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49 year old woman with alcoholic cirrhosis, with increased work\n of breathing and shortness of breath. Worsening hypoxema, bandemia,\n leukocytosis. Assessment for interval change.\n\n COMPARISON: Supine AP portable chest x-ray from .\n\n TECHNIQUE: Semi-upright AP portable chest x-ray.\n\n FINDINGS: The position of the feeding tube is unchanged. Gaseous distention\n of the stomach persists with some lateral displacement toward the left. The\n tip of the catheter is not visualized on this film. The cardiac and\n mediastinal contours are stable. There has been no overall significant change\n in the appearance of bibasilar areas of atelectasis or consolidation, with\n adjacent pleural effusion or in the appearance of prominent bilateral\n interstitial markings. There is no pneumothorax.\n\n IMPRESSION:\n 1) Persistent bibasilar atelectasis or consolidation with pleural effusions,\n but no significant interval change.\n\n 2) Continued gaseous distention.\n\n ADDENDUM: The findings were discussed with referring MD at 1:45 p.m. on\n .\n\n" }, { "category": "Radiology", "chartdate": "2143-09-06 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 842040, "text": " 1:38 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: ALCOHOLIC CIHOSSIS, ASCITES, MARK FOR THERAPEUTIC PARACENTESIS\n Admitting Diagnosis: CIRRHOSIS;NEW ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with ?alcoholic cirrhosis presents with tense ascites and\n diffuse abdominal pain.\n REASON FOR THIS EXAMINATION:\n Please mark spot for therapeutic paracentesis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain and ascites.\n\n COMPARISON: None.\n\n A survey of the abdomen reveals moderate ascites. There is no large\n persistent pocket that can be marked for future paracentesis.\n\n IMPRESSION: Moderate ascites.\n\n" }, { "category": "Radiology", "chartdate": "2143-09-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 843070, "text": " 2:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate volume status and for pulmonary infiltrate.\n Admitting Diagnosis: CIRRHOSIS;NEW ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with cirrhosis with SOB and increased work of breathing.\n\n REASON FOR THIS EXAMINATION:\n Evaluate volume status and for pulmonary infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49 year old woman with cirrhosis, increased work of breathing and\n shortness of breath. Evaluation for volume status or pulmonary infiltrate.\n\n COMPARISON: Supine AP portable chest x-ray of .\n\n TECHNIQUE: Supine AP portable chest x-ray.\n\n FINDINGS: The nasogastric tube remains in unchanged position. The lung\n volumes are low. There is cardiomegaly with left ventricular prominence, with\n a slight interval increase in the heart size. The mediastinal and hilar\n contours are stable. There are increased diffuse bilateral interstitial\n markings, consistent with pulmonary edema. There are also worsening bibasilar\n areas of atelectasis or consolidation with adjacent pleural effusions. There\n is no evidence of pneumothorax. The stomach shows gaseous distention on this\n film.\n\n IMPRESSION: Evidence of worsening congestive heart failure. Worsening\n bibasilar atelectasis or consolidation with adjacent pleural effusion.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2143-09-02 00:00:00.000", "description": "CHEST (LAT DECUB ONLY)", "row_id": 841533, "text": " 4:56 PM\n CHEST (LAT DECUB ONLY) Clip # \n Reason: Please assess if fluid is layering and if there is an infilt\n Admitting Diagnosis: CIRRHOSIS;NEW ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with acute liver failure etoh hepatitis, now with\n cough, increasing sob and rising WBC.\n REASON FOR THIS EXAMINATION:\n Please assess if fluid is layering and if there is an infiltrate present.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST BILATERAL DECUBITUS VIEWS:\n\n There is free layering of the right and left pleural effusion. There is\n atelectasis in the left lower lobe and at the right lung base. The NG tube is\n not completely included on this film but follows a somewhat unusual course\n below the diaphragm and if clinically indicated, could be better evaluated\n with an abdominal film or contrast injection.\n\n IMPRESSION: Free layering of bilateral pleural effusions. Unusual course of NG\n tube below diaphragm as described.\n\n" }, { "category": "Nursing/other", "chartdate": "2143-09-18 00:00:00.000", "description": "Report", "row_id": 1366429, "text": "MICU NURSING PROGRESS NOTE 7A-7P\nFamily meeting today with MICU and liver team. Pts family all in attendance. Decision made to make pt . Pt lethargic, able to make needs known. Continues to say she \"Wants to go home\". MSO4 gtt started @ 1 mg/hr after MSO4 boluses 1 mg x 2. Foley d/c'd per pt request (pt is anuric). All meds, labs and tube feeds stopped. NC 6L applied for pt comfort. Family at bedside. Turned and repositioned for comfort. Social work and case management have talked to family and offered support. Titrate MSO4 to pt comfort.\n" }, { "category": "Nursing/other", "chartdate": "2143-09-19 00:00:00.000", "description": "Report", "row_id": 1366430, "text": "NURSING MICU NOTE 7P-7A\n\nPT DIED AT 0145 WITH FAMILY AT BEDSIDE. DR. TO PRONOUNCE.\nPT RECIEVED ON . MSO4 GTT AT 1.5MG/HR. GTT INCREASED FOR COMFORT. ONE TIME DOSE ATIVAN GIVEN AT 0115, 2MG IV FOR COMFORT. HUSBAND, CHILDREN AND SIBLINGS IN ROOM. PT'S CLOTHES AND PERSON EFFECT GIVEN TO HUSBAND. PT HAS A PLATUM DIAMOND AND EMERALD RING ON LEFT RING FINGER.\n" }, { "category": "Nursing/other", "chartdate": "2143-09-17 00:00:00.000", "description": "Report", "row_id": 1366427, "text": "MICUB 1800-1900 RN NOTE\n\nRECIEVED PT transfer FROM CCU @ 1800 (MICU Green team)\n 42 yo female ESLD\nAwake lethargic Oriented X3 follows commands, husband present. Color jaundice. no apparent distress. HR 110-130 ST no ectopy NIBP 110-124 MAPS >65. IV access 2 Peripheral. Dopkoff TF L nares. TF probal 40cc/hr @ Goal. Abd firm distended/Ascites, Foley cath icteric urine 20cc/hr Recieved Lasix 80mg @ 1850. Plan Start broad spectrum ABx for WBC 27.5. Blood cult to be drawn. requested Popsicle to well\n" }, { "category": "Radiology", "chartdate": "2143-08-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 840576, "text": " 6:49 PM\n CHEST (PA & LAT) Clip # \n Reason: consolidation\n Admitting Diagnosis: CIRRHOSIS;NEW ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with acute liver failure etoh hepatitis, now with cough,\n increasing sob\n REASON FOR THIS EXAMINATION:\n consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute liver failure, now with cough, increasing shortness of\n breath.\n\n CHEST X-RAY, PA AND LATERAL: There are no prior films for comparison. The\n cardiomediastinal silhouette is within normal limits. There are bilateral\n small pleural effusions. Opacity is noted in the basilar regions adjacent to\n the effusions. There is no evidence of congestive heart failure. The osseous\n structures are unremarkable.\n\n IMPRESSION:\n\n 1) Small bilateral pleural effusions.\n 2) Basilar opacities, possibly representing atelectasis. Aspiration and\n pneumonia are in the radiological differential diagnosis.\n\n" }, { "category": "Nursing/other", "chartdate": "2143-09-18 00:00:00.000", "description": "Report", "row_id": 1366428, "text": "NPN-MICU\nMrs. cont to slowly deteriorate.\nNeuro:pt now waxing and with her mental status. She was much more lethargic later in the evening, saying she could not sleep and wanting her ambien. She got .5mg po ativan and slept some. She is now more confused and just wants to go home. She has no idea how much care she needs.Family meeting for today.\nResp:Pt has required much more Fio2 as the night has progressed. She was switched to CN d/t dry nares but than she got more confused and would take her mask off and desat to 86%. She untimately is now on 6L NP with 98%high flow neb.Her sats have slowly dropped down over night and she looks tired with accessories muscle use. Ho eval and than we tried some more lasix, reposition and some C &DB. We had to restrain her hands as she was getting more confused and taking the mask off. She has not rsp to the lasix and her sats have increased to 96%, but she is still confused and desats(86%) if mask is off. Her lungs are decreased at bases and her belly may also be in the way.\nGU: as noted above, lasix given but still min rsp. Renal fucntion cont to deteriorate with u/o of 20cc/hr despite all efforts.\nGI: NPO, mild c/o nausea, relief with compazine.She is still rsp to lactolose but she is confused d/t her lower O2 sat.\nHeme:hct still 25,sm amt of blood per rectum.\nID: pt hypothermic, IV and po antivbiotics cont\nSkin:peri area still red, medicated aloe vista applied\nA/P:Will cont to minimize activity,wean Fio2 as able, encourage C&DB, note renal function and results of family meeting.\n" }, { "category": "ECG", "chartdate": "2143-09-17 00:00:00.000", "description": "Report", "row_id": 182761, "text": "Sinus tachycardia. Otherwise, probably normal ECG. Since the previous tracing\nof no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2143-09-17 00:00:00.000", "description": "Report", "row_id": 182998, "text": "Sinus tachycardia. Otherwise, normal ECG. Since the previous tracing\nof T wave amplitude has improved.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2143-09-02 00:00:00.000", "description": "Report", "row_id": 182999, "text": "Sinus tachycardia. Low limb lead voltage is non-specific. Modest non-specific\ninferolateral ST-T wave changes. Since the previous tracing of sinus\ntachycardia rate is faster and modest ST-T wave changes are seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2143-09-01 00:00:00.000", "description": "Report", "row_id": 183000, "text": "Sinus tachycardia. Low limb lead QRS voltage is non-specific and probably\nwithin normal limits. Since the previous tracing of sinus tachycardia\nis present.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2143-08-23 00:00:00.000", "description": "Report", "row_id": 183001, "text": "Normal sinus rhythm\n\n" } ]

[ { "category": "Radiology", "chartdate": "2114-12-25 00:00:00.000", "description": "R UNILAT LOWER EXT VEINS RIGHT", "row_id": 945200, "text": " 9:09 AM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: EVAL FOR DVT\n Admitting Diagnosis: NON HEALING ULCER RIGHT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with rt. leg pain s/pl-r fem/fem\n\n REASON FOR THIS EXAMINATION:\n ? dvt\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Venous ultrasound of right lower limb.\n\n INDICATION: Query DVT.\n\n FINDINGS: The right common femoral vein, right saphenofemoral junction, right\n superficial femoral vein, and right popliteal veins are all normal to\n compression and augmentation. There is no evidence of any thrombus.\n\n IMPRESSION: No evidence of right lower extremity DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2114-12-19 00:00:00.000", "description": "UNILAT LOWER EXT VEINS", "row_id": 944409, "text": " 8:10 AM\n UNILAT LOWER EXT VEINS Clip # \n Reason: ? DVT\n Admitting Diagnosis: NON HEALING ULCER RIGHT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with rt. leg pain\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right lower extremity venous Doppler ultrasound.\n\n CLINICAL HISTORY: 61-year-old woman with right leg pain post scoliosis\n surgery. Rule out DVT.\n\n FINDINGS: Color doppler and duplex ultrasound interrogation of the right\n lower extremity venous system was performed. The right common femoral,\n superficial femoral and popliteal veins are widely patent and demonstrate\n normal compressibility, augmentation and venous waveforms. The right peroneal\n and posterior tibial veins are patent. The left common femoral vein is also\n patent.\n\n Note is made of edema of the visualized subcutaneous tissues.\n\n IMPRESSION: No evidence of right lower extremity deep venous thrombosis.\n\n" }, { "category": "ECG", "chartdate": "2114-12-18 00:00:00.000", "description": "Report", "row_id": 202388, "text": "Sinus rhythm\nProlonged Q-Tc interval - clinical correlation is suggested\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2114-12-17 00:00:00.000", "description": "Report", "row_id": 202389, "text": "Sinus rhythm\nProlonged Q-Tc interval - clinical correlation is suggested\nSince previous tracing of , sinus tachycardia absent and prolonged Q-Tc\ninterval seen\n\n" }, { "category": "Radiology", "chartdate": "2114-12-19 00:00:00.000", "description": "MRA ABDOMEN W&W/O CONTRAST", "row_id": 944503, "text": " 7:02 PM\n MRA ABDOMEN W&W/O CONTRAST Clip # \n Reason: Need MRV (not MRA).Please eval inferior vena cava and iliac\n Admitting Diagnosis: NON HEALING ULCER RIGHT LEG\n Contrast: MAGNEVIST Amt: 32\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with blood clot in R EIA w/p spinal surgery.\n REASON FOR THIS EXAMINATION:\n Need MRV (not MRA).Please eval inferior vena cava and iliac veins for venous\n injury or thrombus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Known clot in right external iliac artery after spinal surgery.\n Assess for venous thrombosis.\n\n TECHNIQUE: Multiplanar T1 and T2-weighted imaging of the abdomen and pelvis\n was performed at 1.5 Tesla, including dynamic 3D images acquired before,\n during, and after the uneventful intravenous administration of 0.2 mmol/kg\n gadolinium-DTPA. Multiplanar 2D and 3D reformations and subtraction sequences\n were made and analyzed apparently on an adjacent workstation.\n\n COMPARISON: Reference is made to a right lower extremity venous ultrasound\n from earlier the same day.\n\n ABDOMINAL/PELVIC MRV: The IVC, common iliac veins, and internal/external\n iliac veins are widely patent along their course. There is complete\n thrombosis of the right external iliac artery, which is likely reconstituted\n via pelvic and inferior epigastric collateral vessels. This is incompletely\n assessed by this study, which was tailored to assess the venous structures.\n Atherosclerotic plaque involves the abdominal aorta. The left external iliac\n artery appears widely patent.\n\n There are extensive changes in the region of the lumbar spine from prior\n spinal surgery. Vague areas of intermediate signal intensity on both T1 and\n T2-weighted images are seen in the right retroperitoneum which displace the\n kidney anteriorly. This is likely some degree of retroperitoneal hematoma.\n Appearance is similar to a prior lumbar spine CT from . The\n visualized portions of the liver, gallbladder, spleen, kidneys, and bowel\n loops were unremarkable. No intraabdominal or pelvic fluid collection is\n identified.\n\n Multiplanar 2D and 3D reformations and subtraction sequences were essential in\n evaluating vascular structures.\n\n IMPRESSION:\n\n 1. IVC, and bilateral common iliac, internal iliac, and external iliac veins\n are patent.\n\n 2. Complete thrombosis of right external iliac artery, which is likely\n reconstituted via pelvic and inferior epigastric collateral vessels.\n\n (Over)\n\n 7:02 PM\n MRA ABDOMEN W&W/O CONTRAST Clip # \n Reason: Need MRV (not MRA).Please eval inferior vena cava and iliac\n Admitting Diagnosis: NON HEALING ULCER RIGHT LEG\n Contrast: MAGNEVIST Amt: 32\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2114-12-17 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 944195, "text": " 5:35 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: NON HEALING ULCER RIGHT LEG\n Admitting Diagnosis: NON HEALING ULCER RIGHT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman s/p multiple spine surgeries now w/ ischemic R foot\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preop before foot surgery.\n\n PA AND LATERAL CHEST: The heart is normal in size. Mediastinal and hilar\n contours are normal. The lungs are clear. There are no consolidations,\n pleural effusions or pneumothoraces. Spinal fusion rods are again seen.\n There is diffuse demineralization of the thoracic spine. Fusion hardware is\n also seen in the cervical spine.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2139-06-21 00:00:00.000", "description": "Report", "row_id": 1558922, "text": "FOCUSED NURSING NOZTE\n58 y.o. female w/ long-standing HX Metastatic Breast Ca s/p whole brain radiation therapy and multiple chemo regimens admitted to SICU from PACU for removal of infected ommaya resorvoir and placement of external ventriculostomy drain.\n\nNEURO: Pt w/ flat affect, A/O x 3, moves all extremities well, PEERL 3-4mm, brisk, no pronator drifts, denies H/A, n/v, change in vision.\nVentriculostomy drain leveled 15cm at tragus, dressing C/D/I. Draining 2-8cc/hr clear fluid. S/P MRI L-spine, tolerated well.\n\nRESPIRATORY: No resp distress, lungs CTA, diminished bases. SPO2 >93% on RA.\n\nCARDIAC: NSR to ST 95-114, increased ST during MRI procedure secondary to mild anxiety. SBP left arm 78-95, MD aware of SBP <80 overnight- >100ml/hr u.o. and no changes in LOC. NINV BP measured left thigh 105-115/45-50, MD aware. Potassium 3.3, repleted with 40meq IV KCL. No edema. Maintenance fluid NS w/ 20meq KCL at 100ml/hr.\n\nID: Tmax 99.2, no changes in LOC, no HA or neck stiffness. Urine clear pale yellow to colorless. Vancomycin/Ceftaz given as ordered.\n\nSKIN INTEGRITY/COMFORT: Duoderm intact to coccyx for previously documented stage II ulcer. Stage I erythema posterior skull and upper back area secondary to XRT, aloe vesta applied to areas. Turn and repositioned q2-3hr. Pt denies pain, pregabalin administered per usual pain regimen for neuropathies.\n\nPLAN: Monitor neuro status q2hr, ventriculosotmy drain 15cm, level of tragus, monitor hourly outputs. Monitor sx infection, f/u cultures, pancx for T>101.6. Further plan of care per neurosurgery team. diet, monitor nutrition intake, electrolytes, replete prn.\nAggressive skin care, ET RN consult pending. Emotional support/education to pt and family ongoing.\n" }, { "category": "Nursing/other", "chartdate": "2139-06-23 00:00:00.000", "description": "Report", "row_id": 1558926, "text": "neuro Alert and oriented. more lethargic this am but follows commands.\ndenies pain. icp=3 vent drain output 2cc for shift/ clear.\ncv/resp nsr. hypotension noted this am HO aware. 500ccns ordered and infusing. lungs clear. on room air.\ngi/gu tol pos but no intake over night. foley w good uop. no stools.\nendo reg sliding scale insulin for fingerstick glucoses.\ninteg skin warm and dry/pale. coccyx dsg intact.\nplan Continue plan of care. Fluid challenge for low bp.\nmonitor mental status/neuro signs.\n" }, { "category": "Nursing/other", "chartdate": "2139-06-23 00:00:00.000", "description": "Report", "row_id": 1558927, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT WITH 2 EPISODES OF DIFFICULT TO AROUSE. TEAM AWARE AND IN TO EVAL. PT FINALLY AWOKE AND THEN A+OX3. PERRL. MAE, LIFTS/HOLDS. FOLLOWS COMMANDS. TONGUE MIDLINE. SMILE SYMETRICAL. ICP 3-20. VENT DRAIN IN PLACE, OPEN WITH SCANT CLEAR DRG. HEAD INCISION WITH SUTURES, C/D/I, OTA.\n\nCV-HR 80-100'S, SINUS. SBP DOWN TO 60'S. TEAM AWARE. IVF BOLUSES GIVEN AND SBP UP TO 80'S. PT AND ASYMPTOMATIC WITH SBP 80'S. SKIN PALE, W+D. +PP. PBOOTS ON. DENIES CARDIAC COMPLAINTS.\n\nRESP-O2 SAT 98% ON RA. LS CTA. NARD NOTED.\n\nGI-ABD SOFT, NT/ND. +BS. TOL PO'S.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS LIGHT YELLOW URINE.\n\nCOMFORT-DENIES PAIN.\n\nENDO-SSRI.\n\nID-AFEB. ON ABX.\n\nP-CON'T WITH CURRENT PLAN. MONITOR FOR CHANGES. NEURO CHECKS. TX TO SDU WHEN BED AVAIL.\n" }, { "category": "Nursing/other", "chartdate": "2139-06-21 00:00:00.000", "description": "Report", "row_id": 1558923, "text": "Neuro:Pt alert and oriented X3, napping most of day. MAE and able to reposition self in bed. Pupils 3mm = & brisk. Vent drain remains at 15cm above the tragus, draining minimal amount of clear drg.\n\nCV: afebrile, HR 100's sinus tach with no ectopy. SBP 100-110's. extremities warm with +PP.\n\nRESP: lungs clear to dim at bases. O2 sats >95% on room air.\n\nGI: tol diet with no difficulty. No stool today.\n\nGU: Foley patent, auto diuresing.\n\nENDO: blood sugars elevated, Requiring coverage per RISS.\n\nPLAN: Monitor Vent drain and drg. Monitor Neuro status.\n" }, { "category": "Nursing/other", "chartdate": "2139-06-22 00:00:00.000", "description": "Report", "row_id": 1558924, "text": "FOCUSED NURSING NOTE\nPLEASE SEE CAREVUE FLOWSHEET FOR FURTHER DETAILS\n\nNEURO: GCS 15, PEERL 3mm, brisk- no changes in neuro status. Ventriculostomy drain intact to 15cm H2o leveled at tragus, draining total 2cc clear drainage. No sz activity, no headaches. Decadron taper as ordered.\n\nID: Afebrile. Vanco trough 8.0, Vanco 1GM administered. Ceftaz as ordered. Urine clear/yellow.\n\nENDOCRINE: Glucose 317, ?gatorade, covered with RISS- repeat glucose this am 110.\n\nCV/RESP: Stable, no acute issues.\n\nSKIN INTEGRITY/COMFORT: Stage III decubitus, coccyx, wound base yellow with 5-10% soft eschar- draining serous, pink perimeter, additional decubitus in same region, left buttock, stage II, red wound base. Cleansed sites with wound cleanser, vigilon drsg by . Recc change and re-eval in 24hrs. Pt denies pain, n/v.\n\nPLAN: Monitor neuro status and ventriculostomy drain. Monitor for sx infection. Neuro-oncology plan per team. Check with team re: Vancomycin dose. Aggressive skin care. diet as tolerated. Emotional support and education to pt and family ongoing.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-06-22 00:00:00.000", "description": "Report", "row_id": 1558925, "text": "npn 0700-1900;\nuneventful day awaiting bed on stepdown unit.\n\nneuro; aoox3 mae to command .interactive at times affect flat but is interested in things going on around her.perla 3mm moves upper arms with good strentgh moving lower limbs on bed. husband visited pt writing checks and doing bills. pt denies pain.\n\nresp; lungs clear diminished at bases encouraged to c/db sats 95-06% on ra. no cough to speak.rr 16-20.\n\ncvs; tmax 98.7 po sinus tack 94-110 with occas burst to 130 no ectopy noted. bp 94-35-110/70. team aware.\n\ngu; passing good amounts of clear urine via foley.spontaneously.\n\ngi; belly soft pos bs taking good diet. bs covered on increased riss.\n\nskin; seen by skincare nurse decub on coccyx 3''x3\"with necrotic non viable tissue on cooccyx with smalller on lower on lt buttock 3\"x1\".recommended protecting surroundingtisse wwith no sting barrier wipes,then duoderm gel to decub tisse with allevyn to cover, recommend chnging every 48 hours instead of 72 because of degree of drainage. they also recommend removing allevyn with adhesive removal pads.\nid vanco level 8pm vanco increased to 1250 mgs i.v. q12 level to be drawn befor 3rd dose.\n\nsoc; husband in for few hours updated wtih pts current condition and plan of care\n\n a/p stable day continue with neuro obs q2,\nmonitor ventriculostomy output offer emotional support to pt and family\nfollowup lytes and pending cultures\n\n\n\n" }, { "category": "ECG", "chartdate": "2139-06-19 00:00:00.000", "description": "Report", "row_id": 280102, "text": "Sinus rhythm. Borderline low limb lead voltage. Compared to the previous\ntracing of the anterolateral ST-T wave abnormalities have improved.\nOtherwise, no diagnostic interim change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2143-05-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792354, "text": " 8:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check tube placement\n Admitting Diagnosis: BRADYCARDIA SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with CAD s/p CABG and cath/stent in past, recent admissions\n for chf exacerbation and MI's, now with complete heart blocks, indwelling\n subclavian lines bilat, hypotensive s/p intubation\n REASON FOR THIS EXAMINATION:\n check tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old female status post intubation for respiratory\n distress.\n\n Comparison is made to the prior exam of the same day at 7:24 hours.\n\n FINDINGS: A newly placed ET tube is seen in good position a few centimeters\n above the carina. A newly inserted NG tube is seen with its tip in the distal\n stomach. A right internal jugular central venous line and catheter sheath is\n stable in position with its tip in the right atrium. No pneumothorax seen. The\n heart is enlarged but stable in size. There is improved aeration of the lungs\n compared with prior exam. Perihilar vascular haze remains with small\n effusions, but with improvement.\n\n IMPRESSION:\n 1. Satisfactory placement of ET tube and NG tube.\n 2. Overall improved aeration of the lungs, and improved appearance of mild\n cardiac failure.\n\n" }, { "category": "Radiology", "chartdate": "2143-05-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792434, "text": " 6:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chemical pneumonitis\n Admitting Diagnosis: BRADYCARDIA SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with CAD s/p CABG and cath/stent in past, recent\n admissions for chf exacerbation and MI's, now with complete heart blocks,\n indwelling subclavian lines bilat, hypotensive s/p intubation. Concern for\n asp. pna.\n REASON FOR THIS EXAMINATION:\n r/o chemical pneumonitis\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, , 1854\n\n CLINICAL INDICATION: Shortness of breath and fever.\n\n Comparison is made to a study of 10 hours previously.\n\n FINDINGS: The position of the endotracheal tube is unchanged, approximately 3\n cm above the carina. There is a right IJ dual-lumen central venous catheter\n with the tip in the right atrium. There is an NG tube within the distal\n stomach. There is a defibrillator pad on the patient's right chest. The\n heart size is unchanged. There is no redistribution of the pulmonary\n vasculature. There has been slight interval decrease in a retrocardiac\n opacity. There are no effusions and there is no pneumothorax.\n\n IMPRESSION: Mild interval decrease in a retrocardiac opacity. No CHF. The\n tubes and lines are unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2143-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792846, "text": " 8:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema\n Admitting Diagnosis: BRADYCARDIA SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with CAD s/p CABG and cath/stent in past, recent\n admissions for chf exacerbation and MI's, now with complete heart\n blocks, indwelling subclavian lines bilat, hypotensive s/p intubation.\n Concern for asp. pna.\n REASON FOR THIS EXAMINATION:\n eval for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypotension. Assess for aspiration.\n\n PORTABLE AP CHEST, 1 VIEW: Comparison . There is a right double lumen\n catheter with tip in the right atrium. There is no pneumothorax. The patient\n is s/p sternotomy. The cardiac silhouette is enlarged. There are diffuse\n bilateral multifocal alveolar opacities. There is blunting of the lateral CP\n angles bilaterally. Appearances are consistent with worsening CHF.\n\n IMPRESSION: Probable pulmonary edema with small bilateral effusions.\n Underlying consolidation at the bases cannot be excluded. Follow up after\n diuresis would be helpful for further evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2143-05-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792757, "text": " 6:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF\n Admitting Diagnosis: BRADYCARDIA SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with CAD s/p CABG and cath/stent in past, recent\n admissions for chf exacerbation and MI's, now with complete heart blocks,\n indwelling subclavian lines bilat, hypotensive s/p intubation. Concern\n for asp. pna.\n REASON FOR THIS EXAMINATION:\n CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypotension. Assess for aspiration.\n\n AP CHEST, ONE VIEW: Comparison . There is a right central line with tip\n in the right atrium. The patient is status post sternotomy. There is no\n pneumothorax.\n\n The cardiac silhouette is enlarged. There is vascular indistinctness with\n perihilar haze. In addition, there is increased opacity in both lower lobes.\n There is blunting of the lateral CP angles bilaterally.\n\n IMPRESSION:\n 1. Cardiomegaly with CHF and small bilateral effusions, with progression of\n CHF since the prior exam.\n 2. Increased density at the bases. This could represent atelectasis, however\n underlying consolidation cannot be excluded. Followup films after diuresis\n would be helpful for further evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2143-05-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792572, "text": " 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA?, CHF progress.\n Admitting Diagnosis: BRADYCARDIA SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with CAD s/p CABG and cath/stent in past, recent\n admissions for chf exacerbation and MI's, now with complete heart blocks,\n indwelling subclavian lines bilat, hypotensive s/p intubation. Concern for\n asp. pna.\n REASON FOR THIS EXAMINATION:\n PNA?, CHF progress.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CHF, exacerbation and MI's. Concern for aspiration\n pneumonia.\n\n Comparison is made to the prior examination of .\n\n FINDINGS: There has been an interval removal of an ET tube and NG tube. A\n right internal jugular central venous catheter sheath is unchanged in\n position. No pneumothorax. The cardiomediastinal borders are unchanged.\n There are low lung volumes with prominence of the central pulmonary\n vasculature. There are minimal increased opacity seen at the bases and\n probale small effusions, unchanged. There has been an interval improvement of\n diffuse haziness of the right lung field.\n\n IMPRESSION: No new focal opacity to suggest aspiration pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2143-05-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792663, "text": " 7:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema, pna\n Admitting Diagnosis: BRADYCARDIA SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with CAD s/p CABG and cath/stent in past, recent\n admissions for chf exacerbation and MI's, now with complete heart blocks,\n indwelling subclavian lines bilat, hypotensive s/p intubation. Concern for\n asp. pna.\n REASON FOR THIS EXAMINATION:\n eval for pulm edema, pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate pulmonary edema and pneumonia in patient with severe\n coronary disease and recent admissions for CHF currently with complete heart\n block.\n\n TECHNIQUE: A single portable AP view of the chest was compared with the study\n from yesterday.\n\n FINDINGS: Right-sided dual lumen central venous catheter terminates in the\n SVC/RA junction, or possibly slightly into the RA. The cardiac silhouette\n remains enlarged. This is a retrocardiac opacity with air bronchogram. Small\n layering right-sided effusion remains present. There is calcification of the\n aorta. There is some alveolar opacity, essentially unchanged.\n\n IMPRESSION: Cardiomegaly and mild failure unchanged. Right-sided pleural\n effusion. No evidence of pneumonia at this time.\n\n" }, { "category": "Radiology", "chartdate": "2143-05-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792342, "text": " 7:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF progress, any infiltrate?\n Admitting Diagnosis: BRADYCARDIA SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with CAD s/p CABG and cath/stent in past, recent admissions\n for chf exacerbation and MI's, now with complete heart blocks, indwelling\n subclavian lines bilat, hypotensive\n REASON FOR THIS EXAMINATION:\n CHF progress, any infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST:\n\n INDICATION: Complete heart block and hypotensive, s/p CABG.\n\n COMPARISON is made to prior exam of the same day at 226 hours.\n\n FINDINGS: No left subclavian line is seen. A right subclavian central venous\n catheter is seen with its tip in the right atrium, unchanged. No\n pneumothorax. The heart is enlarged, but cardiomediastinal borders are\n unchanged. There is continued bilateral perihilar vascular haze, but overall\n improved aeration of the lungs, compared with prior exam. There are small\n bilateral pleural effusions.\n\n IMPRESSION:\n\n Slightly improved aeration of the lungs, with slight improved appearance of\n cardiac failure. Please note that the right IJ central venous catheter sheath\n tip continues to be within the right atrium.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2143-05-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792336, "text": " 2:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia, bilat subclavian line placements\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with CAD s/p CABG and cath/stent in past, recent admissions\n for chf exacerbation and MI's, now with complete heart blocks, indwelling\n subclavian lines bilat, hypotensive\n REASON FOR THIS EXAMINATION:\n eval for pneumonia, bilat subclavian line placements\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypotensive, s/p line placement.\n\n COMPARISON: .\n\n FINDINGS: Patient is s/p CABG. A right internal central venous line is noted\n with tip difficult to discern, but probably within the right atrium. The heart\n is enlarged, and the cardiac borders are difficult to discern. The aortic knob\n is calcified. Pulmonary vasculature remains indistinct, and there is edema\n bilaterally. Probable small bilateral pleural effusions. No pneumothorax.\n The bones are unremarkable.\n\n IMPRESSION: CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2143-05-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792460, "text": " 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for pulmonary edema\n Admitting Diagnosis: BRADYCARDIA SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with CAD s/p CABG and cath/stent in past, recent\n admissions for chf exacerbation and MI's, now with complete heart blocks,\n indwelling subclavian lines bilat, hypotensive s/p intubation\n REASON FOR THIS EXAMINATION:\n please evaluate for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST:\n\n INDICATION: S/P intubation for respiratory distress. Evaluate for pulmonary\n edema.\n\n Comparison is made to the prior examination of .\n\n FINDINGS: Lines and tubes are unchanged. There is no pneumothorax. The\n cardiomediastinal borders are unchanged. There is increased diffuse haziness\n of the right lung and increased left-sided retrocardiac opacity since the\n prior exam. There is slight upper zone vascular redistribution seen.\n\n IMPRESSION: Likely mild cardiac failure slightly worse since the prior exam.\n\n" }, { "category": "Radiology", "chartdate": "2143-05-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792760, "text": " 7:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema, pna.\n Admitting Diagnosis: BRADYCARDIA SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with CAD s/p CABG and cath/stent in past, recent\n admissions for chf exacerbation and MI's, now with complete heart blocks,\n indwelling subclavian lines bilat, hypotensive s/p intubation. Concern for\n asp. pna.\n REASON FOR THIS EXAMINATION:\n eval for pulm edema, pna.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypotension. Subclavian line. Assess for aspiration.\n\n PORTABLE AP CHEST, ONE VIEW: Comparison is made to study of 1 1/2 hours\n earlier. The patient is status post sternotomy. The heart is enlarged. There\n is mild vascular congestion with perihilar haze, consistent with mild CHF.\n There are probable small bilateral effusions. There is no focal area of\n consolidation to suggest pneumonia. There is bibasilar atelectasis. There is a\n double lumen right central line with tip in the right atrium. There is no\n pneumothorax.\n\n IMPRESSION: Cardiomegaly with mild CHF. Bibasilar atelectasis. I doubt the\n presence of underlying pneumonia.\n\n" }, { "category": "ECG", "chartdate": "2143-05-09 00:00:00.000", "description": "Report", "row_id": 269368, "text": "Normal sinus rhythm. Borderline A-V conduction delay. RSR' pattern in lead V6.\nT wave inversions in I, aVL and leads V4-V6 suggest possible anterolateral\nischemia. Compared to the previous tracing of no diagnostic interval\nchange.\n\n" }, { "category": "ECG", "chartdate": "2143-05-08 00:00:00.000", "description": "Report", "row_id": 269369, "text": "Normal sinus rhythm. Borderline A-V conduction delay. RSR' pattern in lead V3.\nT wave inversions in leads I, aVL and V4-V6 suggest possible anterolateral\nischemia. Compared to the previous tracing of no diagnostic interval\nchange.\n\n" }, { "category": "ECG", "chartdate": "2143-05-07 00:00:00.000", "description": "Report", "row_id": 269370, "text": "Normal sinus rhythm with A-V conduction delay and intraventricular conduction\ndelay. Compared to tracing #2, atrial fibrillation is no longer present.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2143-05-07 00:00:00.000", "description": "Report", "row_id": 269371, "text": "Atrial fibrillation with a slow ventricular response. Compared tracing #1\natrial fibrillation is new.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2143-05-07 00:00:00.000", "description": "Report", "row_id": 269372, "text": "Normal sinus rhythm. A-V conduction delay. Left atrial enlargement. Delayed\nR wave transition. Low limb lead voltage. T wave inversions in leads I, aVL and\nV5-V6 suggest possible anterolateral ischemia. Compared to the previous tracing\nof there has been no diagnostic interval change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2143-05-10 00:00:00.000", "description": "Report", "row_id": 269142, "text": "Normal sinus rhythm. Compared to tracing #1 no diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2143-05-09 00:00:00.000", "description": "Report", "row_id": 269143, "text": "Normal sinus rhythm. Borderline low limb lead voltage. T wave inversions in\nleads I and aVL suggest possible anterolateral ischemia. Left atrial\nabnormality. RSR' complexes in leads V2-V3. Compared to the previous tracing\nof the T waves in the lateral leads are no longer inverted.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2143-05-11 00:00:00.000", "description": "Report", "row_id": 1291248, "text": "NURSING PROGRESS NOTE 7P-7A\nPT. ALERT AND ORIENTED. SLEPT IN SHORT NAPS OVERNIGHT. MOVING ALL EXTREMITIES WELL. AMB TO COMMODE WITH 1 ASSIST. SL UNSTEADY ON FEET.\nFOLLOWING ALL COMMANDS, PURPOSEFUL MOVEMENTS.\n\nCV: HR 82 SR WITH OCC PVC. BP STABLE 90-115/30-40. DENIES C/O CHEST DISCOMFORT. DOPA OFF FOR 24 HRS. BP 20 PTS. LOWER ON LEFT ARM THAN RIGHT ARM.\n\nRESP: ON 3L NC MOST OF NOC. BECAME ANXIOUS AND SOB AT 2400 GIVEN ALB NEB AND MDI'S WITH GOOD EFFECT. LUNGS WITH I/E WHEEZE. 0400 BECAME EXTREMELY SOB WITH AUDIBLE WHEEZES AND RALES UP. GIVEN ALB NEB AND MDI'S WITH MIN EFFECT. DR. NOTIFIED. STAT CXR DONE. GIVEN 200 MG IV LASIX. EKG OBTAINED. RR 38-40. O2 SATS 88% ON 3L, O2 INCREASED TO 5L. O2 SATS NOW 98%, LESS TACHYPNEIC.\n\nGU: FOLEY PATENT. NO RESPONSE TO LASIX. URINE BROWN, CLOUDY U/O 5 CC/HR. TO BE DIALYZED THIS AM.\n\nGI: FAIR APPETITE. + BOWEL SOUNDS MOD SIZED TAN STOOL THIS AM. ABD SOFT.\n\nID: AFEBRILE. WAITING VANCO LEVELS FOR DOSING.\n\nENDO: BLOOD GLUCOSE ELEVATED. COVERING WITH SSRI, CONT ON GLARGINE INSULIN .\n\nACCESS; RIGHT SC QUINTON INTACT. RIGHT PIV INFILTRATED. LEFT LOWER ARM IV INSERTED. # 22 G.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2143-05-07 00:00:00.000", "description": "Report", "row_id": 1291233, "text": "CCU Nursing Admsission Progress Note 1900-0700\nHPI: In brief this is 66 year old female who presented to ED with weakness after being found by her husband slumped over in her WC at home. On arrival pt found to have a HR in the 30s and in CHB. In addition to a BP in the 70s. Pt subsenquently treated with IVF, Atropine, CaGluc, and Dopamine and sent to the CCU for further managment.\n\nSEE FHP for complete summary of HPI and allergies\n\nMS: Intially lethargic when recieved from the ED. Knowing time period and location but with short term memory. Prior to coming to the ED reportedly A/O/X/3. In ED given 1mg of Versed and 50mcgs of Fentanyl for transcutaneous pacing and post very lethargic. In CCU orderd for Narcan but held since noted improvement in CCU. Pt conversing with family but remaining forgetful. In and out of sleeping. Responding to verbal commands and able to follow and obey commands consistently. Right side with occasional jerking motion post residual post CVA.\n\nCV: HR 60s to 70s. NSR with no use of trancutaneous pacer since\narrival to unit. Prior to paced in ED with mA of 20. BPs 90s to 100s with MAPs greater > 60 on 4.6mcg/kg/min of Dopamine. Extremeties cool to touch. BLEs dopplerable throughout. Denies CP. CK and Troponin thus far flat.\n\nRESP: LS with crackles throughout. Denies SOB. \"Belly breathing.\" RR mid 20s. O2Sat 97-99% on 4LNP.\n\nGU/GI: Anuric. No foley inserted. Reportedly urinates very infrequently at home. BUN/Creat 66/10.1. Unsure of baseline Creat. ESRD with HD T-TH-SAT and is due today. Recieving 1L of IVF in ED. Abd firm with hypoactive BSs. Pt not recalling last BM. Trialed with ice chip and tolerating.\n\nID: Afebrile. Prophalatic IV Abx of Vanco and Levo times one dose. BCs drawn prior to with AM labs.\n\nHEME: Baseline anemia. Last HCT 33 with AM HCT pending. PLTs stable.\n\nENDO: FS from EW 194. Previously given 10U of R for question of falsely elevated K. AM FS pending.\n\nA/P: 66 year old ESRD, CAD, CABG with new LBBB\n\nContinue to follow.\n\n" }, { "category": "Nursing/other", "chartdate": "2143-05-07 00:00:00.000", "description": "Report", "row_id": 1291234, "text": "CCU NURSING NOTE ADDEDUM 1900-0700:\nAT 530AM PT VOMITING SMALL AMOUNT OF UNDIGESTED FOOD AFTER VOMITING FEELING \"BETTER\" AND DENIED NAUSEA. LATER BECOMING INCREASINGLY SOB AT FIRST PT DENYING BUT NOTED TO DESAT DOWN TO 80S ON 6LS NC. AUDIBLY AND AUSCULTATING RALES THROUGHOUT. ALB/ATROV NEB GIVEN. 100% NRB APPLIED AND PT \"FEELING LIKE GETTING AIR NOW.\" SATS UP INTO 100S. FOLEY INSERTED AND 80MG OF LASIX GIVEN WITH POOR RESPONSE. HR NOTED TO BE TRENDING DOWN INTO 50S, PRIOR TO 60S TO 70S. IN ADDITION TO BPS TRENDING DOWN AS WELL INTO 70S. DOPA INCREASED TO 10MCG/KG/MIN AND LATER MAXED AT 20MCGS/KG/MIN WITH MOST RECENT PRESSURE IN THE 90S. ABG SENT AND EKG DONE. CCU TEAM AT BEDSIDE.\n" }, { "category": "Nursing/other", "chartdate": "2143-05-07 00:00:00.000", "description": "Report", "row_id": 1291235, "text": "CCU Nursing PRogress Note\nAddendum:\nWhile turning pt to side, pt shaking arms but also noted face/neck shaking. Pt felt warm and checked rectal temp 104. Ho aware.Pt received tyelnol 1000mg OGT and blood cultures to be drawn. Cooling blanket ordered.\n" }, { "category": "Nursing/other", "chartdate": "2143-05-07 00:00:00.000", "description": "Report", "row_id": 1291236, "text": "CCU Nursing PRogress Note\nS-\"\"I'm trying to catch the oranges from falling off the bed.\"\nNeruo-Pt hallucinating early this morning before ETT. Oriented x1 to person only. Thought she was at a nursing home. Pt now receiving ativan 1mg IVB q2-4hrs and fentanyl 50-100mcg IVB q2-4hrs with good effect. MAE occ wakes up appears frightened and shaking arms. Wrist restraints applied.\nCV-HR and rythym SB with freq junc escape beats. Hyperkalemia persisted with K , treated with dextrose/insulin and bicarb/calcium gluconate. After treatment of elevated K+ pt converted to NSR rate 80. Please see serial EKG's in chart. SBP 90-120's on dopamine 20mcg/kg gradual wean of dopamine to 10mcg/kg with MAPs 65-68. External pacer pads left on.\nResp-Pt required intubation for possible EPS and temp pacer placement.\nrr 30 labored and using all accessory muscles on 100% NRB and 6l NP. O2 sats 80-100%. ETT on vent 100% 600x14 Peep5. PLease see careview for vent changes and ABG's. Last set ABG's 7.30/42/111 on 50% 650x20 PEEP 5. Ett sx q2-4hrs scant thin tan secretions. LS coarse with rales\nID afebrile on levo and vanco cultures pnd.\nGU- foley draining 5cc/hr. Received HD for 4hrs removed 2 liters. Tolerated well. Of note pt has a chest A/V graft(marked) ?unlcear when it was placed. Area is eccymotic surrounding graft.\nGI- vomited 100cc yellow bile after receiving meds to treat hyperkalemia. Pt now has a OGT and at LIS with coffee grounds. +BS\nDM- persistant hyperglycemia started insulin gtt at 3u/hr following\na 3u regular insulin IVB. Following q1hr BS until stable on gtt.\n husband calling and came to visit. Very concerned.\nA/P-postponed pacer with conversion to NSR after treatment of high K+\nFOllow electrolytes closely-next check at 12 am.\nMOnitor MAPs keep MAP >65 wean dopamine as tolerates\nGoal BS 80-120 on insulin gtt\nOffer support to family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2143-05-08 00:00:00.000", "description": "Report", "row_id": 1291237, "text": "CCU Nursing Progress Note 1900-0700\nS-Sedated and intubated\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND VS\nMS-Sedated and intubated. Recieving PRN boluses of Ativan and Fentanyl and tolerating well. Responding and opening eyes to voice. Able to obey and follow commands. Periods of agitation and hallucinations and responding well to sedation. Last sedated at 4AM.\nCV-HR 90s to 100s. NSR to ST with no ectopy. Period on telemetry in lead III where ST appeared more depressed than prior. EKG done with no change. Dr. made aware. Transcutaneous pacing pads left in place. BPs very labile. BPs 70s to 100s. Dopa increased as high as 15mcgs. BPs later stabalizing with MAPs in the 70s and Dopa weaned as low as 13mcgs and maintaining MAPs 60-65. Lytes rechecked at MN and K 5.0. Given 30gm of Kayelate times one. AM labs pending.\nRESP: Many vent changes overnight. PLEASE SEE CAREVUE FOR CHANGES AND ABG TRENDS. Goal to keep pt on the \"akalotic side\" due to history of COPD. pH goal 7.45-7.50. Current vent settings AC/600/14/.40/5 PEEP. LSs course and dim at right base. Suctioning for thick tan colored secretions in moderate amounts.\nGU/GI: Foley draining golden yellow urine. Anuric for most part and draining 5-10cc/hr. Last HD yesterday. BUN/CREAT 6.3/31 and actually up from previous of 5.1/28. Abd soft with (+) BSs. OGT in place and NPO.\nID: Febrile for most of night. Tm 102.4 and Tc 99.4. Pan cultured for spike of 104.0. Preliminary sputum with gram (-) diplococci. All other culture data pending. Cooling blanket in place. Tylenol given. Levo dose given times one last night. Vanco dose given yesterday prior to dialysis. Question if needs to recieve dose today. Will add Vanco level to AM levels if already not done.\nENDO: Insulin gtt titrated to scale. BS 60s to 150s. Currently at 2u/hr.\nACC: TLL in , in left radial, Quinton and RSCL, and A/V Fistula in LSCL.\nPLAN:\nWean to extubate\nWean Dopa if possible to MAP of 60.\nContinue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2143-05-09 00:00:00.000", "description": "Report", "row_id": 1291243, "text": "CCU Nursing Progress Note 2300-0700:\nS-\"That a champagne glass!\"\nSEE CAREVUE FOR ALL VS AND DATA:\nMS: MS improving. Oriented to self and place, still forgets time period. Very pleasant. Frequently re-oriented to time and events to take place today, ie HD. Hallucinates and sees champagne glasses and calling out for her mother and husband during night. Emotionally supported and updated with husband visits. .\nCV: HR 90s. NSR with no noted ectopy. K treated on evenings with Kayelate. AM K down to 4.5. Dopamine with attemped wean overnight but unsuccesful at 14mcgs this morning. Not requiring use of tracutaneous pacer but remains in place. Right groin CDI.\nRESP: Extubated afternoon without incident. LS with some crackles, 1/4 up bilaterally. Breathing appearing normal but RR tachypenic in mid 20s to 30s. O2Sat with poor tracing with many attempts. ABG checked times two during night with SaO2 of 91 and PaO2 mid 60s on 4LNP. No noted coughing overnight.\nGU/GI: Anuric. Foley draining 5-10cc/hr. (+) since MN > 1L. Due for HD today.Abd soft and passing flatus but no BM overnight. Taking POs well. Given clears liq overnight. Pt stating, \"hungry.\"\nID: Tm 102.4 and Tc 100.9. Cooling blanket on briefly and off this AM. Blood and urine cx sent with spike. No sputum. Other cx data pending. Levo QOD and Vanco dosing with HD\nENDO: FS 75-198. Insulin gtt restarted around 2am at 2u/hr. Gtt as high as 4u/hr. Currently at 3u/hr.\nA: Temp and hypotension\nContinue to follow temps, Levo due today in addition to Vanco\nUnsuccesful at weaning Dopamine. Quesion to trial other pressor\nHD today\nRe-establishing access other than femoral, so pt can get OOB.\n pt on Glucargine and Regular insulin regimen\n" }, { "category": "Nursing/other", "chartdate": "2143-05-09 00:00:00.000", "description": "Report", "row_id": 1291244, "text": "CCU Nursing PRogress Note\nS-\"I'm hungry\"\nO-Neuro lethargic most of day, but easily arousable. Alert and oriented x2-3, reorients to place and time.\nO-CV surgical report from about pt unusual chest A/V fisutal. On pt's surgical report that a graft was attached to the left SC artery and tunneled and looped to the left SC vein. Explains the intermitant flow to the left radial artery. Will be using the right arm for following NBP pressure, which has an old scar from a ?fistual ( no thrill or bruit). LBP 20-26 points lower than the RBP. Dopamine wean to 8mcg/kg during HD from 14mcg/kg. Keeping SBP >85. Radial to be removed. INR 4.7 to receive vit K 10mg po x1.\nResp-rr 16-22 less SOB, LS BBR with occ rhonchi, strong productive cough, thick blood tinged sputum. O2 sats difficult to read.\nID WBC 12.4, afebrile on levo and vanco blood culture sent from a/v fistual.\nGU- foley urine output 10-20cc/hr Received HD removed 2.5 liters over 4 hours, tolerated well.\nGI- appetite fair-to good, taking fluids well. No BM, HCT 32\nSkin-intact\nActivity-bedrest maintained d/t right fem TLC.\n husband calling and anxious.\nA/P-stable but still requiring dopamine. POssibly look into PICC line to removed fem line. Repeat SMA7 post HD.\n" }, { "category": "Nursing/other", "chartdate": "2143-05-08 00:00:00.000", "description": "Report", "row_id": 1291238, "text": "Resp Care Note:\n\nPt cont intub sedated on mech vent as per Carevue. Lung sounds coarse suct sm-mod th off white sput. MDI given as per order. ABGs stable. Cont mech vent.\n" }, { "category": "Nursing/other", "chartdate": "2143-05-08 00:00:00.000", "description": "Report", "row_id": 1291239, "text": "CCU Nursing Progress Note\nS: orally intubated\nO: See careview for all objective data\nT max 102 rectally. to rec 1x dose of Vano and Levo restarted q48hrs.\nCV - HR 90's NSR with no vea. K+ 5.1 this am. No rx. Will re check level this pm.\nBP 98-90/48-50 via l radial . Dopamine (via r fem TLC) cont 13mcgs/kg for MAP > 60. Transcutaneous pacing pads in place but unused.\nResp - cont ventilated, but attempting to wean. See flow for vent changes and ABG's. Currently on 40%/10PS/5peep. BS are coarse throughout. Sx for small to scant amt thick yellow/tan secretions.\nGU/GI - New ogt placed d/t plugging of old ogt. No aspirates noted. +bowel sounds and flatus, but no stool.\nEndo - cont on insulin gtt (via r fem TLC) titrated per scale. BS 70's 120's.\n1cm x 1cm pink open area on coccyx, washed with soap and water and covered with tegaderm. Turned and positioned q2-3hrs.\nHusband present through most of day and has spoken with MD's.\nA: Starting to PS wean\nCont febrile\nBP cont labile on Dopa titrated to MAP\nP: Cont attempt extubation, monitoring ABG's and lytes, Cont attempt to decrease Dopa. CXR for placement of new ogt, monitor status of coccyx, keep husband and pt informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2143-05-08 00:00:00.000", "description": "Report", "row_id": 1291240, "text": "Respiratory Care Note;\n\nPt received on Full vent support SIMV +++. We started weaning in late AM and eventually extubated to FT 50% FIO2 ~ 1700 hr, MD Team resident aware. Pt awake with weak cough. Combivent MDI given ~ Q4h. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2143-05-08 00:00:00.000", "description": "Report", "row_id": 1291241, "text": "CCU NURSING PORGRESS NOTE 3P-11P\nS. \"COULD YOU MAKE ME A ?\"\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nID: TEMP 101.4 DOWN TO 100 R, RECEIVED VANCO TODAY\n\nRESP: WEANED AND EXTUBATED AT 1700 TO 50% NEB - O2 WEANED TO 4L N/C W/ABG 7.37/44/76/26/0 AT 2115, LUNGS RALES - 1/3 UP, RR HIGH 20'S TO 30; PRODUCTIVE COUGH OF THICK BLOODY SPUTUM\n\nCV: HR 90'S SR NO VEA - K+ 5.3 - ORDERED FOR KAYEXALATE, BP 86-101/40-50'S - REMAINS ON DOPAMINE AT 13 MCGS\n\nNEURO/MS: ALERT, ORIENTED X2, FOLLOWS COMMANDS CONSISTENTLY BUT AWAKENS CONFUSED FROM SLEEP\n\nENDOCRINE: CONTINUES ON INSULIN DRIP TITRATED TO Q 1 HR FINGER STICKS\nBS RANGE 153-79, INSULIN FROM U/HR\n\nGI: OGT TUBE D/C'D WHEN EXTUBATED, PT W/ + STRONG GAG, TOLERATING ICE CHIPS/CLEAR LIX, SWALLOWED MEDS W/O DIFFICULTY - NO STOOL\n\nRENAL/GU: FOLEY DRAINING MINIMAL AMTS AMBER URINE, DIALYSIS DUE TOMORROW\n\nSOCIAL: HUSBAND IN TO VISIT UNTIL 8PM, APPEARS SUPPORTIVE\n\nA: SUCCESSFULLY EXTUBATED, CONTINUES TO REQUIRE HIGH DOSE DOPAMINE\n\nP: MONITOR O2 SATS, ABG'S, MONITOR BP, WEAN DOPAMINE AS TOLERATED, FOLLOW K+ LEVEL, FOLLOW TEMPS/CX'S, CONTINUE Q 1 HOUR FINGER STICKS AND TITRATE INSULIN GTT PER PROTOCOL, REORIENT PATIENT PRN; EMOTIONAL SUPPORT FOR PT/FAMILY, CONT SUPPORTIVE CARE.\n" }, { "category": "Nursing/other", "chartdate": "2143-05-08 00:00:00.000", "description": "Report", "row_id": 1291242, "text": "CCU NURSING ADDENDUM\nFINGER STICK AT 2200 - 71 - INSULIN GTT OFF - 2245 REPEAT FS - 57;\n JUICE GIVEN, PT AWAKE, ALERT @ THIS TIME. REPEAT FS AT 2320 75; INSULIN GTT REMAINS OFF.\n" }, { "category": "Nursing/other", "chartdate": "2143-05-09 00:00:00.000", "description": "Report", "row_id": 1291245, "text": "CCU NPN 1500-2300\nS/O:\n\nCV: HR 70'S-80'S SR WITH OCC PVC. DOPA WEANED DOWN TO 3 MG/KG, THEN MAPS BELOW 60. DOPA TITRATED UP TO 5 MCG AGAIN. LYTES PND FROM 2100. PT C/O CP FOR PAST 20 MINUTES AT , PT APPEARED COMFORTABLE WITH NO CHANGE IN BP/RR, NO DIAPHORESIS. EKG DONE WITHOUT CHANGES AND CP DISAPPEARED WITH IN 2 MINUTES AFTER EKG DONE WITHOUT INTERVENTION. TLC IN RIGHT GROIN D/I, PULSES PRESENT BUT FEET CONT SLIGHTLY COOL BILAT.\n\nRESP: SATS IN HIGH 90'S, RR COMFORTABLE LYING FLAT. PT WITH MOD PROD COUGH. LUNGS WITH CRACKLES AT BASES, OCC RHONCHI. CONT ON 4LNP.\n\nID: AFEB, WBC TO 11. CX STILL PND. CONT WITH LEVO IV, WILL ASK HO ABOUT ANOTHER DOSE OF VANCO.\n\nGI: EATING SMALL AMOUNTS OF FOOD. PT HAD LARGE LOOSE BM, GOLDEN BROWN BUT OB POS. SENEKOT AND COLACE HELD.\n\nGU: CONT WITH SMALL AMOUNTS OF URINE FROM FOLEY. BUN/CR PND.\n\nENDO: BS CLIMBING DESPITE SS REGULAR INSULIN COVERAGE Q2H. HO AWARE AND WILL COME TO EVALUATE. ? RESTART LANTIS INSULIN TONIGHT?\n\nMS: NO HALLUCINATIONS, PT LETHARGIC BUT ALERT/ORIENTED WHEN AWAKE. SOMETIMES FORGETS WHY SHE HAS TUBES OR CAN'T GET OOB. HUSBAND AND GRANDSON IN TO VISIT MOST OF EVENING.\n\nA/P: RISING BS, WILL CHANGE SS INSULIN COVERAGE OR RESTART LANTIS. CONT TO FOLLOW LYTES, U/O. WEAN DOPA IF POSSIBLE LATER TONIGHT OR TOMORROW. FOLLOW TEMP AND CX RESULTS. ? VANCO TONIGHT? CONT TO EXPLAIN PROCEDURES AND ACTIVITY RESTRICTIONS TO PT.\n" }, { "category": "Nursing/other", "chartdate": "2143-05-10 00:00:00.000", "description": "Report", "row_id": 1291246, "text": "CCU NPN 11P-7A\nNeuro: Pt sleeping most of the night, lethargic but alert & oriented x when awake.\n\nCV: Tele SR 80s, no ectopy. BP 90-104/36-45 w/ MAPs 57-64. Only able to wean dopamine to 4mcg/kg/min to maintain MAPs>60. R groin TLC-groin C/D/I, palp distal pulses. Mg 1.7, received 2gm MgSO4. Evening INR down to 4.1 from 4.7.\n\nPulm: LS crackles @ bases. RR 18-28, sats 95-97% on 4L NC, drops to 84% on RA. Denies dyspnea.\n\nGI/GU: +BS, abd soft, non-tender. Foley patent, pt is nearly anuric w/ minimal u/o.\n\nEndo: Started on lantus insulin 20u/10u . BS trending down . HO does not want pt to get SS coverage after dinner-don't want pt's sugar to \"bottom out.\"\n\nSocial: No calls o/n.\n\nID: Tmax 99.6, Tc 99.0\n\nA/P: Wean dopamine as tol, ?PICC if needed for central access. Follow BS, treat aggressively, cont Abx. Emotional support for pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2143-05-10 00:00:00.000", "description": "Report", "row_id": 1291247, "text": "CCU Nursing Progress Note\nS-\"I'm \"\nO-Neuro alert and oriented x3, pleasant and cooperative. Less lethargic today.\nCV-Weaned and d/c'd dopamine at 1000. Per HO observe for s/s of hypotension, pt able to tolerate SBP 80-90 without symptoms. All cardiac meds on hold until .\nResp-LS BBR with occ productive cough. O2 weaned down to 3lnp (pt home\nO2 3lnp) O2 sats 95%. RA sat 90%\nID afebrile on vanco/levo\nGU-Foley anuric\nGI-appetite improving, LBM \nEndo hyperglycemia treated with SSRI and glargine started.\nActivity- after right fem line removed pt OOB chair with assist tolerated well.\nSOcial-husband in and happy she is doing better.\nA/P-Follow BP in right arm observe for s/s hypotension\nMOnitor blood sugars q2hrs until stable\n" } ]

[ { "category": "Radiology", "chartdate": "2101-10-28 00:00:00.000", "description": "CHEST AP ONLY", "row_id": 775761, "text": " 7:50 AM\n TUNNEDLED DIALYSIS CATH PLACE Clip # \n Reason: please change R subclavian triple lumen placed in IR previou\n ********************************* CPT Codes ********************************\n * IMPLANT VENOUS ACCESS PORT -51 MULTI-PROCEDURE SAME DAY *\n * FLUORO 1 HR W/RADIOLOGIST -59 DISTINCT PROCEDURAL SERVICE *\n * CHEST AP ONLY C1750 CATH,HEMO/PERTI DIALYSIS LONG *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with end stage CHF and renal failure and severe volume overload\n with difficult access on admission necessitating placement of triple lumen in\n IR for access.\n REASON FOR THIS EXAMINATION:\n please change R subclavian triple lumen placed in IR previously to an Arrow\n dialysis catheter on friday so we can begin dialysis fri pm or sat am. Arrow\n cath is dialysis cath with 3rd lumen for meds, etc. I think we have some in\n dialysis if needed.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71 year old male with renal failure and congestive heart failure.\n Current right subclavian triple lumen catheter not adequately for\n hemodialysis. Patient needs exchange for a dual lumen hemodialysis catheter.\n\n RADIOLOGISTS: Drs. and . Dr.\n , the staff radiologist, was present and supervised the entire\n procedure.\n\n MEDICATIONS/CONTRAST: Lidocaine 1% for local anesthesia. No IV contrast was\n administered.\n\n PROCEDURE/TECHNIQUE: Informed and signed consent was obtained from the\n patient. The patient was placed supine on the angiographic table and the\n right upper chest/skin entry site of the pre-existing right subclavian\n catheter were prepped in standard sterile fashion. A .018 guidewire was\n advanced through the indwelling catheter to the level of the distal superior\n vena cava. The catheter was then exchanged for a 10 FR dilator. The .018\n guidewire was then exchanged for a .035 guidewire which was advanced to the\n level of the IVC. 1% Lidocaine was then applied to the right upper chest and\n a tunneled tract was created. A dual lumen hemodialysis catheter was advanced\n through the tract and over the guidewire into the right subclavian vein, while\n simultaneously removing a peel-away sheath. The guidewire was then removed\n and both ports were flushed. A chest radiograph was then obtained to confirm\n position. The film showed the distal tip of the hemodialysis catheter to be\n in the proximal right atrium. The skin entry site at the level of the right\n subclavian vein was closed with a suture. An additional suture was applied to\n the skin entry site within the right upper chest wall. The external portion\n of the hemodialysis catheter was also sutured to the chest wall.\n\n COMPLICATIONS: None.\n\n IMPRESSION: Successful exchange of a pre-existing triple lumen catheter for a\n 14 FR, 19 cm long (from cuff to tip), Vaxcel tunneled hemodialysis catheter\n (Over)\n\n 7:50 AM\n TUNNEDLED DIALYSIS CATH PLACE Clip # \n Reason: please change R subclavian triple lumen placed in IR previou\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n via the right subclavian vein using fluoroscopic guidance. The catheter is\n ready for use.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2101-10-28 00:00:00.000", "description": "CVL/PICC", "row_id": 775795, "text": " 11:02 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: difficult IV access\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with need for HD and other iv access. Please place PICC in\n addition to HD tunnelled cath.\n REASON FOR THIS EXAMINATION:\n difficult IV access\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71 y/o man with no peripheral IV access. End stage renal disease.\n Failed bedside attempt at PICC placement.\n\n PROCEDURE: The procedure was performed by Dr. and Dr.\n , attending radiologist, being present and supervising the\n procedure. The right upper arm was prepped in a sterile fashion. Since no\n suitable superficial veins were visible, ultrasound was used for localization\n of a suitable vein. The basilic vein was patent and compressible. After local\n anesthesia with 2 mg of 1% Lidocaine, the basilic vein was entered under\n ultrasonographic guidance with a 21 gauge needle. A 0.018 guide wire was\n advanced under fluoroscopy into the superior vena cava. Based on the markers\n on the guide wire it was determined a length of 40 cm would be suitable. The\n PICC was trimmed to length and advanced over a 4 FR introducer sheath under\n fluoroscopic guidance into the superior vena cava. The sheath was removed. The\n catheter was flushed. A final chest X-ray was obtained. The film demonstrated\n the tip to be in the superior vena cava just above the atrium. The line is\n ready for use.\n\n A statlock was applied and the line was heplocked.\n\n IMPRESSION: Successful placement of a 40 cm total length 4 FR single lumen\n PICC with tip in the superior vena cava, ready for use.\n\n" }, { "category": "Radiology", "chartdate": "2101-10-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 775635, "text": " 7:42 PM\n CHEST (PA & LAT) Clip # \n Reason: Evaluate for infiltrate, pleural effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with volume overload presents with productive cough, crackles\n at R base\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrate, pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man with volume overload with productive cough and\n crackles.\n\n COMPARISON: \n\n CHEST, AP AND LATERAL RADIOGRAPHS: There is stable mild to moderate\n cardiomegaly in a patient with a dual lead pacemaker. The pacer tips are in\n unchanged positioning in the right atrium and right ventricle. The\n mediastinal and hilar contours are otherwise unremarkable. The right lung is\n grossly clear. The pulmonary vasculature is unremarkable. Again noted is the\n small left pleural effusion and left lower lobe retrocardiac patchy opacity.\n The soft tissue and osseous structures are unremarkable. A right subclavican\n catheter is noted with tip in the distal SVC.\n\n IMPRESSION:\n 1) Persistent left lower lobe retrocardiac patchy opacity with associated\n small pleural effusion.\n 2) Stable cardiomegaly, without evidence of overt CHF.\n\n" }, { "category": "Radiology", "chartdate": "2101-10-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 774907, "text": " 3:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: new loud wheezing, eval for change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with cardiomyopathy, afib, htn, niddm s/p vfib arrest\n with sob\n REASON FOR THIS EXAMINATION:\n new loud wheezing, eval for change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cardiomyopathy, status post ventricular fibrillation arrest.\n\n TECHNIQUE: Portable chest x-ray.\n\n Comparison with prior study from .\n\n FINDINGS: Again seen is a dual chamber pacemaker in unchanged position.\n There is moderate cardiomegaly. The pulmonary vessels are indistinct.\n Allowing for bilateral low lung volumes, there are increased bilateral\n interstitial opacities. There is a left lower lobe consolidation which has\n also increased in the interval. The bones are unremarkable.\n\n IMPRESSION: Cardiomegaly and worsening CHF.\n\n" }, { "category": "Radiology", "chartdate": "2101-10-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 775433, "text": " 3:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval SC placement, pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p dual chamber ICD with ms changes\n REASON FOR THIS EXAMINATION:\n Please eval SC placement, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post placement of dual-chamber ICD with mental status\n changes.\n\n TECHNIQUE: Again seen is a left-sided dual-chamber ICD. Atrial and\n ventricular leads are in satisfactory position. There has been interval\n placement of a right-sided subclavian central line catheter. The tip cannot\n be visualized beyond the superior SVC/right brachiocephalic junction. No\n pneumothorax. There is marked LV dominant cardiomegaly, stable. An element\n of congestive failure cannot be excluded, but there is no definite pulmonary\n vascular redistribution. There is a retrocardiac opacity present. Osseous\n structures are unremarkable.\n\n IMPRESSION:\n\n 1. Right-sided central line. Tip cannot be visualized beyond the junction of\n the right brachiocephalic and SVC.\n\n 2. ICD leads are in satisfactory position.\n\n 3. Persistent marked cardiomegaly. While there are no overt signs of failure,\n mild failure cannot be excluded.\n\n 4. Retrocardiac opacity may represent consolidation or collapse.\n\n" }, { "category": "Radiology", "chartdate": "2101-10-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 774741, "text": " 6:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for chf\\\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with cardiomyopathy, afib, htn, niddm s/p vfib arrest\n with sob\n REASON FOR THIS EXAMINATION:\n assess for chf\\\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71 y/o with cardiomyopathy, afib, hypertension, noninsulin\n dependent diabetes mellitus. Status post V-fib arrest with shortness of\n breath.\n\n PORTABLE AP CHEST: Comparison: . A dual lead pacemaker is again\n noted. There is cardiac enlargement and prominence of the pulmonary\n vasculature. There are small bilateral pleural effusions. Patchy interstitial\n opacities are present at both bases, left greater than right. There is an old\n right sided lateral rib fracture.\n\n IMPRESSION: Cardiomegaly with mild congestive heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2101-10-15 00:00:00.000", "description": "RENAL U.S.", "row_id": 774780, "text": " 4:19 PM\n RENAL U.S. Clip # \n Reason: please rule out ureteral obstruction and hydronephrosis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with h/o CHF who presents with ARF and metabolic acidosis.\n REASON FOR THIS EXAMINATION:\n please rule out ureteral obstruction and hydronephrosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71 year old man with CHF presents with acute renal failure and\n metabolic acidosis.\n\n TECHNIQUE: Multiple -scale images were obtained from the abdomen and\n pelvis.\n\n FINDINGS: The right kidney measures 8.9 cm and the left kidney measures 8.9\n cm. There are no stones, hydronephrosis or masses seen. There is ascites\n seen around the liver. The visualized portion of the liver is heterogeneous.\n\n IMPRESSION:\n\n 1) No hydronephrosis.\n\n 2) Ascites.\n\n" }, { "category": "Radiology", "chartdate": "2101-10-17 00:00:00.000", "description": "CVL/PICC", "row_id": 774855, "text": " 7:48 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place picc\n Contrast: OPTIRAY Amt:\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * C1751 CATH ,/CENT/MID(NOT D C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with arf and chf who is difficult to gain iv access.\n REASON FOR THIS EXAMINATION:\n please place picc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: History of ARF and CHF. Difficult IV access.\n\n PROCEDURE: The procedure was performed with Dr. and , with Dr.\n being present and supervising. The right upper arm was prepped\n in a sterile fashion. Since no suitable superficial veins were visible,\n ultrasound was used for localization of a suitable vein. The basilic vein was\n patent and compressible. After local anesthesia with 2 ml of 1% lidocaine the\n basilic vein was entered under ultrasonographic guidance with a 21 gauge\n needle. A 0.018 guidewire was advanced under fluoroscopy into the superior\n vena cava. Based on the markers on the guidewire, it was determined that the\n length of 43 cm would be suitable. The PICC line was trimmed to length and\n advanced over a 5 French introducer sheath under fluoroscopic guidance into\n the superior vena cava. The sheath was removed. The catheter was flushed. A\n final chest x-ray was obtained. The film demonstrates the tip to be at the\n caval atrial junctional. The line is ready for use.\n\n A stat-lock was applied and the line was heplocked.\n\n IMPRESSION: Successful placement of a 43 cm total length 5 French doulbe\n lumen PICC line with the tip at the cavo-atrial junction, ready for use.\n\n\n" }, { "category": "Echo", "chartdate": "2101-10-21 00:00:00.000", "description": "Report", "row_id": 66384, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 63\nWeight (lb): 200\nBSA (m2): 1.94 m2\nBP (mm Hg): 100/70\nStatus: Inpatient\nDate/Time: at 11:23\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 markedly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is dilated. A catheter or\npacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is dilated. There is severe global left ventricular\nhypokinesis. There is no resting left ventricular outflow tract obstruction.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. There are focal calcifications\nin the aortic root.\n\nAORTIC VALVE: The number of aortic valve leaflets cannot be determined. The\naortic valve leaflets are moderately thickened. There is mild aortic valve\nstenosis. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is moderate mitral annular calcification. There\nis mild thickening of the mitral valve chordae. The tips of the papillary\nmuscles are calcified. There is no significant mitral stenosis. Moderate (2+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. The\nsupporting structures of the tricuspid valve are thickened/fibrotic. Moderate\n[2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\nThe left atrium is markedly dilated. The right atrium is dilated. Left\nventricular wall thicknesses are normal. The left ventricular cavity is\ndilated. There is severe global left ventricular hypokinesis (ejection\nfraction 20-30 percent). Right ventricular chamber size and free wall motion\nare normal. The number of aortic valve leaflets cannot be determined. The\naortic valve leaflets are moderately thickened. There is mild aortic valve\nstenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened. The\nsupporting structures of the tricuspid valve are thickened/fibrotic. Moderate\n[2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nCompared to the previous study of , the mitral and tricuspid\nregurgitation may now be somewhat decreased, but left ventricular contractile\nfunction remains severely reduced.\n\n\n" }, { "category": "ECG", "chartdate": "2101-10-15 00:00:00.000", "description": "Report", "row_id": 136242, "text": "Pacer detection suspended due to external noise-REVIEW ADVISED\n*** technically unsatisfactory tracing ***\nUnclassified ECG\n100% ventricular pacing\nSince last ECG, no A-V sequential pacing\n\n" }, { "category": "Nursing/other", "chartdate": "2101-10-16 00:00:00.000", "description": "Report", "row_id": 1486040, "text": "REPEAT K SENT FROM #20 PIV AND K=4.7.\n" }, { "category": "Nursing/other", "chartdate": "2101-10-16 00:00:00.000", "description": "Report", "row_id": 1486041, "text": "NEURO: PT SLEEPY THROUGHOUT SHIFT BUT EASILY AROUSED AND ORIENTED X3. PURPOSEFUL MOVEMENT OF EXTREMITES X4 NOTED.\nCV: MONITOR SHOWS AV PACED-V-PACED RHYTHM WITH OCC PVC'S NOTED. PT REMAINS HYPOTENSIVE THROUGOUT SHIFT AND METOPROLOL HELD. AMIODARONE D/C'D. PT RECEIVED ONE BOLUS WITH SLIGHT IMPROVEMENT IN SBP.\nRESP: LS COARSE THROUGHOUT. SOB WITH EXERTION NOTED. O2 REMAINS OFF.\nGI: ABD FIRM AND DISTENDED. CONT WITH HEME+ STOOLS. DIET ADVANCED TO AND NEEDS ASSISTANCE WITH MEALS SECONDARY TO ARTHRITIC HANDS. ?WOULD BENEFIT FROM OT CONSULT. U/S FROM YEST WITH +ASCITES ? COMPONENT OF LIVER FAILURE PER MICU TEAM.\nGU: FOLEY INTACT AND PATENT DRAINING SCANT AMTS YELLOW URINE WITH SEDIMENTATION NOTED.\nSKIN: MULTIPLE ECCYMOTIC AREAS ON SKIN SECONDARY TO ATTEMPTS FOR LINE ACCESS. COCCYX DUODERM D+I AND BARRIER CREAM APPLIED TO REDDENED AREAS.\nHEME: LAST K GROSSLY HEMOLYSED WITH VALUE OF 6.9. ATTEMPTED PERIPHERAL STICK WITHOUT SUCCESS. TEAM AWARE AND WILL ATTEMPT. LAB WORK FOR THIS EVE AND ABG. AM HCT 27.5 ABD 1U PRBC. WILL NEED REPEAT HCT @ .\nENDO: REMAINS ON FINGERSTICKS Q6HR WITH RISS. CORTISOL SKIN TEST D/ AND PT STARTED ON HYDROCORTISONE.\nACCESS: PT HAS ONE PIV AND A-LINE SLUGGISH WITH BLOOD DRAWS. PLAN FOR PICC LINE PLACEMENT TOMORROW UNDER IR.\nPSY-SOC: DTR CALLED IN AM AND UPDATED ON STATUS AND PLAN OF CARE.\n\n" }, { "category": "Nursing/other", "chartdate": "2101-10-17 00:00:00.000", "description": "Report", "row_id": 1486042, "text": "nursing note 7p-7a\nNeuro Pt pleasant during night. slept on/off. Pt helps with turning no neuro deficit. perrla and brisk. afebrile. WBC 10.2 this am.\n\nCard. Pt vpaced to av paced at times. Pt with occasional PVC's. Mg 1.8 during night 2g mgso4 given. Hct 27.5 after 1uPrbc during day, pt given 1 more unit prbc hct this am 29.4 INR 1.4 Able to place 20g in L hand to run blood products+fluid during night 1 attempt. Pt still with very poor peripheral access d/t edema. PICC consult today. lytes redrawn this am d/t hemolysis. Pt vss map >60\n\nRR Pt on RA abg per flow. wnl. Lung ausc coarse b/l no crackles noted. Pt doe.\n\nGI Pt firm disteded abdomen yet active BS. Pt without diarrhea tonight. Glucose 200's covered SSI.\n\nGU Pt UO still minimal yellow with sediment. Pt 8 LITERS POSITIVE for LOS and 5L positive last 24hr. Pt with noted peripheral edema.\n\nSkin Pt still with petechiae left upper back area. Eccymotic areas still remain unchanged.\n\nSocial Pt's daughter called and updated spoke with pt on phone.\n" }, { "category": "Nursing/other", "chartdate": "2101-10-15 00:00:00.000", "description": "Report", "row_id": 1486038, "text": "NEURO: A+OX3. PURPOSEFUL MOVEMENT OF EXTREMITES NOTED.\nCV: MONITOR SHOWS AV PACED RHYTHM. EKG OBTAINED IN AFTERNOON SECONDARY TO ELEVATED K AND NO ACUTE CHANGES PER TEAM. DENIES CP OR DISCOMFORT. METOPROLOL HELD SECONADRY TO SBP. AMIO GIVEN AS ORDERED. R RADIAL A-LINE PLACED WITH GOOD WAVEFORM AND ACC TO NIBP.\nRESP: LS COARSE WITH BIBASILAR CRACKLES AND OCC EXP WHEEZES NOTED. SOB WITH POSITION CHANGE NOTED. FIO2 WEANED TO 2LNP. MOST RECENT ABG 7.29/30/132.\nGI: ABD FIRM AND DISTENDED. +BS NOTED. NPO. NO STOOLS. PT TO RECEIVE KAEXYALTE 30 GM THIS EVE.\nGU: SCANT UO. FOLEY FOUND OUT IN BED. TEAM AWARE AND UROLOGY TO BE RECONSULTED FOR FURTHER PLACEMENT. UNABLE TO SEND URINE. PLAN FOR RENAL U/S THIS EVE. RENAL CONSULTED AND HD NO INDICATED AT THIS TIME BUT WILL CONT TO MONITOR AND CONSIDER IF ACIDEMIA AND HYPERKALEMIA PERSIST.\nSKIN: D+I WITH NO OPEN AREAS NOTED.\nHEME: INR ELEVATED. ORDER FOR 2 U FFP AND VIT K FOR LINE PLACEMENT. K REMAINS ELEVATED DESPITE TREATMENTS AND TEAM IN TO PLACE CVL AFTER 1ST UFFP INFUSED. PLAN TO OBTAIN CXR POST PLACEMENT. ORDER FOR CA CHLORIDE TO BE GIVEN POST LINE AND AFTER LAB WORK RECHECKED FOR ? HEMOLYSIS. PT HAS 100 MEQ NA BICARB IN 1L D5W AND TO BE RESUMED ONCE CENTRAL ACCESS OBTAINED.\nENDO: FINGERSTINKS Q6HR WITH RISS COVERAGE.\nPSY-SOC: DTR WITH PT IN EW AND HAS BEEN UPDATED BY TEAM OF STATUS AND PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2101-10-16 00:00:00.000", "description": "Report", "row_id": 1486039, "text": "Neuro Pt a+o mentating adequatly throughout night. Pt did not sleep well d/t nights events. Afebrile WBC 6.6 this am. PERRLA brisk. Pt assisting with rolling and care at times.\n\nCard Pt HR 70-75 during night avpaced to vpaced at times. Pt with occ pvc's this am. K from 5.6 to 4.6 this am. Pt given 30g kayexalate during night. INR 1.9 HCT 27.5 md aware, pt with blood loss with central line placement attempt. Pt also with sl heme pos stool. PT in need of central line d/t poor IV access (need for additional port d/t nahco3 incapatability with other iv solutions), labile bp (fluid bolusing), and monitoring of cvp to assess pt fluid status. IV team at bs this am. Pt with labile BP during night given 1 500cc ns bolus and 1.5L of MIVF. Pt responds well to boluses.\n\nResp Pt DOE ABG. Pt on 2lnc weaned to RA. O2 sats 92-95%. Coarse b/l lung ausc. MD in to assess pt during fluid administration during night. No crackles noted this am. ABG RA 7.38/35/73/22\n\nGI Pt with firm distended abd. Pt given 3 doses total kayexalate during 24hr pt with liquid heme + stool golden color. Rectal bag placed to prevent breakdown/better stool management yet d/c r/t leaking. Attempt of mushroom cath yet stool too thick. Pt taking PO well with meds.\n\nGU Foley catheter placed at via MD, tip of penis with oozing of blood d/t trauma of insertion previously in day. Catheter passed with 1 attempt. Pt UO approx 10cc/hr md's aware. Renal US during eve hours no significant findings. BUN 92 Creat 3.5 PT approx 3L pos this am MD's aware.\n\nSkin Pt with several eccymotic areas. L groin and R IJ area with pressure dressings after attempted line placements. Barrier cream applied to rectal area d/t frequent stooling. R upper back area with questionable petechiae vs rash. MD's observed site.\n\nSocial Pt's daughter called, updated with pt's condition.\n" } ]

[ { "category": "Physician ", "chartdate": "2133-12-11 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 615563, "text": "TITLE:\n Chief Complaint:\n HPI:\n 62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade lymphoma. Transferred for\n further management from . Admitted to the ICU for CVVH for\n possible tumour lysis syndrome.\n Pt states that 4 weeks ago she noted some jaw pain as well as total\n body weakness, malaise, \"body burning sensation\". She had also noted\n some decreased appetite to food and water, insomnia accompanied by a\n bloating sensation in her abdomen. She saw her PCP last for a\n check up and received bld work which was noted to be 'abnormal'.\n Unfortunately she was not told what labs were abnormal, given her\n malaise she decided to come to the ED. In the \n ED she was noted to have a leukocytosis of 27.2, in addition to w/\n Creatinine of 2.2, Plt 66, LDH 25, 348. She was initially given\n Ceftriaxone for ?UTI given appearance of her urine. 4+ bacteria, \n WBC were seen on a U/A that was notable for squamous cells. As part of\n her work up she underwent a CT torso which showed Left Subclavian node,\n retroperitoneal adenopathy, L hydronephrosis. She was then referred to\n the ED on day of admission.\n In the ED her initial vitals were noted to be T99.0, HR 110, BP 126/72,\n RR 14, Sat 99%. Her labs were notable for a leukocytosis of 28.4 with\n 29N, Band 4, L 23, M14, E11, B1, Meta5, Myelos1, Nrbcs5, Other 12.\n BUN/Creatinine 38/2.4, Glc 66. Uric Acid 26.3, LDH 26, 420, AST 211,\n ALT 65, Ca .4, K 3.8, Ph 4.2, TB 1.6, Alk Phos 477. Fibrinogen 266.\n Oncology were consulted given the suspicion for Lymphoma and obtained a\n BM bx, cytology was obtained from aspirate.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n Levothyroxine 100mcg daily\n Furosemide dose unknown daily\n Lipitor unknown\n Calcium\n Vitamin D\n Past medical history:\n Family history:\n Social History:\n Hypothyroidism\n Hyperlipidemia\n Sister - Cirrhosis, Brother - DM, Anterograde Amnesia. Denies any h.o.\n lymphoma or other malignancies.\n Pt currently works as a system analysis at NHIC. She denies any Etoh,\n tobacco or IVDU history.\n Review of systems:\n Flowsheet Data as of 10:52 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 117 (117 - 120) bpm\n BP: 133/54(72) {124/54(69) - 133/54(72)} mmHg\n RR: 25 (25 - 27) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 61 Inch\n Total In:\n 1,000 mL\n PO:\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 825 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GENERAL: Fatigued appearing Caucasian Female lying down in bned in NARD\n HEENT: No scleral icterus, PERRL, EOMI.\n Neck: No LAD noted.\n CARDIAC: Regular rhythm, tachy (110 bpm). Normal S1, S2. No murmurs,\n rubs or .\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Soft, distended, tender in the epigastric region. No HSM\n EXTREMITIES: No edema noted.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout.\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Prelim read from Heme-Path suggests large cell lymphoma w/ vacuoles\n suggestive of possible Burkitt's Lymphoma. Oncology has already seen pt\n and recommends initiating treatment with steroids. Concern that this\n may be high grade lymphoma given progression, LDH level. Pt received CT\n torso from OSH, films in chart. On review of pt's labs although she\n does not qualify for tumour lysis syndrome given her normal Phos,\n elevated Ca her LDH, Uric Acid suggests the possibility of tumour lysis\n syndome once treatment begins. Will thus consult Nephrology for\n possible CVVH initiation tonight, per Onc recs will start on\n Dexamethasone 40 mg IV once CVVH is initiated given the likelihood of\n TLS. Will check tumour lysis labs (K, Creatinine, Ca, Phos, Mg, LDH) as\n well as DIC labs. Will also start on Rasburicase for uric acid\n converion.\n - will upload CT torso films in PACS\n - will check TLS labs q4hrs (K, Cr, Ca, Mg, Ph, LDH)\n - will give Rasburicase 7.5mg IV x 1 now\n - will check Uric Acid level 4 hours after Rasburicase per Rasburicase\n protocol\n - f/u heme onc recs\n - will check EBV, CMV, HIV viral loads, antibody panels\n - will give Dexamthasone 40mg IV x 1 once CVVH is initiated\n - check Echo in the AM, to eval systolic function\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Tumour Lysis\n As mentioned above pt noted to have elevated uric acid, however\n phosphorous is still low, Calcium is high. Given LDH and suspected high\n grade lymphoma have high suspicion for tumour lysis syndrome once\n dexamethasone is started.\n - will continue to monitor Tumour lysis labs q3hrs\n - pt receiving Rasburicase for Uric Acid conversion for renal\n protection\n - will place HD line and start CVVH\n - will start Allopurinol in the AM\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis given her prior labs from . Pt\n will start CVVH given the anticipation of possible TLS from tumour\n response to dexamethasone.\n - will start on CVVH\n - f/u renal recs\n - trend Creatinine\n - will continue with 3amps HCO in D5W @ 250cc/hr\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n ##. Anion Gap Acidosis: Pt noted to have an anion gap acidosis on\n admission, likely lactic acidosis given her aggressive lymphoma.\n - will check lactate level\n - trend chemistry panel\n URINARY TRACT INFECTION (UTI)\n Pt was given IV Ceftriaxone for ?UTI however U/A was notable for\n several epi cells in addition to bacteria. No dysuria noted, urine\n appearance likely related to her , recheck U/A and urine\n culture.\n - recheck U/A, Urine culture\n - contact OSH for culture results\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact son in the AM to reconciliate Furosemide, Lipitor\n dosing.\n ICU Care\n Nutrition: Regular Diet, replete lytes PRN\n Glycemic Control:\n Lines:\n 18 Gauge - 08:17 PM\n 20 Gauge - 08:18 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: Patient, Husband \n status: FULL CODE\n Disposition: Pending resolution of symptoms.\n" }, { "category": "Nursing", "chartdate": "2133-12-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 615845, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade lymphoma. Transferred for\n further management from . Admitted to the ICU for CVVH for\n tumor lysis syndrome.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with ? UTI dx in OSH; known renal calculi with hydronephrosis.. Cr\n 1.6. On CVVH---pt (-) 2.6 L at beginning of shift. Making little urine,\n however difficult to asses as pt on CBI\n Action:\n Replaced 1.5 L as pt became hypotensive to high 80\ns, pale and\n difficult to arouse. Discussed fluid goal with BMT and they would like\n the pt even to slightly negative, depending on how the pt\ns BP\n tolerates. They also added cont IVF @ 100 cc/hr but want pt even for\n day???? running fluid @ 100 cc/hr. Stopped CBI. Gave phenazopyridine\n for c/o bladder spasm.\n Response:\n Foley draining 15-20 cc/hr of amber urine. CVVH machine running great\n without problems. balance for day as of 1800 -------------\n Plan:\n Continue with CVVH with goal of even to slightly negative as BP\n tolerates, BMT will re-evaluate goal tomorrow.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Received pt with CBI\nurine yellow and clear. TLS labs WNL. Pt somnolent\n but arousable and alert and oriented x3. Intermittently crying with\n confused expressions.\n Action:\n TLS labs q6h with coags and fibrinogen q4h.\n Response:\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and Fibrinogen\n q4 hours. Cont with chemo and follow heme onc recs. Provide emotionas\n support to pt and to family.\n" }, { "category": "Physician ", "chartdate": "2133-12-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 616107, "text": "TITLE:\n Chief Complaint: - we huddled with Renal and BMT -> CBI for cytoxan,\n run even on CVVH for volume\n - A-line resited\n - AM labs with HCT of 22, PLTs of 26. As actively oozing, gave 2 units\n of platelets, 2 units PRBC in anticipation of falling below 21 given\n overall trend.\n 24 Hour Events:\n ARTERIAL LINE - STOP 02:00 PM\n ARTERIAL LINE - START 03:17 PM\n ARTERIAL LINE - START 03:26 PM\n ARTERIAL LINE - STOP 06:50 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Morphine Sulfate - 12:47 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 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.1\nC (95.2\n HR: 77 (49 - 82) bpm\n BP: 161/87(117) {115/60(78) - 180/93(126)} mmHg\n RR: 16 (8 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 5,103 mL\n 635 mL\n PO:\n TF:\n IVF:\n 4,473 mL\n 513 mL\n Blood products:\n 630 mL\n 123 mL\n Total out:\n 5,288 mL\n 354 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -185 mL\n 281 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: 7.45/27/103/23/0\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: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 26 K/uL\n 8.0 g/dL\n 156 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 31 mg/dL\n 99 mEq/L\n 134 mEq/L\n 22.8 %\n 2.2 K/uL\n [image002.jpg]\n 08:42 PM\n 04:13 AM\n 09:56 AM\n 10:04 AM\n 04:10 PM\n 04:34 PM\n 05:04 PM\n 09:00 PM\n 12:00 AM\n 04:13 AM\n WBC\n 16.9\n 6.5\n 3.4\n 2.5\n 2.2\n Hct\n 22.1\n 20.1\n 25.1\n 26.1\n 22.8\n Plt\n 80\n 60\n 42\n 40\n 26\n Cr\n 1.0\n 0.7\n 0.7\n 0.2\n 0.6\n 0.5\n TCO2\n 23\n 22\n Glucose\n 171\n 160\n 150\n 153\n 156\n Other labs: PT / PTT / INR:12.8/23.6/1\n Tbili 1.6, D-dimer:510 ng/mL, Fibrinogen:245 mg/dL, LDH:8425 IU/L,\n Ca++:7.5 mg/dL, Mg++:1.8 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and spontaneous tumor lysis\n syndrome. Received Rasburicase for uric acid converion. Pt had e/o TL,\n now labs improving. All counts are falling, pt received PRBC and\n platelet transfusions. Today day of cytoxan and decadron,\n continues on CVVH and CBI prophylactically.\n - cont allopurinol 100 mg daily\n - appreciate heme/onc recs\n - will check TLS labs Q6hrs (K, Cr, Ca, Mg, Ph, LDH)\n - DIC labs q6h\n - f/u EBV, CMV (-), HIV viral loads (-), antibody panels\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Has renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD in retroperitoneum. Had marginal urine output. Pt on CVVH\n given the anticipation of possible TLS from tumour response to\n dexamethasone. Has had difficulty with HD line and air infiltration.\n - discuss re-siting line with renal\n - on CVVH running even\n - f/u renal recs\n - trend Creatinine\n .\n ##. COAGULOPATHY/PANCYTOPENIA: Pt had profuse oozing from HD site, with\n associated Hct drop. Also had hematuria, requiring CBI with 3way Foley.\n No evidence of coagulopathy by PTT/INR. Cryo\ns pending. Pt is not\n receiving anticoagulation in CVVH. Likely has platelet qualitative\n dysfunction. Hct and plt count cont to trend down, likely to chemo\n and CVVH.\n - monitor Foley output, hematuria, concern for hemorrhagic cystitis\n - consider repeat CT for obstruction prior to urology consult\n - monitor q6h coags for r/o DIC\n - transfuse for goal Hct>21, plt>50 since bleeding\n .\n URINARY TRACT INFECTION (UTI)/HEMATURIA\n Positive UA and neg cx x 2. Will not treat for UTI.\n - CBI for hematuria to prophylax against hemorrhagic cystitis\n - oxybutynin for possible bladder spasm\n - consider CT and urology c/s\n .\n ##. Anion Gap Acidosis: normalized, AG 12 today.\n .\n ## Pain/discomfort\n morphine PRN\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n -\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact to reconcile Furosemide, dosing.\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer : famotidine\n VAP: none\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: \n" }, { "category": "Nursing", "chartdate": "2133-12-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616110, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade lymphoma. Transferred for\n further management from . Admitted to the ICU for CVVH for\n possible tumour lysis syndrome.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Very recent dx of high grade Lymphoma Possible Burkitts.\n Action:\n Last evening pt received the 3^rd dose of 5 Cytoxin doses. #4 tonight.\n During the day shift yesterday pt received 2 units of prbc fro Hct of\n 20. pt is having the tumor lysis labs q4 hrs and is getting a cbi for\n bladder protectin. Pt will receive 2 units of prbc and FFp this am.,\n Response:\n Pending\n Plan:\n Pt will receive chemo tonight. Possible scan in future looking for\n obstruction.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt is making urine each hour but with cbi difficult to assess the\n hourly amt. No clots noted in the urine. Urine does color at pink, at\n times with pyridium.\n Action:\n Pt is on pyridium, ditropan. Pt is also getting morphine for painful\n bladder. pt has complained of\n I need to pee and I can\n since adm\n to micu. Foley has been maually irriganted many times with some small\n clots noted in the previous days. Pt remains on CVVH. Pre pump\n increased to 4000cc. CVVH stopped at 0615 with line issues which will\n be addressed today\n Response:\n Hemodynamically stabe.\n Plan:\n Cont with cvvh while pt is getting chemo. Will probably do a CT scan\n for possible obstruction after cvvvh.\n" }, { "category": "Nursing", "chartdate": "2133-12-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616196, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade burkits lymphoma. Transferred\n for further management from . Admitted to the ICU for CVVH\n for tumor lysis syndrome.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with ? UTI dx in OSH; known renal calculi with hydronephrosis.\n creatinine high at 3.0/ BUN of 39; Started on CVVH for tumor lysis\n syndrome and while she is on chemotherapy; CVVH machine alarming air in\n the system and filter changed twice overnight; 10L positive I/O had\n 1100cc of urine out 17 hrs after 3L NS ( CBI) hang yesterday\n Action:\n CVVHD initiated 0920 this am, replacement fluid running at 4200 ml/hr (\n 4000 PBP) and dialysate at 1000ml/hr with goal to run patient even;\n calculated urine output at 60cc/hr in reference to 1100 output via CBI\n for 17hrs; BUN and phos drawn from , and effluent at\n 1500; results are (Effluent) 17/2.2 () 19/2.1 ( 25/3.2)\n renal aware of results; ports reversed ( access port switched with\n return port)\n Response:\n 1000 cc urine out from CBI at 1800 ( for 9hrs from 0900-1800 that\n about 100cc/hr);\n Plan:\n Continue with CVVH with goal of even; urine output of 100cc/hr is goal\n while on cytoxan\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n + burkits lymphoma, continues on CBI in the setting of hematuria\n previous days but kept her on CBI to flush kidney while getting\n chemotherapy; urine and clear;\n Action:\n TLS labs q6h includingcoags and fibrinogen. Pre-medicated for chemo, 40\n mg IV decadron and Zofran. 1 mg ativan given for anxiety/restlessness.\n Allopurinol 100mgs daily; received decadron and zofran pre chemo\n Response:\n K 3.6 this pm, phos down to 3.2, ionized calcium 0.96\n on KCL and\n Calcium gluconate repletion, uric acid down to 5.6 form 8.0 this am;\n Coags stable FDP 10-40;\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and\n Fibrinogen. Cytoxan at tonight\n" }, { "category": "Nursing", "chartdate": "2133-12-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 615753, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade lymphoma. Transferred for\n further management from . Admitted to the ICU for CVVH for\n possible tumour lysis syndrome.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2133-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616346, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade burkits lymphoma. Transferred\n for further management from . Admitted to the ICU for CVVH\n for tumor lysis syndrome.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with ? UTI dx in OSH; known renal calculi with hydronephrosis.\n creatinine high at 3.0/ BUN of 39; Started on CVVH for tumor lysis\n syndrome and while she is on chemotherapy; CVVH machine alarming air in\n the system and filter changed twice overnight; 10L positive I/O had\n 1100cc of urine out 17 hrs after 3L NS ( CBI) hang yesterday; reversed\n - access port switched with return port yesterday\n Action:\n CVVHD initiated 12noon, replacement fluid changed to K4 running at 4200\n ml/hr ( 4000 PBP) and dialysate at 1000ml/hr with goal to keep patient\n 50cc/hr negative; negative but per oncology and ICU team we can run\n patient 1-2 liters negative since she is almost 11L positive for LOS\n and desatted down 87-88% this am calculated urine output at 80cc/hr in\n reference to 1000 output via CBI for 12hrs; ports\n Response:\n 1000 cc urine out from CBI at 1800 ( for 9hrs from 0900-1800 that\n about 100cc/hr);\n Plan:\n Continue with CVVH with goal to keep her 50cc/hr; urine output of\n 100cc/hr is goal while on cytoxan\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n + burkits lymphoma, continues on CBI in the setting of hematuria\n previous days but kept her on CBI to flush kidney while getting\n chemotherapy; urine and clear;\n Action:\n TLS labs q6h includingcoags and fibrinogen. Pre-medicated for chemo, 40\n mg IV decadron and Zofran. 1 mg ativan given for anxiety/restlessness.\n Allopurinol 100mgs daily; received decadron and zofran pre chemo; last\n dose of cytoxan given this afternoon\n Response:\n K 3.6 this pm, phos down to 3.2, ionized calcium 0.96\n on KCL and\n Calcium gluconate repletion, uric acid down to 5.6 form 8.0 this am;\n Coags stable FDP 10-40;\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and\n Fibrinogen.\n" }, { "category": "Physician ", "chartdate": "2133-12-10 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 615545, "text": "TITLE:\n Chief Complaint:\n HPI:\n 62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade lymphoma. Transferred for\n further management from . Admitted to the ICU for CVVH for\n possible tumour lysis syndrome.\n Pt states that 4 weeks ago she noted some jaw pain as well as total\n body weakness, malaise, \"body burning sensation\". She had also noted\n some decreased appetite to food and water, insomnia accompanied by a\n bloating sensation in her abdomen. She saw her PCP last for a\n check up and received bld work which was noted to be 'abnormal'.\n Unfortunately she was not told what labs were abnormal, given her\n malaise she decided to come to the ED. In the \n ED she was noted to have a leukocytosis of 27.2, in addition to w/\n Creatinine of 2.2, Plt 66, LDH 25, 348. She was initially given\n Ceftriaxone for ?UTI given appearance of her urine. 4+ bacteria, \n WBC were seen on a U/A that was notable for squamous cells. As part of\n her work up she underwent a CT torso which showed Left Subclavian node,\n retroperitoneal adenopathy, L hydronephrosis. She was then referred to\n the ED on day of admission.\n In the ED her initial vitals were noted to be T99.0, HR 110, BP 126/72,\n RR 14, Sat 99%. Her labs were notable for a leukocytosis of 28.4 with\n 29N, Band 4, L 23, M14, E11, B1, Meta5, Myelos1, Nrbcs5, Other 12.\n BUN/Creatinine 38/2.4, Glc 66. Uric Acid 26.3, LDH 26, 420, AST 211,\n ALT 65, Ca .4, K 3.8, Ph 4.2, TB 1.6, Alk Phos 477. Fibrinogen 266.\n Oncology were consulted given the suspicion for Lymphoma and obtained a\n BM bx, cytology was obtained from aspirate.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n Levothyroxine 100mcg daily\n Furosemide dose unknown daily\n Lipitor unknown\n Calcium\n Vitamin D\n Past medical history:\n Family history:\n Social History:\n Hypothyroidism\n Hyperlipidemia\n Sister - Cirrhosis, Brother - DM, Anterograde Amnesia. Denies any h.o.\n lymphoma or other malignancies.\n Pt currently works as a system analysis at NHIC. She denies any Etoh,\n tobacco or IVDU history.\n Review of systems:\n Flowsheet Data as of 10:52 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 117 (117 - 120) bpm\n BP: 133/54(72) {124/54(69) - 133/54(72)} mmHg\n RR: 25 (25 - 27) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 61 Inch\n Total In:\n 1,000 mL\n PO:\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 825 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GENERAL: Fatigued appearing Caucasian Female lying down in bned in NARD\n HEENT: No scleral icterus, PERRL, EOMI.\n Neck: No LAD noted.\n CARDIAC: Regular rhythm, tachy (110 bpm). Normal S1, S2. No murmurs,\n rubs or .\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Soft, distended, tender in the epigastric region. No HSM\n EXTREMITIES: No edema noted.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout.\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Prelim read from Heme-Path suggests large cell lymphoma w/ vacuoles\n suggestive of possible Burkitt's Lymphoma. Oncology has already seen pt\n and recommends initiating treatment with steroids. Concern that this\n may be high grade lymphoma given progression, LDH level. Pt received CT\n torso from OSH, films in chart. On review of pt's labs although she\n does not qualify for tumour lysis syndrome given her normal Phos,\n elevated Ca her LDH, Uric Acid suggests the possibility of tumour lysis\n syndome once treatment begins. Will thus consult Nephrology for\n possible CVVH initiation tonight, per Onc recs will start on\n Dexamethasone 40 mg IV once CVVH is initiated given the likelihood of\n TLS. Will check tumour lysis labs (K, Creatinine, Ca, Phos, Mg, LDH) as\n well as DIC labs. Will also start on Rasburicase for uric acid\n converion.\n - will upload CT torso films in PACS\n - will check TLS labs q4hrs (K, Cr, Ca, Mg, Ph, LDH)\n - will give Rasburicase 7.5mg IV x 1 now\n - will check Uric Acid level 4 hours after Rasburicase per Rasburicase\n protocol\n - f/u heme onc recs\n - will check EBV, CMV, HIV viral loads, antibody panels\n - will give Dexamthasone 40mg IV x 1 once CVVH is initiated\n - check Echo in the AM, to eval systolic function\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Tumour Lysis\n As mentioned above pt noted to have elevated uric acid, however\n phosphorous is still low, Calcium is high. Given LDH and suspected high\n grade lymphoma have high suspicion for tumour lysis syndrome once\n dexamethasone is started.\n - will continue to monitor Tumour lysis labs q3hrs\n - pt receiving Rasburicase for Uric Acid conversion for renal\n protection\n - will place HD line and start CVVH\n - will start Allopurinol in the AM\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis given her prior labs from . Pt\n will start CVVH given the anticipation of possible TLS from tumour\n response to dexamethasone.\n - will start on CVVH\n - f/u renal recs\n - trend Creatinine\n - will continue with 3amps HCO in D5W @ 250cc/hr\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n URINARY TRACT INFECTION (UTI)\n Pt was given IV Ceftriaxone for ?UTI however U/A was notable for\n several epi cells in addition to bacteria. No dysuria noted, urine\n appearance likely related to her , recheck U/A and urine\n culture.\n - recheck U/A, Urine culture\n - contact OSH for culture results\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact son in the AM to reconciliate Furosemide, Lipitor\n dosing.\n ICU Care\n Nutrition: Regular Diet, replete lytes PRN\n Glycemic Control:\n Lines:\n 18 Gauge - 08:17 PM\n 20 Gauge - 08:18 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: Patient, Husband \n status: FULL CODE\n Disposition: Pending resolution of symptoms.\n" }, { "category": "Nursing", "chartdate": "2133-12-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 615703, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade lymphoma. Transferred for\n further management from . Admitted to the ICU for CVVH for\n possible tumour lysis syndrome.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n No c/o pain except neck..where dialysis line is.\n ?? abdomen getting larger.. Somewhat firm, no bowel sounds\n Decreasing uric acid and ionized calcium\n Pt has been bleeding from neck line all day\n Action:\n Bladder pressure checked\n Given dose of dexamethasone this am\n Given 2 u FFP for bleeding\n Response:\n Bladder pressure =12\n Continues to bleed\n Plan:\n Per heme-onc to start Chemo this evening..\n Will continue to follow labs and bladder pressures\n Renal to change line, follow bleeding, coags..\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt restarted on CVVHD early am.\n Difficulty with access line spasming when attempting high flows also\n setting off high access alarms whenever pt moved..\n Pt having minimal urine output..dark, thick bloody drainage\n Action:\n Renal is changing line to arrow catheter\n Tried to manually irrigate foley,\n Changed to a 3-way\n Response:\n Able to do CVVHD uninterrupted for a few hours\ndecrease in uric acid\n and LDH\n Line eventually not working well\n Unable to irrigate foley d/t clots\n Plan:\n To start bladder irrigation..\n Restart CVVHD once line replaced\n Social:\n Pt son and wife and Pts husband in to visit..\n Another son .. and girlfriend in.\n Heme-onc spoke with them at length about their mothers condition and\n plan of care.\n Social service also met with son \n social service also aware.\n" }, { "category": "Physician ", "chartdate": "2133-12-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 615832, "text": "TITLE:\n Chief Complaint: denies any pain, feeling improved from yesterday\n 24 Hour Events:\n - hematuria and oozing from HD line, however no coagulopathy on labs,\n received 2 U FFP\n - Foley with hematuria and clots, got clogged and had to place 3way\n for bladder irrigation, was not retrieving much urine, bladder scan for\n only 200cc, urine coming out was clearing of , need to call\n urology in AM\n - started CODOX with dexameth 40IV qd\n - tumor lysis labs stable, DIC labs stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Lorazepam (Ativan) - 07:29 PM\n Famotidine (Pepcid) - 09:13 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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.3\nC (95.5\n HR: 96 (75 - 103) bpm\n BP: 122/61(83) {98/47(66) - 154/81(104)} mmHg\n RR: 22 (14 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Bladder pressure: 12 (12 - 12) mmHg\n Total In:\n 7,169 mL\n 926 mL\n PO:\n TF:\n IVF:\n 6,604 mL\n 926 mL\n products:\n 565 mL\n Total out:\n 2,902 mL\n 2,681 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 4,267 mL\n -1,755 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.45/46/106/21/1\n Physical Examination\n GENERAL: Somnolent but arousable, Caucasian Female lying down in bed\n in NAD, AOx3\n HEENT: No scleral icterus, PERRL, EOMI.\n Neck: No LAD noted.\n CARDIAC: Regular rhythm, tachy (110 bpm). Normal S1, S2. No murmurs,\n rubs or .\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Soft, distended, tender in the epigastric region. No HSM\n EXTREMITIES: No edema noted.\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 97 K/uL\n 8.7 g/dL\n 116 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 94 mEq/L\n 135 mEq/L\n 25.3 %\n 34.5 K/uL\n [image002.jpg]\n 08:20 AM\n 08:41 AM\n 10:32 AM\n 10:51 AM\n 12:39 PM\n 02:26 PM\n 05:35 PM\n 09:55 PM\n 11:49 PM\n 04:36 AM\n WBC\n 19.8\n 29.0\n 34.5\n Hct\n 22.9\n 23.5\n 25.3\n Plt\n 86\n 88\n 97\n Cr\n 2.8\n 2.5\n 2.0\n 2.2\n 1.8\n 1.6\n TCO2\n 28\n 29\n Glucose\n 135\n 138\n 143\n 161\n 197\n 134\n 116\n Other labs: PT / PTT / INR:14.8/23.1/1.3, ALT / AST:49/171, Alk Phos /\n T Bili:346/2.3, D-dimer:510 ng/mL, Fibrinogen:534 mg/dL, Lactic\n Acid:5.7 mmol/L, LDH: IU/L, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.1 mg/dL\n .\n TTE:\n The left atrium is mildly dilated. Left ventricular wall thicknesses\n are normal. The left ventricular cavity size is normal. Overall left\n ventricular systolic function is normal (LVEF>55%). Right ventricular\n chamber size and free wall motion are normal. The aortic valve leaflets\n (3) appear structurally normal with good leaflet excursion and no\n aortic regurgitation. There is no aortic valve stenosis. The mitral\n valve leaflets are mildly thickened. There is no mitral valve prolapse.\n Trivial mitral regurgitation is seen. There is mild pulmonary artery\n systolic hypertension. There is no pericardial effusion.\n RUQ U/S\n 1. No intra or extrahepatic biliary dilatation. CBD 2 mm.\n 2. No evidence of cholecystitis.\n 3. Several sub-cm nonobstructing right renal collecting system calculi,\n as\n seen on OSH CT.\n 4. Mild left hydronephrosis with no left renal calculi seen, as on OSH\n CT.\n 5. Enlarged uterus.\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and high risk for tumor lysis\n syndrome. On review of pt's labs although she does not qualify for\n tumour lysis syndrome given her normal Phos, elevated Ca her LDH, Uric\n Acid suggests the possibility of tumour lysis syndome with treatment.\n Received Rasburicase for uric acid converion. Pt intiated CVVH and\n CODOX yesterday. Labs remained stable.\n - cont dexa 40 mg IV daily, CODOX per heme/onc orders\n - cont allopurinol 100 mg daily\n - appreciate heme/onc recs\n - will check TLS labs q4hrs (K, Cr, Ca, Mg, Ph, LDH)\n - DIC labs q6h\n - f/u EBV, CMV, HIV viral loads, antibody panels\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Has renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD. Had marginal urine output. Pt on CVVH given the anticipation\n of possible TLS from tumour response to dexamethasone.\n - on CVVH, will readdress goal fluid balance with renal and BMT\n - currently would run her even given decreased BP and tachycardia with\n aggressive diuresis overnight, our goal is to maintain adequate\n hydration and prevent TLS and not necessarily to diurese\n - f/u renal recs\n - trend Creatinine\n .\n ##. COAGULOPATHY: Pt had profuse oozing from HD site, with associated\n Hct drop yesterday. Also had hematuria, requiring CBI with 3way Foley.\n No evidence of coagulopathy by PTT/INR. Received 2 U FFP despite normal\n INR. Cryo\ns pending. Pt is not receiving anticoagulation in CVVH.\n Likely has platelet qualitative dysfunction.\n - monitor Foley output, trial off CBI this AM since saline coming\n through is now clear\n - consider urology consult if concerned\n - monitor q6h coags for r/o DIC\n - f/u cryo and give cryo if needed\n - if continued bleeding or Hct drop, give ddAVP to stabilize presumed\n plt dysfunction\n .\n URINARY TRACT INFECTION (UTI)\n Pt was given IV Ceftriaxone for ?UTI however U/A was notable for\n several epi cells in addition to bacteria. Patient complained of\n bladder discomfort with Foley in place, improved with pyridium. Repeat\n UA may suggest infection, although urine cx still pending. Leukocytosis\n and fever are difficult to follow in this patient given lymphoma and\n CVVH.\n - review OSH imaging for perinephric stranding\n - follow up Urine culture OSH and here and consider treatment\n .\n ##. Anion Gap Acidosis: Pt noted to have an anion gap acidosis on\n admission, likely lactic acidosis given her aggressive lymphoma. AG 20\n today.\n - will check lactate level\n - trend chemistry panel\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n -\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact son in the AM to reconciliate Furosemide, Lipitor\n dosing.\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines:\n 18 Gauge - 08:17 PM\n Dialysis Catheter - 12:00 AM\n 20 Gauge - 04:50 AM\n Prophylaxis:\n DVT: P. boots\n Stress ulcer: Ranitidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: pending initiation of methotrexate\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n On this day I examined Ms and reviewed her historical, lab, and\n imaging data. I was present for the key portions of the services\n provided. I also have reviewed Dr \ns note above and agree with\n her findings and plan of care. The patient has Burkitt\ns lymphoma with\n nephropathy likely due to uric acid from her huge tumor burden (LDH\n 25,000) and from some mild left hydronephrosis from retroperitoneal\n adenopathy. She also has lactic acidosis (AG 20), likely from her\n tumor burden as well, though she is compensating fine. Chemo with\n Cytoxan and high dose Decadron has been started and the goal is to keep\n her hydrated and keep her and kidneys flushed out with the help\n of IVF and CVVH. Frequent lab checks in order. She is somnolent but\n arousable and answers questions appropriately when asked.\n 40 min spent in the care of this critically ill patient.\n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 14:38 ------\n" }, { "category": "Physician ", "chartdate": "2133-12-11 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 615553, "text": "Chief Complaint: Acute renal failure, lysis syndrome\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 62 year old woman with one month hx of fatigue. Diagnosed with high\n grade lymphoma. Has had decreased appetite, malaise. Had labs drawn\n last week. Told this week, she had abnormal blood tests. Went to S.\n hospital where WBC was 22 with elevated creat and LDH > 20,000.\n CT of chest/abdomen showed retroperitoneal nodes and hydronephrosis on\n the left. UA showed bacteria and a few WBC's with epis. Started on\n ceftriaxone.\n Peripheral smear felt consistent with Burkitts lymphoma. Transferred to\n for further care.\n HR has been >120. WBC 28.4 with premature elements. Creat 2.4. Mild\n transaminitis, UA greatly elevated. Patient admitted to the MICU. Bone\n marrow bx performed by Heme-onc service.\n Patient admitted from: Transfer from other hospital, S Shore\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Hypothyroidism\n Hyperlipidemia\n Meds at home: thryoxine, furosemide\n cirrhosis, DM\n Occupation: systems analyst\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Flowsheet Data as of 12:44 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 114 (107 - 125) bpm\n BP: 128/56(74) {99/49(63) - 136/63(78)} mmHg\n RR: 18 (17 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 61 Inch\n Total In:\n 1,000 mL\n PO:\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 175 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 825 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ////\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 Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: No(t) Normal, 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: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath\n Sounds: Clear : Anterior and lateral)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right lower extremity edema: Absent edema, Left lower\n extremity edema: Absent, 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): X 3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 31\n 2.9 mg/dL\n 3.4 mEq/L\n [image002.jpg]\n 09:43 PM\n Cr\n 2.9\n Other labs: PT / PTT / INR:15.5/23.1/1.4, Fibrinogen:538 mg/dL,\n LDH:, Ca++:10.6 mg/dL, Mg++:2.2 mg/dL, PO4:4.9 mg/dL\n Imaging: CXR: no infiltrates or effusions. No hilar or mediastinal\n adenopathy\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Tumour Lysis\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n TACHYCARDIA, OTHER\n HYPOTHYROIDISM\n URINARY TRACT INFECTION (UTI)\n ACIDOSIS\n ANEMIA\n =============================\n Patient with new diagnosis of large cell lymphoma with evidence of very\n active tumor with tumor lysis even before treatment started. Patient\n with minimal urine output; small amounts of bloody urine in Foley\n catheter. Patient likely has tubular damage from uric acid with element\n of hydronephosis on left. Patient to start on dexamethasone.\n Clinically, patient appears intravascularly volume depleted - would\n give fluid bolus now. CVVH to be started to aid with clearance of\n electrolytes with initiation of chemotherapy (dexamethasone) and tumor\n lysis.\n Anion gap acidosis present. Would check lactate. Her renal failure is\n likely a major contributing cause to the anion gap as well. Patient\n getting liter of D5W with 3 amps of sodium bicarbonate. Oxygenation\n good with no supplemental oxygen.\n Hct is down. Stool guaiac to be checked. No obvious bleeding. Probably\n relates to her underlying malignancy. Not at transfusion threshold.\n Diagnosis of UTI not well substantiated. Given anuria, will hold\n antibiotics for now.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 08:17 PM\n 20 Gauge - 08:18 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments: Not indicated.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 60minutes\n Patient is critically ill\n" }, { "category": "General", "chartdate": "2133-12-11 00:00:00.000", "description": "ICU Event Note", "row_id": 615554, "text": "Clinician: Attending\n I supervised the renal fellow, Dr. in placment of dialysis catheter\n in right IJ. Vein visualized easily with ultrasound. Procedure\n performed under sterile conditions. Time out conducted. Vein accessed\n on first pass. Wire and catheter passed easily. Wire removed. No\n apparent complications. CXR pending.\n Total time spent: 30 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2133-12-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 615888, "text": "Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt was dx with high grade lymphoma, possible Burkitts. Team suspects\n that the bladder pain is due to the lymphoma.\n Action:\n Pt on CVVH. Foley irrigated several times with no clots noted.,\n irrigated easily. Pyridium changed to q4 hours and ditropan ordered.\n Morphine 2mg iv given with relief noted. Pt received day 2 of chemo\n last evening, Cytoxin.\n Response:\n Pt very restless and cont to say\n I have to pee\n pyridium was very\n helpful yesterday but has not been effective this shift. Ditropan was\n helpful for a short while but pt very uncomfortable within 1.5 hours.\n Pt so restless that both periph ivs were dislodged. Morphine more\n effective in pain relief.\n Plan:\n Pt may be placed on scheduled pain meds. Cont with chemo days 3,4 and\n 5.BMT will reevaluate goals today.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O 30-45cc hr. urine in color, due to pyridum. Last Bun/Creat\n 25/1.0( pt on CVVH). ARF and hydronephrosis\n Action:\n Pt remains on CVVH. Team stated they would like pt to run neg if able\n to tolerate.\n Response:\n Pt is tolerating CVVH well.\n Plan:\n Cont with cvvh and repleat the lytes as needed.\n lll\n" }, { "category": "Nursing", "chartdate": "2133-12-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 615612, "text": "Pt is a 62 year old lady with a 4 week hx of not feeling well, fatigued\n with insomnia and decreased po intake. Went to see Pcp and with the\n labs it was discovered pt had Lymphoma of a high grade. hosp\n and was transferred to for further treatment . transferred to\n MIcu for further treatment.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt dx with new onset high grade lymphoma.\n Action:\n Oncology was consulted pt received Rasburicase for uric acid levels.\n Labs done q4hrs. pt was to start CVVH but have had trouble with\n machine. Currently attempting troubleshooting\n Response:\n pending\n Plan:\n Follow heme onc recs. CVVH\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat 3.0 ARF\n Action:\n Cvvh started\n Response:\n Currently pending\n Plan:\n Cont cvvh\n Urinary tract infection (UTI)\n Assessment:\n Occ bacteria in urine. Urine bloody\n Action:\n Foley changed\n Response:\n pending\n Plan:\n Cont with cvvh and follow urine\n" }, { "category": "Nursing", "chartdate": "2133-12-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 615933, "text": "Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt was dx with high grade lymphoma, possible Burkitts. Team suspects\n that the bladder pain is due to the lymphoma.\n Action:\n Pt on CVVH. Foley irrigated several times with no clots noted.,\n irrigated easily. Pyridium changed to q4 hours and ditropan ordered.\n Morphine 2mg iv given with relief noted. Pt received day 2 of chemo\n last evening, Cytoxin.\n Response:\n Pt very restless and cont to say\n I have to pee\n pyridium was very\n helpful yesterday but has not been effective this shift. Ditropan was\n helpful for a short while but pt very uncomfortable within 1.5 hours.\n Pt so restless that both periph ivs were dislodged. Morphine more\n effective in pain relief.\n Plan:\n Pt may be placed on scheduled pain meds. Cont with chemo days 3,4 and\n 5.BMT will reevaluate goals today.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O 30-45cc hr. urine in color, due to pyridum. Last Bun/Creat\n 25/1.0( pt on CVVH). ARF and hydronephrosis\n Action:\n Pt remains on CVVH. Team stated they would like pt to run neg if able\n to tolerate.\n Response:\n Pt is tolerating CVVH well.\n Plan:\n Cont with cvvh and repleat the lytes as needed.\n lll\n" }, { "category": "Physician ", "chartdate": "2133-12-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 615948, "text": "Chief Complaint: Burkitt's lymphoma, acute renal failure, tumor lysis\n 24 Hour Events:\n - day 2 cytoxan and decadron, tolerating well\n - CVVH continues, evidence of TLS on labs\n - no evidence of DIC or hemorrhage\n - goal Is/Os even to (-) one liter\n - CVVH intermittently stopped overnight air infiltrate\n - c/o bladder spasm\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:33 PM\n Lorazepam (Ativan) - 12:00 AM\n Morphine Sulfate - 04:20 AM\n Other medications:\n Changes to medical and family history:\n sleeping this morning, denies pain, bladder spasm improving\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Genitourinary: Foley\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.3\nC (97.3\n HR: 85 (76 - 109) bpm\n BP: 123/64(85) {91/47(63) - 172/92(124)} mmHg\n RR: 15 (12 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 5,210 mL\n 1,176 mL\n PO:\n TF:\n IVF:\n 5,210 mL\n 1,176 mL\n Blood products:\n Total out:\n 6,113 mL\n 1,855 mL\n Urine:\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n -903 mL\n -679 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.45///21/\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: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 60 K/uL\n 6.9 g/dL\n 171 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 4.5 mEq/L\n 39 mg/dL\n 96 mEq/L\n 132 mEq/L\n 20.1 %\n 6.5 K/uL\n [image002.jpg]\n 12:39 PM\n 02:26 PM\n 05:35 PM\n 09:55 PM\n 11:49 PM\n 04:36 AM\n 09:59 AM\n 03:51 PM\n 08:42 PM\n 04:13 AM\n WBC\n 19.8\n 29.0\n 34.5\n 16.9\n 6.5\n Hct\n 22.9\n 23.5\n 25.3\n 22.1\n 20.1\n Plt\n 86\n 88\n 97\n 80\n 60\n Cr\n 2.0\n 2.2\n 1.8\n 1.6\n 1.4\n 1.0\n 1.0\n Glucose\n 143\n 161\n 197\n 134\n 116\n 112\n 114\n 171\n Other labs: PT / PTT / INR:13.5/21.3/1.2, CK / CKMB / Troponin-T:331//,\n ALT / AST:35/109, Alk Phos / T Bili:280/1.4, D-dimer:510 ng/mL,\n Fibrinogen:333 mg/dL, Lactic Acid:1.8 mmol/L, LDH: IU/L, Ca++:7.4\n mg/dL, Mg++:2.3 mg/dL, PO4:8.3 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n > Hct\n > Thrombocytopenia\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Tumour Lysis\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n TACHYCARDIA, OTHER\n HYPOTHYROIDISM\n URINARY TRACT INFECTION (UTI)\n HYPERCALCEMIA (HIGH CALCIUM)\n HYPERPHOSPHATEMIA (HIGH PHOSPHATE)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2133-12-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 615949, "text": "Chief Complaint: Burkitt's lymphoma, acute renal failure, tumor lysis\n 24 Hour Events:\n - day 2 cytoxan and decadron, tolerating well\n - CVVH continues, evidence of TLS on labs\n - no evidence of DIC or hemorrhage\n - goal Is/Os even to (-) one liter\n - CVVH intermittently stopped overnight air infiltrate\n - c/o bladder spasm\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:33 PM\n Lorazepam (Ativan) - 12:00 AM\n Morphine Sulfate - 04:20 AM\n Other medications:\n Changes to medical and family history:\n sleeping this morning, denies pain, bladder spasm improving\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Genitourinary: Foley\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.3\nC (97.3\n HR: 85 (76 - 109) bpm\n BP: 123/64(85) {91/47(63) - 172/92(124)} mmHg\n RR: 15 (12 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 5,210 mL\n 1,176 mL\n PO:\n TF:\n IVF:\n 5,210 mL\n 1,176 mL\n Blood products:\n Total out:\n 6,113 mL\n 1,855 mL\n Urine:\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n -903 mL\n -679 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.45///21/\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: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 60 K/uL\n 6.9 g/dL\n 171 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 4.5 mEq/L\n 39 mg/dL\n 96 mEq/L\n 132 mEq/L\n 20.1 %\n 6.5 K/uL\n [image002.jpg]\n 12:39 PM\n 02:26 PM\n 05:35 PM\n 09:55 PM\n 11:49 PM\n 04:36 AM\n 09:59 AM\n 03:51 PM\n 08:42 PM\n 04:13 AM\n WBC\n 19.8\n 29.0\n 34.5\n 16.9\n 6.5\n Hct\n 22.9\n 23.5\n 25.3\n 22.1\n 20.1\n Plt\n 86\n 88\n 97\n 80\n 60\n Cr\n 2.0\n 2.2\n 1.8\n 1.6\n 1.4\n 1.0\n 1.0\n Glucose\n 143\n 161\n 197\n 134\n 116\n 112\n 114\n 171\n Other labs: PT / PTT / INR:13.5/21.3/1.2, CK / CKMB / Troponin-T:331//,\n ALT / AST:35/109, Alk Phos / T Bili:280/1.4, D-dimer:510 ng/mL,\n Fibrinogen:333 mg/dL, Lactic Acid:1.8 mmol/L, LDH: IU/L, Ca++:7.4\n mg/dL, Mg++:2.3 mg/dL, PO4:8.3 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n > Hct\n > Thrombocytopenia\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Tumour Lysis\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n TACHYCARDIA, OTHER\n HYPOTHYROIDISM\n URINARY TRACT INFECTION (UTI)\n HYPERCALCEMIA (HIGH CALCIUM)\n HYPERPHOSPHATEMIA (HIGH PHOSPHATE)\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and high risk for tumor lysis\n syndrome. On review of pt's labs although she does not qualify for\n tumour lysis syndrome given her normal Phos, elevated Ca her LDH, Uric\n Acid suggests the possibility of tumour lysis syndome with treatment.\n Received Rasburicase for uric acid converion. Pt intiated CVVH and\n CODOX yesterday. Labs remained stable.\n - cont dexa 40 mg IV daily, CODOX per heme/onc orders\n - cont allopurinol 100 mg daily\n - appreciate heme/onc recs\n - will check TLS labs q4hrs (K, Cr, Ca, Mg, Ph, LDH)\n - DIC labs q6h\n - f/u EBV, CMV, HIV viral loads, antibody panels\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Has renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD. Had marginal urine output. Pt on CVVH given the anticipation\n of possible TLS from tumour response to dexamethasone.\n - on CVVH, will readdress goal fluid balance with renal and BMT\n - currently would run her even given decreased BP and tachycardia with\n aggressive diuresis overnight, our goal is to maintain adequate\n hydration and prevent TLS and not necessarily to diurese\n - f/u renal recs\n - trend Creatinine\n .\n ##. COAGULOPATHY: Pt had profuse oozing from HD site, with associated\n Hct drop yesterday. Also had hematuria, requiring CBI with 3way Foley.\n No evidence of coagulopathy by PTT/INR. Received 2 U FFP despite normal\n INR. Cryo\ns pending. Pt is not receiving anticoagulation in CVVH.\n Likely has platelet qualitative dysfunction.\n - monitor Foley output, trial off CBI this AM since saline coming\n through is now clear\n - consider urology consult if concerned\n - monitor q6h coags for r/o DIC\n - f/u cryo and give cryo if needed\n - if continued bleeding or Hct drop, give ddAVP to stabilize presumed\n plt dysfunction\n .\n URINARY TRACT INFECTION (UTI)\n Pt was given IV Ceftriaxone for ?UTI however U/A was notable for\n several epi cells in addition to bacteria. Patient complained of\n bladder discomfort with Foley in place, improved with pyridium. Repeat\n UA may suggest infection, although urine cx still pending. Leukocytosis\n and fever are difficult to follow in this patient given lymphoma and\n CVVH.\n - review OSH imaging for perinephric stranding\n - follow up Urine culture OSH and here and consider treatment\n .\n ##. Anion Gap Acidosis: Pt noted to have an anion gap acidosis on\n admission, likely lactic acidosis given her aggressive lymphoma. AG 20\n today.\n - will check lactate level\n - trend chemistry panel\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n -\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact son in the AM to reconciliate Furosemide, Lipitor\n dosing.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2133-12-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 615606, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Many issues with CVVH overnight, delayed methylpred until cvvh was\n fully functional.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.2 grams/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 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 101 (101 - 125) bpm\n BP: 113/51(64) {99/49(63) - 136/97(104)} mmHg\n RR: 17 (17 - 27) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 61 Inch\n Total In:\n 1,000 mL\n 125 mL\n PO:\n TF:\n IVF:\n 500 mL\n 125 mL\n Blood products:\n Total out:\n 175 mL\n 74 mL\n Urine:\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 825 mL\n 51 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\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 89 K/uL\n 10.2 g/dL\n 124 mg/dL\n 3.0 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 38 mg/dL\n 94 mEq/L\n 136 mEq/L\n 29.9 %\n 27.2 K/uL\n [image002.jpg]\n 09:43 PM\n 11:46 PM\n 03:50 AM\n WBC\n 27.2\n Hct\n 29.9\n Plt\n 89\n Cr\n 2.9\n 2.8\n 3.0\n Glucose\n 124\n Other labs: PT / PTT / INR:15.6/24.1/1.4, D-dimer:510 ng/mL,\n Fibrinogen:532 mg/dL, Lactic Acid:5.3 mmol/L, LDH: IU/L, Ca++:10.2\n mg/dL, Mg++:2.1 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Tumour Lysis\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n TACHYCARDIA, OTHER\n HYPOTHYROIDISM\n URINARY TRACT INFECTION (UTI)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:17 PM\n Dialysis Catheter - 12:00 AM\n 20 Gauge - 04:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2133-12-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 615608, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Many issues with CVVH overnight, delayed methylpred until cvvh was\n fully functional.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.2 grams/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 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 101 (101 - 125) bpm\n BP: 113/51(64) {99/49(63) - 136/97(104)} mmHg\n RR: 17 (17 - 27) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 61 Inch\n Total In:\n 1,000 mL\n 125 mL\n PO:\n TF:\n IVF:\n 500 mL\n 125 mL\n Blood products:\n Total out:\n 175 mL\n 74 mL\n Urine:\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 825 mL\n 51 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\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 89 K/uL\n 10.2 g/dL\n 124 mg/dL\n 3.0 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 38 mg/dL\n 94 mEq/L\n 136 mEq/L\n 29.9 %\n 27.2 K/uL\n [image002.jpg]\n 09:43 PM\n 11:46 PM\n 03:50 AM\n WBC\n 27.2\n Hct\n 29.9\n Plt\n 89\n Cr\n 2.9\n 2.8\n 3.0\n Glucose\n 124\n Other labs: PT / PTT / INR:15.6/24.1/1.4, D-dimer:510 ng/mL,\n Fibrinogen:532 mg/dL, Lactic Acid:5.3 mmol/L, LDH: IU/L, Ca++:10.2\n mg/dL, Mg++:2.1 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Prelim read from Heme-Path suggests large cell lymphoma w/ vacuoles\n suggestive of possible Burkitt's Lymphoma. Oncology has already seen pt\n and recommends initiating treatment with steroids. Concern that this\n may be high grade lymphoma given progression, LDH level. Pt received CT\n torso from OSH, films in chart. On review of pt's labs although she\n does not qualify for tumour lysis syndrome given her normal Phos,\n elevated Ca her LDH, Uric Acid suggests the possibility of tumour lysis\n syndome once treatment begins. Will thus consult Nephrology for\n possible CVVH initiation tonight, per Onc recs will start on\n Dexamethasone 40 mg IV once CVVH is initiated given the likelihood of\n TLS. Will check tumour lysis labs (K, Creatinine, Ca, Phos, Mg, LDH) as\n well as DIC labs. Will also start on Rasburicase for uric acid\n converion.\n - will upload CT torso films in PACS\n - f/u BM bx\n - start dex after 30-60 minutes of well working CVVH\n - will check TLS labs q4hrs (K, Cr, Ca, Mg, Ph, LDH)\n - will give Rasburicase 7.5mg IV x 1 now (pharmacy error only got 6mg)\n - will check Uric Acid level 4 hours after Rasburicase per Rasburicase\n protocol\n - will check EBV, CMV, HIV viral loads, antibody panels\n - will give Dexamthasone 40mg IV x 1 once CVVH is initiated\n - check Echo in the AM, to eval systolic function\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Tumour Lysis\n As mentioned above pt noted to have elevated uric acid, however\n phosphorous is still low, Calcium is high. Given LDH and suspected high\n grade lymphoma have high suspicion for tumour lysis syndrome once\n dexamethasone is started.\n - will continue to monitor Tumour lysis labs q3hrs\n - pt receiving Rasburicase for Uric Acid conversion for renal\n protection\n - will place HD line and start CVVH\n - will start Allopurinol in the AM\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis given her prior labs from . Pt\n will start CVVH given the anticipation of possible TLS from tumour\n response to dexamethasone.\n - will start on CVVH\n - f/u renal recs\n - trend Creatinine\n - will continue with 3amps HCO in D5W @ 250cc/hr\n .\n ##. Anion Gap Acidosis: Pt noted to have an anion gap acidosis on\n admission, likely lactic acidosis given her aggressive lymphoma.\n - will check lactate level (5.3)\n - trend chemistry panel\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n .\n URINARY TRACT INFECTION (UTI)\n Pt was given IV Ceftriaxone for ?UTI however U/A was notable for\n several epi cells in addition to bacteria. No dysuria noted, urine\n appearance likely related to her , recheck U/A and urine\n culture.\n - recheck U/A, Urine culture\n - contact OSH for culture results\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact son in the AM to reconciliate Furosemide, Lipitor\n dosing.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:17 PM\n Dialysis Catheter - 12:00 AM\n 20 Gauge - 04:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2133-12-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616043, "text": "Significant Events:\n ----BMT, renal, and MICU services discussed pt\ns fluid status and\n hydration for chemo today and have come to a goal of running pt even on\n CVVHD, not giving pre-chemo fluids but rather keeping CBI to protect\n bladder from hemorrhagic cystitis.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt received 2^nd dose of 5 cytotoxin doses. On CVVHD for txt tumor\n lysis. Plts dropping as well as Hct and WBC---most likely too early to\n be from chemo\n Action:\n Transfused 2 units PRBC for Hct 20; coags and tumor lysis labs q6h;\n premedicated for chemo; CBI to help maintain bladder integrity from\n chemo\n Response:\n Post transfusion hct 25. CBI, draining clear urine. LDH down to\n . Labs stable.\n Plan:\n Chemo this evening---2 more doses after tonight.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Running CVVHD, making more urine, 20-70 cc/hr. Urine appearing\n intermittently pink/red with NO clots. Cr down but this is due to\n CVVHD. Initally running pt slightly negative prior to fluid status\n convo. Pt with temp as low as 95.2 orally, requiring warming blanket\n Action:\n Manually flushed foley q3h and then placed pt on CBI. CVVHD with q6h\n labs---Calcium sliding scale changed. Started to run pt even at around\n 1200. Frequent rescue flushes as filter pressure rising.\n Response:\n Filter pressures stable at 160-180. Hard to asseses\n Plan:\n" }, { "category": "Nursing", "chartdate": "2133-12-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616173, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade burkitts lymphoma. Transferred\n for further management from . Admitted to the ICU for CVVH\n for tumor lysis syndrome.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with ? UTI dx in OSH; known renal calculi with hydronephrosis.\n creatinine high at 3.0/ BUN of 39; Started on CVVH for tumor lysis\n syndrome and while she is on chemotherapy; CVVH machine alarming air in\n the system and filter changed twice overnight; 10L positive I/O\n Action:\n CVVHD initiated 0920 this am, replacement fluid running at 4200 ml/hr (\n 4000 PBP) and dialysate at 1000ml/hr with goal to run patient even\n Response:\n Plan:\n Continue with CVVH with goal of even\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Received pt with CBI\nurine and clear.\n Action:\n TLS labs q6h includingcoags and fibrinogen. Pre-medicated for chemo, 40\n mg IV decadron and Zofran. 1 mg ativan given for anxiety/restlessness.\n Allopurinol 100mgs daily\n Response:\n Per latest labs, K and Ph increasing but WNL and Ca decreasing. Uric\n acid 8.0 this am, Phos 5.1 Coags stable\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and\n Fibrinogen. Cont with chemo and follow heme onc recs---chemo nurse will\n be by at 7:30. Provide emotional support to pt and to family.\n" }, { "category": "Nursing", "chartdate": "2133-12-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616176, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade burkits lymphoma. Transferred\n for further management from . Admitted to the ICU for CVVH\n for tumor lysis syndrome.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with ? UTI dx in OSH; known renal calculi with hydronephrosis.\n creatinine high at 3.0/ BUN of 39; Started on CVVH for tumor lysis\n syndrome and while she is on chemotherapy; CVVH machine alarming air in\n the system and filter changed twice overnight; 10L positive I/O had\n 1100cc of urine out 17 hrs after 3L NS ( CBI) hang yesterday\n Action:\n CVVHD initiated 0920 this am, replacement fluid running at 4200 ml/hr (\n 4000 PBP) and dialysate at 1000ml/hr with goal to run patient even\n Response:\n Plan:\n Continue with CVVH with goal of even\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n + burkits lymphoma, continues on CBI in the setting of hematuria\n previous days but kept her on CBI to flush kidney while getting\n chemotherapy; urine and clear\n Action:\n TLS labs q6h includingcoags and fibrinogen. Pre-medicated for chemo, 40\n mg IV decadron and Zofran. 1 mg ativan given for anxiety/restlessness.\n Allopurinol 100mgs daily; received decadron and zofran pre chemo\n Response:\n K 3.6 this pm, phos down to 3.2, ionized calcium 0.96\n on KCL and\n Calcium gluconate repletion, uric acid down to 5.6 form 8.0 this am;\n Coags stable FDP 10-40\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and\n Fibrinogen. Cytoxan at tonight\n" }, { "category": "Physician ", "chartdate": "2133-12-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 615789, "text": "TITLE:\n Chief Complaint: denies any pain, feeling improved from yesterday\n 24 Hour Events:\n - hematuria and oozing from HD line, however no coagulopathy on labs,\n received 2 U FFP\n - Foley with hematuria and clots, got clogged and had to place 3way\n for bladder irrigation, was not retrieving much urine, bladder scan for\n only 200cc, urine coming out was clearing of , need to call\n urology in AM\n - started CODOX with dexameth 40IV qd\n - tumor lysis labs stable, DIC labs stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Lorazepam (Ativan) - 07:29 PM\n Famotidine (Pepcid) - 09:13 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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.3\nC (95.5\n HR: 96 (75 - 103) bpm\n BP: 122/61(83) {98/47(66) - 154/81(104)} mmHg\n RR: 22 (14 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Bladder pressure: 12 (12 - 12) mmHg\n Total In:\n 7,169 mL\n 926 mL\n PO:\n TF:\n IVF:\n 6,604 mL\n 926 mL\n products:\n 565 mL\n Total out:\n 2,902 mL\n 2,681 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 4,267 mL\n -1,755 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.45/46/106/21/1\n Physical Examination\n GENERAL: Fatigued appearing Caucasian Female lying down in bed in NAD\n HEENT: No scleral icterus, PERRL, EOMI.\n Neck: No LAD noted.\n CARDIAC: Regular rhythm, tachy (110 bpm). Normal S1, S2. No murmurs,\n rubs or .\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Soft, distended, tender in the epigastric region. No HSM\n EXTREMITIES: No edema noted.\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 97 K/uL\n 8.7 g/dL\n 116 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 94 mEq/L\n 135 mEq/L\n 25.3 %\n 34.5 K/uL\n [image002.jpg]\n 08:20 AM\n 08:41 AM\n 10:32 AM\n 10:51 AM\n 12:39 PM\n 02:26 PM\n 05:35 PM\n 09:55 PM\n 11:49 PM\n 04:36 AM\n WBC\n 19.8\n 29.0\n 34.5\n Hct\n 22.9\n 23.5\n 25.3\n Plt\n 86\n 88\n 97\n Cr\n 2.8\n 2.5\n 2.0\n 2.2\n 1.8\n 1.6\n TCO2\n 28\n 29\n Glucose\n 135\n 138\n 143\n 161\n 197\n 134\n 116\n Other labs: PT / PTT / INR:14.8/23.1/1.3, ALT / AST:49/171, Alk Phos /\n T Bili:346/2.3, D-dimer:510 ng/mL, Fibrinogen:534 mg/dL, Lactic\n Acid:5.7 mmol/L, LDH: IU/L, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.1 mg/dL\n .\n TTE:\n The left atrium is mildly dilated. Left ventricular wall thicknesses\n are normal. The left ventricular cavity size is normal. Overall left\n ventricular systolic function is normal (LVEF>55%). Right ventricular\n chamber size and free wall motion are normal. The aortic valve leaflets\n (3) appear structurally normal with good leaflet excursion and no\n aortic regurgitation. There is no aortic valve stenosis. The mitral\n valve leaflets are mildly thickened. There is no mitral valve prolapse.\n Trivial mitral regurgitation is seen. There is mild pulmonary artery\n systolic hypertension. There is no pericardial effusion.\n RUQ U/S\n 1. No intra or extrahepatic biliary dilatation. CBD 2 mm.\n 2. No evidence of cholecystitis.\n 3. Several sub-cm nonobstructing right renal collecting system calculi,\n as\n seen on OSH CT.\n 4. Mild left hydronephrosis with no left renal calculi seen, as on OSH\n CT.\n 5. Enlarged uterus.\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and high risk for tumor lysis\n syndrome. On review of pt's labs although she does not qualify for\n tumour lysis syndrome given her normal Phos, elevated Ca her LDH, Uric\n Acid suggests the possibility of tumour lysis syndome with treatment.\n Received Rasburicase for uric acid converion. Pt intiated CVVH and\n CODOX yesterday. Labs remained stable.\n - cont dexa 40 mg IV daily, CODOX per heme/onc orders\n - cont allopurinol 100 mg daily\n - appreciate heme/onc recs\n - will check TLS labs q4hrs (K, Cr, Ca, Mg, Ph, LDH)\n - DIC labs q6h\n - f/u EBV, CMV, HIV viral loads, antibody panels\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis given her prior labs from . Pt\n will start CVVH given the anticipation of possible TLS from tumour\n response to dexamethasone.\n - will start on CVVH\n - f/u renal recs\n - trend Creatinine\n - will continue with 3amps HCO in D5W @ 250cc/hr\n .\n ##> COAGULOPATHY: Pt had profuse oozing from HD site, with associated\n Hct drop yesterday. Also had hematuria, requiring CBI with 3way Foley.\n No evidence of coagulopathy by PTT/INR. Received 2 U FFP despite normal\n INR. Cryo\ns pending. Pt is not receiving anticoagulation in CVVH.\n Likely has platelet qualitative dysfunction.\n - monitor Foley output, trial off CBI this AM since saline coming\n through is now clear\n - consider urology consult if concerned\n - monitor q6h coags for r/o DIC\n - f/u cryo and give cryo if needed\n - if continued bleeding or Hct drop, give ddAVP to stabilize presumed\n plt dysfunction\n .\n URINARY TRACT INFECTION (UTI)\n Pt was given IV Ceftriaxone for ?UTI however U/A was notable for\n several epi cells in addition to bacteria. Patient complained of\n bladder discomfort with Foley in place, improved with pyridium. Repeat\n UA may suggest infection, although urine cx still pending. Leukocytosis\n and fever are difficult to follow in this patient given lymphoma and\n CVVH.\n - review OSH imaging for perinephric stranding\n - follow up Urine culture OSH and here and consider resuming treatment\n .\n ##. Anion Gap Acidosis: Pt noted to have an anion gap acidosis on\n admission, likely lactic acidosis given her aggressive lymphoma. AG 20\n today.\n - will check lactate level\n - trend chemistry panel\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n -\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact son in the AM to reconciliate Furosemide, Lipitor\n dosing.\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines:\n 18 Gauge - 08:17 PM\n Dialysis Catheter - 12:00 AM\n 20 Gauge - 04:50 AM\n Prophylaxis:\n DVT: P. boots\n Stress ulcer: Ranitidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: pending initiation of methotrexate\n" }, { "category": "Physician ", "chartdate": "2133-12-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 615815, "text": "TITLE:\n Chief Complaint: denies any pain, feeling improved from yesterday\n 24 Hour Events:\n - hematuria and oozing from HD line, however no coagulopathy on labs,\n received 2 U FFP\n - Foley with hematuria and clots, got clogged and had to place 3way\n for bladder irrigation, was not retrieving much urine, bladder scan for\n only 200cc, urine coming out was clearing of , need to call\n urology in AM\n - started CODOX with dexameth 40IV qd\n - tumor lysis labs stable, DIC labs stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Lorazepam (Ativan) - 07:29 PM\n Famotidine (Pepcid) - 09:13 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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.3\nC (95.5\n HR: 96 (75 - 103) bpm\n BP: 122/61(83) {98/47(66) - 154/81(104)} mmHg\n RR: 22 (14 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Bladder pressure: 12 (12 - 12) mmHg\n Total In:\n 7,169 mL\n 926 mL\n PO:\n TF:\n IVF:\n 6,604 mL\n 926 mL\n products:\n 565 mL\n Total out:\n 2,902 mL\n 2,681 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 4,267 mL\n -1,755 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.45/46/106/21/1\n Physical Examination\n GENERAL: Somnolent but arousable, Caucasian Female lying down in bed\n in NAD, AOx3\n HEENT: No scleral icterus, PERRL, EOMI.\n Neck: No LAD noted.\n CARDIAC: Regular rhythm, tachy (110 bpm). Normal S1, S2. No murmurs,\n rubs or .\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Soft, distended, tender in the epigastric region. No HSM\n EXTREMITIES: No edema noted.\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 97 K/uL\n 8.7 g/dL\n 116 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 94 mEq/L\n 135 mEq/L\n 25.3 %\n 34.5 K/uL\n [image002.jpg]\n 08:20 AM\n 08:41 AM\n 10:32 AM\n 10:51 AM\n 12:39 PM\n 02:26 PM\n 05:35 PM\n 09:55 PM\n 11:49 PM\n 04:36 AM\n WBC\n 19.8\n 29.0\n 34.5\n Hct\n 22.9\n 23.5\n 25.3\n Plt\n 86\n 88\n 97\n Cr\n 2.8\n 2.5\n 2.0\n 2.2\n 1.8\n 1.6\n TCO2\n 28\n 29\n Glucose\n 135\n 138\n 143\n 161\n 197\n 134\n 116\n Other labs: PT / PTT / INR:14.8/23.1/1.3, ALT / AST:49/171, Alk Phos /\n T Bili:346/2.3, D-dimer:510 ng/mL, Fibrinogen:534 mg/dL, Lactic\n Acid:5.7 mmol/L, LDH: IU/L, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.1 mg/dL\n .\n TTE:\n The left atrium is mildly dilated. Left ventricular wall thicknesses\n are normal. The left ventricular cavity size is normal. Overall left\n ventricular systolic function is normal (LVEF>55%). Right ventricular\n chamber size and free wall motion are normal. The aortic valve leaflets\n (3) appear structurally normal with good leaflet excursion and no\n aortic regurgitation. There is no aortic valve stenosis. The mitral\n valve leaflets are mildly thickened. There is no mitral valve prolapse.\n Trivial mitral regurgitation is seen. There is mild pulmonary artery\n systolic hypertension. There is no pericardial effusion.\n RUQ U/S\n 1. No intra or extrahepatic biliary dilatation. CBD 2 mm.\n 2. No evidence of cholecystitis.\n 3. Several sub-cm nonobstructing right renal collecting system calculi,\n as\n seen on OSH CT.\n 4. Mild left hydronephrosis with no left renal calculi seen, as on OSH\n CT.\n 5. Enlarged uterus.\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and high risk for tumor lysis\n syndrome. On review of pt's labs although she does not qualify for\n tumour lysis syndrome given her normal Phos, elevated Ca her LDH, Uric\n Acid suggests the possibility of tumour lysis syndome with treatment.\n Received Rasburicase for uric acid converion. Pt intiated CVVH and\n CODOX yesterday. Labs remained stable.\n - cont dexa 40 mg IV daily, CODOX per heme/onc orders\n - cont allopurinol 100 mg daily\n - appreciate heme/onc recs\n - will check TLS labs q4hrs (K, Cr, Ca, Mg, Ph, LDH)\n - DIC labs q6h\n - f/u EBV, CMV, HIV viral loads, antibody panels\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Has renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD. Had marginal urine output. Pt on CVVH given the anticipation\n of possible TLS from tumour response to dexamethasone.\n - on CVVH, will readdress goal fluid balance with renal and BMT\n - currently would run her even given decreased BP and tachycardia with\n aggressive diuresis overnight, our goal is to maintain adequate\n hydration and prevent TLS and not necessarily to diurese\n - f/u renal recs\n - trend Creatinine\n .\n ##. COAGULOPATHY: Pt had profuse oozing from HD site, with associated\n Hct drop yesterday. Also had hematuria, requiring CBI with 3way Foley.\n No evidence of coagulopathy by PTT/INR. Received 2 U FFP despite normal\n INR. Cryo\ns pending. Pt is not receiving anticoagulation in CVVH.\n Likely has platelet qualitative dysfunction.\n - monitor Foley output, trial off CBI this AM since saline coming\n through is now clear\n - consider urology consult if concerned\n - monitor q6h coags for r/o DIC\n - f/u cryo and give cryo if needed\n - if continued bleeding or Hct drop, give ddAVP to stabilize presumed\n plt dysfunction\n .\n URINARY TRACT INFECTION (UTI)\n Pt was given IV Ceftriaxone for ?UTI however U/A was notable for\n several epi cells in addition to bacteria. Patient complained of\n bladder discomfort with Foley in place, improved with pyridium. Repeat\n UA may suggest infection, although urine cx still pending. Leukocytosis\n and fever are difficult to follow in this patient given lymphoma and\n CVVH.\n - review OSH imaging for perinephric stranding\n - follow up Urine culture OSH and here and consider treatment\n .\n ##. Anion Gap Acidosis: Pt noted to have an anion gap acidosis on\n admission, likely lactic acidosis given her aggressive lymphoma. AG 20\n today.\n - will check lactate level\n - trend chemistry panel\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n -\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact son in the AM to reconciliate Furosemide, Lipitor\n dosing.\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines:\n 18 Gauge - 08:17 PM\n Dialysis Catheter - 12:00 AM\n 20 Gauge - 04:50 AM\n Prophylaxis:\n DVT: P. boots\n Stress ulcer: Ranitidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: pending initiation of methotrexate\n" }, { "category": "Physician ", "chartdate": "2133-12-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 616315, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - got 2 U plts, 1 U PRBCs\n - BMT recs: NS at 150, q6 labs, last cytoxan today, then possibly will\n get doxorubicin/vincristine and stop CVVH ? Wed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 2 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Lorazepam (Ativan) - 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 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.8\nC (96.5\n HR: 83 (49 - 103) bpm\n BP: 171/94(125) {112/50(74) - 171/94(125)} mmHg\n RR: 23 (11 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 4,729 mL\n 2,171 mL\n PO:\n 250 mL\n TF:\n IVF:\n 3,679 mL\n 1,896 mL\n Blood products:\n 800 mL\n 275 mL\n Total out:\n 4,382 mL\n 1,690 mL\n Urine:\n 2,100 mL\n 975 mL\n NG:\n Stool:\n Drains:\n Balance:\n 347 mL\n 481 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: 7.51/32/108/23/1\n Physical Examination\n General Appearance: Well nourished, No acute distress, awake and alert\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: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Follows commands, alert and appropriate\n Labs / Radiology\n 65 K/uL\n 8.4 g/dL\n 144 mg/dL\n 0.4 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 100 mEq/L\n 134 mEq/L\n 23.6 %\n 1.2 K/uL\n [image002.jpg]\n 05:04 PM\n 09:00 PM\n 12:00 AM\n 04:13 AM\n 08:40 AM\n 08:54 AM\n 02:53 PM\n 03:20 PM\n 09:56 PM\n 03:30 AM\n WBC\n 2.5\n 2.2\n 1.7\n 1.7\n 1.1\n 1.2\n Hct\n 26.1\n 22.8\n 20.2\n 23.9\n 21.5\n 23.6\n Plt\n 40\n 26\n 84\n 86\n 66\n 65\n Cr\n 0.7\n 0.2\n 0.6\n 0.5\n 0.6\n 0.5\n 0.4\n TCO2\n 23\n 25\n Glucose\n 153\n 156\n 133\n 164\n 144\n Other labs: PT / PTT / INR:13.1/22.6/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:25/41, Alk Phos / T Bili:211/1.6, Differential-Neuts:80.0 %,\n Band:5.0 %, Lymph:10.0 %, Mono:5.0 %, Eos:0.0 %, D-dimer:510 ng/mL,\n Fibrinogen:196 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.1 g/dL,\n LDH:4815 IU/L, Ca++:7.3 mg/dL, Mg++:1.5 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and spontaneous tumor lysis\n syndrome. Received Rasburicase for uric acid converion. Pt had e/o TL,\n now labs improving. All counts are falling, pt received PRBC and\n platelet transfusions. Today day of cytoxan and decadron,\n continues on CVVH and CBI prophylactically.\n - cont allopurinol 100 mg daily, check renal dosing once off CVVH\n - not neutropenic yet (up to 960 from 550)\n - Cryo for fibrinogen less than 100, Plts for less than 50 because of\n oozing,\n - appreciate heme/onc recs\n - will check TLS labs Q6hrs (K, Cr, Ca, Mg, Ph, LDH)\n - DIC labs q6h\n - f/u EBV, CMV (-), HIV viral loads (-), antibody panels\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Has renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD in retroperitoneum. Had marginal urine output. Pt on CVVH\n given the anticipation of possible TLS from tumour response to\n dexamethasone. Has had difficulty with HD line and air infiltration.\n - Continue CBI while risk of hemorrhagic cystitis from cytoxan\n - once clear of window for hemorrhagic cystitis would d/c CBI and\n monitor urine output.\n - If making urine well off CBI and running even on CVVH, would d/c CVVH\n - on CVVH running even\n - re: above there is some question of +10L length of stay, however with\n CBI urine output is purely an estimate, so making any definitive\n comment on interval fluid, however we can meet with heme-onc and renal\n to discuss fluid goals.\n - f/u renal recs\n - trend Creatinine\n .\n ##. COAGULOPATHY/PANCYTOPENIA: Pt has had profuse oozing from HD site,\n with associated Hct drop. Also had hematuria, requiring CBI with 3way\n Foley. Both are now improving. No evidence of coagulopathy. Cryo\n pending. Pt is not receiving anticoagulation in CVVH. Hct and plt\n count cont to trend down, likely to chemo and CVVH but concern for\n additional etiology especially given severe TCP today.\n - transfusion goals as above.\n - CBI\n - consider repeat CT for obstruction prior to urology consult\n - monitor q6h coags for r/o DIC\n - transfuse for goal Hct>21, plt>50 since bleeding\n .\n URINARY TRACT INFECTION (UTI)/HEMATURIA\n Positive UA and neg cx x 2. Will not treat for UTI.\n - CBI for hematuria to prophylax against hemorrhagic cystitis\n - oxybutynin for possible bladder spasm\n - consider CT and urology c/s\n .\n ##. Anion Gap Acidosis: normalized, AG 12 today.\n .\n ## Pain/discomfort\n morphine PRN\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n -\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact to reconcile Furosemide, dosing.\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer : famotidine\n VAP: none\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: \n" }, { "category": "Nursing", "chartdate": "2133-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616366, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade burkits lymphoma. Transferred\n for further management from . Admitted to the ICU for CVVH\n for tumor lysis syndrome.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with ? UTI dx in OSH; known renal calculi with hydronephrosis.\n creatinine high at 3.0/ BUN of 39; Started on CVVH for tumor lysis\n syndrome and while she is on chemotherapy; chemo drugs dose calculated\n based on creatinine clearance while on CVVHD; filter clotted at 0600,\n off CRRT for about 6hrs\n Action:\n CVVHD initiated 12noon, replacement fluid changed to K4 running at 4200\n ml/hr ( 4000 PBP) and dialysate at 1000ml/hr with goal to keep patient\n 50cc/hr negative per renal although ICU team prefers patient to be at\n least 1 liter negative by MN\n patient became symptomatic being 11L\n positive at start of shift - desatted down 87-88% @ room air;\n calculated urine output at 80cc/hr in reference to 1000 output per CBI\n for 12hrs\n Response:\n 500 cc urine out from CBI at 1800\n Plan:\n Continue with CVVH with goal to keep her negative 50cc/hr, restart\n patient on 150cc/hr NS continues - urine output of at least 100cc/hr\n is goal while on cytoxan per oncology\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n + burkits lymphoma, continues on CBI in the setting of hematuria\n previous days, hematuria resolved but kept her on CBI to flush kidney\n while getting chemotherapy; urine and clear; PTT 63\n patient no\n longer bleeding from RIJ and aline\n Action:\n TLS labs q6hrs including coags and fibrinogen. Pre-medicated 40 mg IV\n decadron and Zofran. 1 mg ativan PO given this am for\n anxiety/restlessness. Allopurinol 100mgs daily; last dose of cytoxan\n given this evening\n Response:\n K 3.3 this pm, phos down to 1.9 ionized calcium 1.02\n on KCL and\n Calcium gluconate repletion, uric acid down to 2.6; Coags stable FDP\n 10-40;\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and Fibrinogen\n with CVVH labs but can be done Q8hrs; will receive vincristine and\n doxorubicin ; run CBI to finish in 6hrs period\n Oriented x 3, denies any pain. Moving all extremties but weak due to\n edema; feels heavy with lifting and moving in bed; movement limited by\n CVVH and dialysis line which is very positional\n Hemodynamically stable, hypertensive in the >160 and tachycardic in the\n 120\ns when she cries\n Desatted down to 87-88% at room air, transiently uses O2 at 2 liters.\n IS use started, needs encouragement. Off O2 2hrs after of being on it;\n lung sounds dim at bases\n On regular diet but patient has poor appetite, drinks ginger ale and\n crackers. problem with swallowing. Bowel sounds present, non tender\n abdomen; on colace as bowel regimen\n Skin intact but bruises noted arms and back area\n Family visited today, ICU team updated them of plans of care. Social\n work follows patient.\n" }, { "category": "Physician ", "chartdate": "2133-12-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 616032, "text": "Chief Complaint: Burkitt's lymphoma, acute renal failure, tumor lysis\n 24 Hour Events:\n - day 2 cytoxan and decadron, tolerating well\n - CVVH continues, evidence of TLS on labs\n - no evidence of DIC or hemorrhage\n - goal Is/Os even to (-) one liter\n - CVVH intermittently stopped overnight air infiltrate\n - c/o bladder spasm\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:33 PM\n Lorazepam (Ativan) - 12:00 AM\n Morphine Sulfate - 04:20 AM\n Other medications:\n Changes to medical and family history:\n sleeping this morning, denies pain, bladder spasm improving\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Genitourinary: Foley\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.3\nC (97.3\n HR: 85 (76 - 109) bpm\n BP: 123/64(85) {91/47(63) - 172/92(124)} mmHg\n RR: 15 (12 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 5,210 mL\n 1,176 mL\n PO:\n TF:\n IVF:\n 5,210 mL\n 1,176 mL\n Blood products:\n Total out:\n 6,113 mL\n 1,855 mL\n Urine:\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n -903 mL\n -679 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.45///21/\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: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 60 K/uL\n 6.9 g/dL\n 171 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 4.5 mEq/L\n 39 mg/dL\n 96 mEq/L\n 132 mEq/L\n 20.1 %\n 6.5 K/uL\n [image002.jpg]\n 12:39 PM\n 02:26 PM\n 05:35 PM\n 09:55 PM\n 11:49 PM\n 04:36 AM\n 09:59 AM\n 03:51 PM\n 08:42 PM\n 04:13 AM\n WBC\n 19.8\n 29.0\n 34.5\n 16.9\n 6.5\n Hct\n 22.9\n 23.5\n 25.3\n 22.1\n 20.1\n Plt\n 86\n 88\n 97\n 80\n 60\n Cr\n 2.0\n 2.2\n 1.8\n 1.6\n 1.4\n 1.0\n 1.0\n Glucose\n 143\n 161\n 197\n 134\n 116\n 112\n 114\n 171\n Other labs: PT / PTT / INR:13.5/21.3/1.2, CK / CKMB / Troponin-T:331//,\n ALT / AST:35/109, Alk Phos / T Bili:280/1.4, D-dimer:510 ng/mL,\n Fibrinogen:333 mg/dL, Lactic Acid:1.8 mmol/L, LDH: IU/L, Ca++:7.4\n mg/dL, Mg++:2.3 mg/dL, PO4:8.3 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n > Hct\n > Thrombocytopenia\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Tumour Lysis\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n TACHYCARDIA, OTHER\n HYPOTHYROIDISM\n URINARY TRACT INFECTION (UTI)\n HYPERCALCEMIA (HIGH CALCIUM)\n HYPERPHOSPHATEMIA (HIGH PHOSPHATE)\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and spontaneous tumor lysis\n syndrome. Received Rasburicase for uric acid converion. Pt intiated\n CVVH and CODOX yesterday. Labs remained stable. Today day 3 of cytoxan\n and decadron, continues on CVVH\n - cont dexa 40 mg IV daily, CODOX per heme/onc orders\n - cont allopurinol 100 mg daily\n - appreciate heme/onc recs -> ? to heme onc and renal re: risk of\n hemorrhagic cystitis, possibility of converting to HD\n - will check TLS labs Q6hrs (K, Cr, Ca, Mg, Ph, LDH)\n - DIC labs q6h\n - f/u EBV, CMV (-), HIV viral loads, antibody panels\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Has renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD. Had marginal urine output. Pt on CVVH given the anticipation\n of possible TLS from tumour response to dexamethasone. Could have\n component of hydroureter retroperitoneal disease\n - on CVVH, will readdress goal fluid balance with renal and BMT and\n possibility of converting to HD\n - currently would run her even given decreased BP and tachycardia with\n aggressive diuresis overnight, our goal is to maintain adequate\n hydration in setting of TLS and risk of hemorrhagic cystitis\n - f/u renal recs\n - trend Creatinine\n .\n ##. COAGULOPATHY: Pt had profuse oozing from HD site, with associated\n Hct drop. Also had hematuria, requiring CBI with 3way Foley. No\n evidence of coagulopathy by PTT/INR. Received 2 U FFP despite normal\n INR. Cryo\ns pending. Pt is not receiving anticoagulation in CVVH.\n Likely has platelet qualitative dysfunction. Hct and plt count cont to\n trend down, likely to recent hemorrhage and CVVH ->\n thrombocytopenia.\n - monitor Foley output, hematuria, concern for hemorrhagic cystitis\n - consider repeat CT for obstruction prior to urology consult\n - monitor q6h coags for r/o DIC\n - 2 units PRBCs for Hct, can give DDAVP for thrombocytopenia\n .\n URINARY TRACT INFECTION (UTI)/HEMATURIA\n Pt was given IV Ceftriaxone for ?UTI however U/A was notable for\n several epi cells in addition to bacteria. Patient complained of\n bladder discomfort with Foley in place, improved with pyridium. Repeat\n UA may suggest infection, although urine cx still pending. Leukocytosis\n and fever are difficult to follow in this patient given lymphoma and\n CVVH.\n - review OSH imaging for perinephric stranding\n - follow up Urine culture OSH and here and consider treatment\n - hematuria management as above\n .\n ##. Anion Gap Acidosis: Pt noted to have an anion gap acidosis on\n admission, likely lactic acidosis given her aggressive lymphoma. AG 20\n today. On CVVH.\n - trend lactate level\n - trend chemistry panel\n .\n ## Pain/discomfort\n morphine PRN\n .\n ## Nutrition- encourage PO intake, careful of aspiration\n .\n ## Fluid goal- even until speaking with Renal/BMT\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n -\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact to reconcile Furosemide, dosing.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer : famotidine\n VAP: none\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: \n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n On this day I examined Ms and was present for the key portions\n of the services provided. I have reviewed Dr \ns note above and\n agree with his findings and plan of care.\n The patient seems brighter and less somnolent today and overall claims\n to feel not bad. She has hematuria and bladder pain, and with her\n Cytoxan Rx we will use continuous bladder irrigation to help prevent\n bladder injury from cytoxan. She continues with met acidosis but has\n no resp compromise. Her intravascular volume status appears fine, so\n we will attempt to keep I=O via our IVF and CVVH. ChemoRx ongoing and\n we are hoping for significant response of her tumor to it. Reimaging\n with abd U/S early next week may be helpful to reassess status of left\n hydonephrosis and adenopathy.\n Pt is anemic and will be transfused. Plt ct is also down to 60K and\n will be closely followed. Pt still not taking well orally, and we\n have to address this (NGT?, TPN?) in the next few days if she can\n improve oral nutrition.\n 35 min spent in the care of this severely ill patient\n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 16:21 ------\n" }, { "category": "Nursing", "chartdate": "2133-12-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 615857, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade lymphoma. Transferred for\n further management from . Admitted to the ICU for CVVH for\n tumor lysis syndrome.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with ? UTI dx in OSH; known renal calculi with hydronephrosis.. Cr\n 1.6. On CVVH---pt (-) 2.6 L at beginning of shift. Making little urine,\n however difficult to asses as pt on CBI\n Action:\n Replaced 1.5 L as pt became hypotensive to high 80\ns, pale and\n difficult to arouse. Discussed fluid goal with BMT and they would like\n the pt even to slightly negative, depending on how the pt\ns BP\n tolerates. They also added cont IVF @ 100 cc/hr but want pt even for\n day???? running fluid @ 100 cc/hr. Stopped CBI. Gave phenazopyridine\n for c/o bladder spasm.\n Response:\n Foley draining 15-25 cc/hr of amber ??? blood tinged urine. CVVH\n machine running great without problems. balance for day as of 1700\n (-) 500 cc. Cr 1.0\n Plan:\n Continue with CVVH with goal of even to slightly negative as BP\n tolerates, BMT will re-evaluate goal tomorrow. Added phosphate scale to\n CVVH orders\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Received pt with CBI\nurine yellow and clear. TLS labs WNL. Pt somnolent\n but arousable and alert and oriented x3. Intermittently crying with\n confused expressions. CBI draining clear, yellow urine.\n Action:\n TLS labs q6h with coags and fibrinogen q4h. Pre-medicated for chemo, 40\n mg IV decadron and Zofran. 1 mg ativan given for anxiety/restlessness.\n Discussed pre-chemo hydration with BMT and 100 cc/hr continuous\n ordered. Family at bedside for most of afternoon\n Response:\n Per latest labs, K and Ph increasing but WNL and Ca decreasing. Uric\n acid 3.5. Coags stable\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and Fibrinogen\n q4 hours. Cont with chemo and follow heme onc recs---chemo nurse will\n be by at 7:30. Provide emotional support to pt and to family.\n" }, { "category": "Nursing", "chartdate": "2133-12-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616156, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade lymphoma. Transferred for\n further management from . Admitted to the ICU for CVVH for\n tumor lysis syndrome.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with ? UTI dx in OSH; known renal calculi with hydronephrosis.. Cr\n 1.6. On CVVH\n Action:\n Response:\n Plan:\n Continue with CVVH with goal of even\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Received pt with CBI\nurine and clear.\n Action:\n TLS labs q6h includingcoags and fibrinogen. Pre-medicated for chemo, 40\n mg IV decadron and Zofran. 1 mg ativan given for anxiety/restlessness.\n Allopurinol 100mgs daily\n Response:\n Per latest labs, K and Ph increasing but WNL and Ca decreasing. Uric\n acid 8.0 this am, Phos 5.1 Coags stable\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and\n Fibrinogen. Cont with chemo and follow heme onc recs---chemo nurse will\n be by at 7:30. Provide emotional support to pt and to family.\n" }, { "category": "Nursing", "chartdate": "2133-12-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 615572, "text": "Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\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 Urinary tract infection (UTI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2133-12-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 616155, "text": "TITLE:\n Chief Complaint: - we huddled with Renal and BMT -> CBI for cytoxan,\n run even on CVVH for volume\n - A-line resited\n - AM labs with HCT of 22, PLTs of 26. As actively oozing, gave 2 units\n of platelets, 2 units PRBC in anticipation of falling below 21 given\n overall trend.\n 24 Hour Events:\n ARTERIAL LINE - STOP 02:00 PM\n ARTERIAL LINE - START 03:17 PM\n ARTERIAL LINE - START 03:26 PM\n ARTERIAL LINE - STOP 06:50 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Morphine Sulfate - 12:47 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 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.1\nC (95.2\n HR: 77 (49 - 82) bpm\n BP: 161/87(117) {115/60(78) - 180/93(126)} mmHg\n RR: 16 (8 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 5,103 mL\n 635 mL\n PO:\n TF:\n IVF:\n 4,473 mL\n 513 mL\n Blood products:\n 630 mL\n 123 mL\n Total out:\n 5,288 mL\n 354 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -185 mL\n 281 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: 7.45/27/103/23/0\n Physical Examination\n General Appearance: Well nourished, No acute distress, awake and alert\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: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Follows commands, alert and appropriate\n Labs / Radiology\n 26 K/uL\n 8.0 g/dL\n 156 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 31 mg/dL\n 99 mEq/L\n 134 mEq/L\n 22.8 %\n 2.2 K/uL\n [image002.jpg]\n 08:42 PM\n 04:13 AM\n 09:56 AM\n 10:04 AM\n 04:10 PM\n 04:34 PM\n 05:04 PM\n 09:00 PM\n 12:00 AM\n 04:13 AM\n WBC\n 16.9\n 6.5\n 3.4\n 2.5\n 2.2\n Hct\n 22.1\n 20.1\n 25.1\n 26.1\n 22.8\n Plt\n 80\n 60\n 42\n 40\n 26\n Cr\n 1.0\n 0.7\n 0.7\n 0.2\n 0.6\n 0.5\n TCO2\n 23\n 22\n Glucose\n 171\n 160\n 150\n 153\n 156\n Other labs: PT / PTT / INR:12.8/23.6/1\n Tbili 1.6, D-dimer:510 ng/mL, Fibrinogen:245 mg/dL, LDH:8425 IU/L,\n Ca++:7.5 mg/dL, Mg++:1.8 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and spontaneous tumor lysis\n syndrome. Received Rasburicase for uric acid converion. Pt had e/o TL,\n now labs improving. All counts are falling, pt received PRBC and\n platelet transfusions. Today day of cytoxan and decadron,\n continues on CVVH and CBI prophylactically.\n - cont allopurinol 100 mg daily, check renal dosing once off CVVH\n - appreciate heme/onc recs\n - will check TLS labs Q6hrs (K, Cr, Ca, Mg, Ph, LDH)\n - DIC labs q6h\n - f/u EBV, CMV (-), HIV viral loads (-), antibody panels\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Has renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD in retroperitoneum. Had marginal urine output. Pt on CVVH\n given the anticipation of possible TLS from tumour response to\n dexamethasone. Has had difficulty with HD line and air infiltration.\n - discuss re-siting line with renal\n - on CVVH running even\n - f/u renal recs\n - trend Creatinine\n .\n ##. COAGULOPATHY/PANCYTOPENIA: Pt had profuse oozing from HD site, with\n associated Hct drop. Also had hematuria, requiring CBI with 3way Foley.\n Both are now improving. No evidence of coagulopathy. Cryo\ns pending. Pt\n is not receiving anticoagulation in CVVH. Hct and plt count cont to\n trend down, likely to chemo and CVVH but concern for additional\n etiology especially given severe TCP today.\n - f/u smear, FDP\n - CBI\n - consider repeat CT for obstruction prior to urology consult\n - monitor q6h coags for r/o DIC\n - transfuse for goal Hct>21, plt>50 since bleeding\n .\n URINARY TRACT INFECTION (UTI)/HEMATURIA\n Positive UA and neg cx x 2. Will not treat for UTI.\n - CBI for hematuria to prophylax against hemorrhagic cystitis\n - oxybutynin for possible bladder spasm\n - consider CT and urology c/s\n .\n ##. Anion Gap Acidosis: normalized, AG 12 today.\n .\n ## Pain/discomfort\n morphine PRN\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n -\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact to reconcile Furosemide, dosing.\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer : famotidine\n VAP: none\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: \n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n On this day I examined the patient and was present for the key portion\n of the services provided. I have reviewed Dr \ns note above and\n agree with her findings and plan of care.\n Mrs looks bright and alert, albeit bored today! She\ns needing\n plt and rbc support given chemoRx and oozing around central line and\n hematuria. Getting continuous bladder irrigation. We\nre watching for\n neutropenia and also continuing to monitor her tumor lysis labs. She\n needs to start eating and we\nll try to put her in reverse Trendelenberg\n to help her take po\ns without aspirating. Should talk to renal and\n oncology to get a sense of how much longer she might need CVVH, as I\n worry about her lines and risk of infection given her declining\n immuncompentence. I would d/c a line if no longer needed.\n 35 min spent in the care of this critically ill patient\n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 15:28 ------\n" }, { "category": "Nursing", "chartdate": "2133-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616218, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade burkits lymphoma. Transferred\n for further management from . Admitted to the ICU for CVVH\n for tumor lysis syndrome.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Dx with Burkitt\ns lymphoma. Pt also known renal calculi with\n hydronephrosis.\n Action:\n Pt completed the 4^th of 5 doses of Cytoxin chemo. Pt also getting CBI\n to ensure kidney flushed throughout the chemo.\n Response:\n Plan:\n Will complete the 5 day course of chemo tonight. Tumor lysis labs q6\n hrs.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Pt is on CVVH for tumor lysis syndrome while on chemo.\n Response:\n Plan:\n Cont on CVVH until chemo is complete, CVVH labs q6 hrs\n" }, { "category": "Nursing", "chartdate": "2133-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616273, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade burkits lymphoma. Transferred\n for further management from . Admitted to the ICU for CVVH\n for tumor lysis syndrome.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Dx with Burkitt\ns lymphoma. Pt also known renal calculi with\n hydronephrosis.\n Action:\n Pt completed the 4^th of 5 doses of Cytoxin chemo. Pt also getting CBI\n to ensure kidney flushed throughout the chemo.\n Response:\n Fibrinogen 196 this am, FDP 40-80.\n Plan:\n Will complete the 5 day course of chemo tonight. Tumor lysis labs q6\n hrs.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Bun/Creat 16/0.4 on the cvvh. u/o after CBI deducted from foley 2was\n 975cc or 81cc hr. pt has had no complaints of pain, discomfort or\n needing to void throughout the shift .\n Action:\n Pt is on CVVH for tumor lysis syndrome while on chemo. Pyridium and\n ditropan discontinued.\n Response:\n Pt cont to put out urine, at times pink and at times from the\n pyridium.\n Plan:\n Cont on CVVH until chemo is complete, CVVH labs q6 hrs\n Cvvh off as tmp pressures excessive.\n" }, { "category": "Physician ", "chartdate": "2133-12-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 616274, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - got 2 U plts, 1 U PRBCs\n - BMT recs: NS at 150, q6 labs, last cytoxan today, then possibly will\n get doxorubicin/vincristine and stop CVVH ? Wed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 2 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Lorazepam (Ativan) - 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 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.8\nC (96.5\n HR: 83 (49 - 103) bpm\n BP: 171/94(125) {112/50(74) - 171/94(125)} mmHg\n RR: 23 (11 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 4,729 mL\n 2,171 mL\n PO:\n 250 mL\n TF:\n IVF:\n 3,679 mL\n 1,896 mL\n Blood products:\n 800 mL\n 275 mL\n Total out:\n 4,382 mL\n 1,690 mL\n Urine:\n 2,100 mL\n 975 mL\n NG:\n Stool:\n Drains:\n Balance:\n 347 mL\n 481 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: 7.51/32/108/23/1\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 65 K/uL\n 8.4 g/dL\n 144 mg/dL\n 0.4 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 100 mEq/L\n 134 mEq/L\n 23.6 %\n 1.2 K/uL\n [image002.jpg]\n 05:04 PM\n 09:00 PM\n 12:00 AM\n 04:13 AM\n 08:40 AM\n 08:54 AM\n 02:53 PM\n 03:20 PM\n 09:56 PM\n 03:30 AM\n WBC\n 2.5\n 2.2\n 1.7\n 1.7\n 1.1\n 1.2\n Hct\n 26.1\n 22.8\n 20.2\n 23.9\n 21.5\n 23.6\n Plt\n 40\n 26\n 84\n 86\n 66\n 65\n Cr\n 0.7\n 0.2\n 0.6\n 0.5\n 0.6\n 0.5\n 0.4\n TCO2\n 23\n 25\n Glucose\n 153\n 156\n 133\n 164\n 144\n Other labs: PT / PTT / INR:13.1/22.6/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:25/41, Alk Phos / T Bili:211/1.6, Differential-Neuts:80.0 %,\n Band:5.0 %, Lymph:10.0 %, Mono:5.0 %, Eos:0.0 %, D-dimer:510 ng/mL,\n Fibrinogen:196 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.1 g/dL,\n LDH:4815 IU/L, Ca++:7.3 mg/dL, Mg++:1.5 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and spontaneous tumor lysis\n syndrome. Received Rasburicase for uric acid converion. Pt had e/o TL,\n now labs improving. All counts are falling, pt received PRBC and\n platelet transfusions. Today day of cytoxan and decadron,\n continues on CVVH and CBI prophylactically.\n - cont allopurinol 100 mg daily, check renal dosing once off CVVH\n - not neutropenic yet (up to 960 from 550)\n - Cryo for fibrinogen less than 100, Plts for less than 50 because of\n oozing, tighten up DIC labs to q4h.\n - appreciate heme/onc recs\n - will check TLS labs Q6hrs (K, Cr, Ca, Mg, Ph, LDH)\n - DIC labs q6h\n - f/u EBV, CMV (-), HIV viral loads (-), antibody panels\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Has renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD in retroperitoneum. Had marginal urine output. Pt on CVVH\n given the anticipation of possible TLS from tumour response to\n dexamethasone. Has had difficulty with HD line and air infiltration.\n - discuss re-siting line with renal\n - on CVVH running even\n - f/u renal recs\n - trend Creatinine\n .\n ##. COAGULOPATHY/PANCYTOPENIA: Pt had profuse oozing from HD site, with\n associated Hct drop. Also had hematuria, requiring CBI with 3way Foley.\n Both are now improving. No evidence of coagulopathy. Cryo\ns pending. Pt\n is not receiving anticoagulation in CVVH. Hct and plt count cont to\n trend down, likely to chemo and CVVH but concern for additional\n etiology especially given severe TCP today.\n - f/u smear, FDP\n - CBI\n - consider repeat CT for obstruction prior to urology consult\n - monitor q6h coags for r/o DIC\n - transfuse for goal Hct>21, plt>50 since bleeding\n .\n URINARY TRACT INFECTION (UTI)/HEMATURIA\n Positive UA and neg cx x 2. Will not treat for UTI.\n - CBI for hematuria to prophylax against hemorrhagic cystitis\n - oxybutynin for possible bladder spasm\n - consider CT and urology c/s\n .\n ##. Anion Gap Acidosis: normalized, AG 12 today.\n .\n ## Pain/discomfort\n morphine PRN\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n -\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact to reconcile Furosemide, dosing.\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer : famotidine\n VAP: none\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 03:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2133-12-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 615573, "text": "Pt is a 62 year old lady with a 4 week hx of not feeling well, fatigued\n with insomnia and decreased po intake. Went to see Pcp and with the\n labs it was discovered pt had Lymphoma of a high grade. hosp\n and was transferred to for further treatment\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\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 Urinary tract infection (UTI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2133-12-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616068, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade lymphoma. Transferred for\n further management from . Admitted to the ICU for CVVH for\n possible tumour lysis syndrome.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Very recent dx of high grade Lymphoma Possible Burkitts.\n Action:\n Last evening pt received the 3^rd dose of 5 Cytoxin doses. #4 tonight.\n During the day shift yesterday pt received 2 units of prbc fro Hct of\n 20. pt is having the tumor lysis labs q4 hrs and is getting a cbi for\n bladder protectin.\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt is making urine each hour but with cbi difficult to assess the\n hourly amt. No clots noted in the urine. Urine does color at pink, at\n times with pyridium.\n Action:\n Pt is on pyridium, ditropan. Pt is also getting morphine for painful\n bladder. pt has complained of\n I need to pee and I can\n since adm\n to micu. Foley has been maually irriganted many times with some small\n clots noted in the previous days. Pt remains on CVVH. Pre pump\n increased to 4000cc.\n Response:\n Hemodynamically stabe.\n Plan:\n Cont with cvvh while pt is getting chemo. Will probably do a CT scan\n for possible obstruction after cvvvh.\n" }, { "category": "Physician ", "chartdate": "2133-12-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 616142, "text": "TITLE:\n Chief Complaint: - we huddled with Renal and BMT -> CBI for cytoxan,\n run even on CVVH for volume\n - A-line resited\n - AM labs with HCT of 22, PLTs of 26. As actively oozing, gave 2 units\n of platelets, 2 units PRBC in anticipation of falling below 21 given\n overall trend.\n 24 Hour Events:\n ARTERIAL LINE - STOP 02:00 PM\n ARTERIAL LINE - START 03:17 PM\n ARTERIAL LINE - START 03:26 PM\n ARTERIAL LINE - STOP 06:50 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Morphine Sulfate - 12:47 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 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.1\nC (95.2\n HR: 77 (49 - 82) bpm\n BP: 161/87(117) {115/60(78) - 180/93(126)} mmHg\n RR: 16 (8 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 5,103 mL\n 635 mL\n PO:\n TF:\n IVF:\n 4,473 mL\n 513 mL\n Blood products:\n 630 mL\n 123 mL\n Total out:\n 5,288 mL\n 354 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -185 mL\n 281 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: 7.45/27/103/23/0\n Physical Examination\n General Appearance: Well nourished, No acute distress, awake and alert\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: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Follows commands, alert and appropriate\n Labs / Radiology\n 26 K/uL\n 8.0 g/dL\n 156 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 31 mg/dL\n 99 mEq/L\n 134 mEq/L\n 22.8 %\n 2.2 K/uL\n [image002.jpg]\n 08:42 PM\n 04:13 AM\n 09:56 AM\n 10:04 AM\n 04:10 PM\n 04:34 PM\n 05:04 PM\n 09:00 PM\n 12:00 AM\n 04:13 AM\n WBC\n 16.9\n 6.5\n 3.4\n 2.5\n 2.2\n Hct\n 22.1\n 20.1\n 25.1\n 26.1\n 22.8\n Plt\n 80\n 60\n 42\n 40\n 26\n Cr\n 1.0\n 0.7\n 0.7\n 0.2\n 0.6\n 0.5\n TCO2\n 23\n 22\n Glucose\n 171\n 160\n 150\n 153\n 156\n Other labs: PT / PTT / INR:12.8/23.6/1\n Tbili 1.6, D-dimer:510 ng/mL, Fibrinogen:245 mg/dL, LDH:8425 IU/L,\n Ca++:7.5 mg/dL, Mg++:1.8 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and spontaneous tumor lysis\n syndrome. Received Rasburicase for uric acid converion. Pt had e/o TL,\n now labs improving. All counts are falling, pt received PRBC and\n platelet transfusions. Today day of cytoxan and decadron,\n continues on CVVH and CBI prophylactically.\n - cont allopurinol 100 mg daily, check renal dosing once off CVVH\n - appreciate heme/onc recs\n - will check TLS labs Q6hrs (K, Cr, Ca, Mg, Ph, LDH)\n - DIC labs q6h\n - f/u EBV, CMV (-), HIV viral loads (-), antibody panels\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Has renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD in retroperitoneum. Had marginal urine output. Pt on CVVH\n given the anticipation of possible TLS from tumour response to\n dexamethasone. Has had difficulty with HD line and air infiltration.\n - discuss re-siting line with renal\n - on CVVH running even\n - f/u renal recs\n - trend Creatinine\n .\n ##. COAGULOPATHY/PANCYTOPENIA: Pt had profuse oozing from HD site, with\n associated Hct drop. Also had hematuria, requiring CBI with 3way Foley.\n Both are now improving. No evidence of coagulopathy. Cryo\ns pending. Pt\n is not receiving anticoagulation in CVVH. Hct and plt count cont to\n trend down, likely to chemo and CVVH but concern for additional\n etiology especially given severe TCP today.\n - f/u smear, FDP\n - CBI\n - consider repeat CT for obstruction prior to urology consult\n - monitor q6h coags for r/o DIC\n - transfuse for goal Hct>21, plt>50 since bleeding\n .\n URINARY TRACT INFECTION (UTI)/HEMATURIA\n Positive UA and neg cx x 2. Will not treat for UTI.\n - CBI for hematuria to prophylax against hemorrhagic cystitis\n - oxybutynin for possible bladder spasm\n - consider CT and urology c/s\n .\n ##. Anion Gap Acidosis: normalized, AG 12 today.\n .\n ## Pain/discomfort\n morphine PRN\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n -\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact to reconcile Furosemide, dosing.\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer : famotidine\n VAP: none\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: \n" }, { "category": "Nursing", "chartdate": "2133-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616352, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade burkits lymphoma. Transferred\n for further management from . Admitted to the ICU for CVVH\n for tumor lysis syndrome.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with ? UTI dx in OSH; known renal calculi with hydronephrosis.\n creatinine high at 3.0/ BUN of 39; Started on CVVH for tumor lysis\n syndrome and while she is on chemotherapy; chemo drugs dose calculated\n based on creatinine clearance while on CVVHD; filter clotted at 0600,\n off CRRT for about 6hrs\n Action:\n CVVHD initiated 12noon, replacement fluid changed to K4 running at 4200\n ml/hr ( 4000 PBP) and dialysate at 1000ml/hr with goal to keep patient\n 50cc/hr negative per renal although ICU team prefers patient to be at\n least 1 liter negative by MN\n patient became symptomatic being 11L\n positive at start of shift - desatted down 87-88% @ room air;\n calculated urine output at 80cc/hr in reference to 1000 output per CBI\n for 12hrs\n Response:\n 500 cc urine out from CBI at 1800\n Plan:\n Continue with CVVH with goal to keep her negative 50cc/hr, restart\n patient on 150cc/hr NS continues - urine output of at least 100cc/hr\n is goal while on cytoxan per oncology\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n + burkits lymphoma, continues on CBI in the setting of hematuria\n previous days, hematuria resolved but kept her on CBI to flush kidney\n while getting chemotherapy; urine and clear; PTT 63\n patient no\n longer bleeding from RIJ and aline\n Action:\n TLS labs q6hrs including coags and fibrinogen. Pre-medicated 40 mg IV\n decadron and Zofran. 1 mg ativan PO given this am for\n anxiety/restlessness. Allopurinol 100mgs daily; last dose of cytoxan\n given this evening\n Response:\n K 3.3 this pm, phos down to 1.9 ionized calcium 1.02\n on KCL and\n Calcium gluconate repletion, uric acid down to 2.6; Coags stable FDP\n 10-40;\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and Fibrinogen\n with CVVH labs but can be done Q8hrs; will receive vincristine and\n doxorubicin ; run CBI to finish in 6hrs period\n Oriented x 3, denies any pain. Moving all extremties but weak due to\n edema; feels heavy with lifting and moving in bed; movement limited by\n CVVH and dialysis line which is very positional\n Hemodynamically stable, hypertensive in the >160 and tachycardic in the\n 120\ns when she cries\n Desatted down to 87-88% at room air, transiently uses O2 at 2 liters.\n IS use started, needs encouragement. Off O2 2hrs after of being on it;\n lung sounds dim at bases\n On regular diet but patient has poor appetite, drinks ginger ale and\n crackers. problem with swallowing. Bowel sounds present, non tender\n abdomen; on colace as bowel regimen\n Skin intact but bruises noted arms and back area\n Family visited today, ICU team updated them of plans of care. Social\n work follows patient.\n" }, { "category": "Physician ", "chartdate": "2133-12-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 615647, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Many issues with CVVH overnight, delayed Dexamethasone until cvvh was\n fully functional.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.2 grams/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 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 101 (101 - 125) bpm\n BP: 113/51(64) {99/49(63) - 136/97(104)} mmHg\n RR: 17 (17 - 27) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 61 Inch\n Total In:\n 1,000 mL\n 125 mL\n PO:\n TF:\n IVF:\n 500 mL\n 125 mL\n Blood products:\n Total out:\n 175 mL\n 74 mL\n Urine:\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 825 mL\n 51 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n GENERAL: Fatigued appearing Caucasian Female lying down in bed in NARD\n HEENT: No scleral icterus, PERRL, EOMI.\n Neck: No LAD noted.\n CARDIAC: Regular rhythm, tachy (110 bpm). Normal S1, S2. No murmurs,\n rubs or .\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Soft, distended, tender in the epigastric region. No HSM\n EXTREMITIES: No edema noted.\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 89 K/uL\n 10.2 g/dL\n 124 mg/dL\n 3.0 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 38 mg/dL\n 94 mEq/L\n 136 mEq/L\n 29.9 %\n 27.2 K/uL\n [image002.jpg]\n 09:43 PM\n 11:46 PM\n 03:50 AM\n WBC\n 27.2\n Hct\n 29.9\n Plt\n 89\n Cr\n 2.9\n 2.8\n 3.0\n Glucose\n 124\n Other labs: PT / PTT / INR:15.6/24.1/1.4, D-dimer:510 ng/mL,\n Fibrinogen:532 mg/dL, Lactic Acid:5.3 mmol/L, LDH: IU/L, Ca++:10.2\n mg/dL, Mg++:2.1 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Prelim read from Heme-Path suggests large cell lymphoma w/ vacuoles\n suggestive of possible Burkitt's Lymphoma. Oncology has already seen pt\n and recommends initiating treatment with steroids. Concern that this\n may be high grade lymphoma given progression, LDH level. Pt received CT\n torso from OSH, films in chart. On review of pt's labs although she\n does not qualify for tumour lysis syndrome given her normal Phos,\n elevated Ca her LDH, Uric Acid suggests the possibility of tumour lysis\n syndome once treatment begins. Will thus consult Nephrology for\n possible CVVH initiation tonight, per Onc recs will start on\n Dexamethasone 40 mg IV once CVVH is initiated given the likelihood of\n TLS. Will check tumour lysis labs (K, Creatinine, Ca, Phos, Mg, LDH) as\n well as DIC labs. Will also start on Rasburicase for uric acid\n converion.\n - will upload CT torso films in PACS\n - f/u BM bx\n - start dex after 30-60 minutes of well working CVVH\n - will check TLS labs q4hrs (K, Cr, Ca, Mg, Ph, LDH)\n - DIC labs q6h\n - will give Rasburicase 7.5mg IV x 1 now (pharmacy error only got 6mg)\n - will check Uric Acid level 4 hours after Rasburicase per Rasburicase\n protocol\n - will check EBV, CMV, HIV viral loads, antibody panels\n - will give Dexamthasone 40mg IV x 1 once CVVH is initiated\n - check Echo in the AM, to eval systolic function\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Tumor Lysis\n As mentioned above pt noted to have elevated uric acid, however\n phosphorous is still low, Calcium is high. Given LDH and suspected high\n grade lymphoma have high suspicion for tumour lysis syndrome once\n dexamethasone is started.\n - will continue to monitor Tumour lysis labs q3hrs\n - pt receiving Rasburicase for Uric Acid conversion for renal\n protection\n - will place HD line and start CVVH\n - will start Allopurinol in the AM\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis given her prior labs from . Pt\n will start CVVH given the anticipation of possible TLS from tumour\n response to dexamethasone.\n - will start on CVVH\n - f/u renal recs\n - trend Creatinine\n - will continue with 3amps HCO in D5W @ 250cc/hr\n .\n ##. Anion Gap Acidosis: Pt noted to have an anion gap acidosis on\n admission, likely lactic acidosis given her aggressive lymphoma.\n - will check lactate level (5.3)\n - trend chemistry panel\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n .\n URINARY TRACT INFECTION (UTI)\n Pt was given IV Ceftriaxone for ?UTI however U/A was notable for\n several epi cells in addition to bacteria. No dysuria noted, urine\n appearance likely related to her , recheck U/A and urine\n culture.\n - recheck U/A, Urine culture\n - contact OSH for culture results\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact son in the AM to reconciliate Furosemide, Lipitor\n dosing.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:17 PM\n Dialysis Catheter - 12:00 AM\n 20 Gauge - 04:50 AM\n Prophylaxis:\n DVT: P. boots\n Stress ulcer: Ranitidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: pending initiation of methotrexate\n" }, { "category": "Nursing", "chartdate": "2133-12-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 615760, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade lymphoma. Transferred for\n further management from . Admitted to the ICU for CVVH for\n possible tumour lysis syndrome.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Bun/Creat 25/1.8, am labs pending. Pt has cont bladder irrigaton as\n there were clots noted at the beginning of the shift and yesterday.\n Currently the returns are clear with only an occ clot noted. Pt has\n generalized edema 6mm.\n Action:\n Pt is on CVVH\n Response:\n Cvvh has been going well throughout the shift, able to remove 300-400cc\n of fluid off per hour since midnight but unable to see the actural I&O\n as the GU irrigant causes a false increase when a new bag is up. The\n urine pt had put prior to the irrigant was small amts and bloody.\n Plan:\n Cont with the cvvh. Attempt to take fluid off as pt tolerates. Follow\n recs of renal.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n High grade Lymphoma newly dx only in the past few days. Possible\n Burkitt\n Action:\n Pt was started on steroids yesterday after the cvvh was started. Chemo\n was started last evening Cyclophosphamide by the chemo nurse. Will have\n 4 more treatments in the evenings. Pt also on Allopurinol for Tumor\n lysis syndrome.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2133-12-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 615764, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade lymphoma. Transferred for\n further management from . Admitted to the ICU for CVVH for\n possible tumour lysis syndrome.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Bun/Creat 25/1.8, am labs pending. Pt has cont bladder irrigaton as\n there were clots noted at the beginning of the shift and yesterday.\n Currently the returns are clear with only an occ clot noted. Pt has\n generalized edema 6mm.\n Action:\n Pt is on CVVH\n Response:\n Cvvh has been going well throughout the shift, able to remove 300-400cc\n of fluid off per hour since midnight but unable to see the actural I&O\n as the GU irrigant causes a false increase when a new bag is up. The\n urine pt had put prior to the irrigant was small amts and bloody. Creat\n 1.6 this am with Bun 25.\n Plan:\n Cont with the cvvh. Attempt to take fluid off as pt tolerates. Follow\n recs of renal.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n High grade Lymphoma newly dx only in the past few days. Possible\n Burkitt\ns. LDH was >26,000 on day of admission.\n Action:\n Pt was started on steroids yesterday after the cvvh was started. Chemo\n was started last evening Cyclophosphamide by the chemo nurse. Will have\n 4 more treatments in the evenings. Pt also on Allopurinol for Tumor\n lysis syndrome.\n Response:\n Labs pending at this time. Pt remains alert and oriented and has stated\n that she had a dream\nI didn\nt make it\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and Fibrinogen\n q4 hours. Cont with chemo and follow heme onc recs. Provide emotionas\n support to pt and to family.\n Son is the HCP, husband is supportive but has copd. Family very\n supportive. Son would like a call from Onc to have the illness\n explained to him. Heme onc did speak to the other family members and\n social services is involved.\n" }, { "category": "Nursing", "chartdate": "2133-12-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616061, "text": "Significant Events:\n ----BMT, renal, and MICU services discussed pt\ns fluid status and\n hydration for chemo today and have come to a goal of running pt even on\n CVVHD, not giving pre-chemo fluids but rather keeping CBI to protect\n bladder from hemorrhagic cystitis.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt received 2^nd dose of 5 cytotoxin doses. On CVVHD for txt tumor\n lysis. Plts dropping as well as Hct and WBC---most likely too early to\n be from chemo\n Action:\n Transfused 2 units PRBC for Hct 20; coags and tumor lysis labs q6h;\n premedicated for chemo; CBI to help maintain bladder integrity from\n chemo\n Response:\n Post transfusion hct 25. CBI, draining clear urine. LDH down to\n . Labs stable.\n Plan:\n Chemo this evening---2 more doses after tonight. Blood products as\n needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Running CVVHD, making more urine, 20-70 cc/hr. Urine appearing\n intermittently pink/red with NO clots. Cr down but this is due to\n CVVHD. Initally running pt slightly negative prior to fluid status\n convo. Pt with temp as low as 95.2 orally, requiring warming blanket\n Action:\n Manually flushed foley q3h and then placed pt on CBI. CVVHD with q6h\n labs---Calcium sliding scale changed. Started to run pt even at around\n 1200. Frequent rescue flushes as filter pressure rising. Pre pump\n blood flow increased to 4000.\n Response:\n Filter pressures stable at 160-180. Hard to assess UO due to CBI.\n Hemodynamically stable.\n Plan:\n CVVHD at least through chemo completetion. Will need a scan to evaluate\n ? obstruction. Labs q6h.\n" }, { "category": "Nursing", "chartdate": "2133-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616262, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade burkits lymphoma. Transferred\n for further management from . Admitted to the ICU for CVVH\n for tumor lysis syndrome.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Dx with Burkitt\ns lymphoma. Pt also known renal calculi with\n hydronephrosis.\n Action:\n Pt completed the 4^th of 5 doses of Cytoxin chemo. Pt also getting CBI\n to ensure kidney flushed throughout the chemo.\n Response:\n Fibrinogen 196 this am, FDP 40-80.\n Plan:\n Will complete the 5 day course of chemo tonight. Tumor lysis labs q6\n hrs.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Bun/Creat 16/0.4 on the cvvh. u/o after CBI deducted from foley 2was\n 975cc or 81cc hr. pt has had no complaints of pain, discomfort or\n needing to void throughout the shift .\n Action:\n Pt is on CVVH for tumor lysis syndrome while on chemo. Pyridium and\n ditropan discontinued.\n Response:\n Pt cont to put out urine, at times pink and at times from the\n pyridium.\n Plan:\n Cont on CVVH until chemo is complete, CVVH labs q6 hrs\n Cvvh off as tmp pressures excessive.\n" }, { "category": "Nursing", "chartdate": "2133-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616264, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade burkits lymphoma. Transferred\n for further management from . Admitted to the ICU for CVVH\n for tumor lysis syndrome.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Dx with Burkitt\ns lymphoma. Pt also known renal calculi with\n hydronephrosis.\n Action:\n Pt completed the 4^th of 5 doses of Cytoxin chemo. Pt also getting CBI\n to ensure kidney flushed throughout the chemo.\n Response:\n Fibrinogen 196 this am, FDP 40-80.\n Plan:\n Will complete the 5 day course of chemo tonight. Tumor lysis labs q6\n hrs.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Bun/Creat 16/0.4 on the cvvh. u/o after CBI deducted from foley 2was\n 975cc or 81cc hr. pt has had no complaints of pain, discomfort or\n needing to void throughout the shift .\n Action:\n Pt is on CVVH for tumor lysis syndrome while on chemo. Pyridium and\n ditropan discontinued.\n Response:\n Pt cont to put out urine, at times pink and at times from the\n pyridium.\n Plan:\n Cont on CVVH until chemo is complete, CVVH labs q6 hrs\n Cvvh off as tmp pressures excessive.\n" }, { "category": "Echo", "chartdate": "2133-12-31 00:00:00.000", "description": "Report", "row_id": 88570, "text": "PATIENT/TEST INFORMATION:\nIndication: Chemotherapy. Evaluate for systolic/diastolic dysfunction.\nHeight: (in) 61\nWeight (lb): 170\nBSA (m2): 1.76 m2\nBP (mm Hg): 130/76\nHR (bpm): 108\nStatus: Inpatient\nDate/Time: at 15:43\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is elongated. 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 diameters of aorta at the\nsinus, ascending and arch levels are normal. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic\nregurgitation. The mitral valve leaflets are mildly thickened. Mild (1+)\nmitral regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function. Mild\nmitral regurgitation. Mild pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n" }, { "category": "Echo", "chartdate": "2133-12-11 00:00:00.000", "description": "Report", "row_id": 88571, "text": "PATIENT/TEST INFORMATION:\nIndication: Chemotherapy.\nHeight: (in) 61\nWeight (lb): 198\nBSA (m2): 1.88 m2\nBP (mm Hg): 132/65\nHR (bpm): 98\nStatus: Outpatient\nDate/Time: at 16:02\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\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal 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.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views.\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%). 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. There is no\naortic valve stenosis. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Trivial mitral regurgitation is seen. There is\nmild pulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Normal biventricular systolic function. Mild pulmonary\nhypertension.\n\n\n" }, { "category": "Nursing", "chartdate": "2133-12-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616960, "text": "62 year old woman transferred to from OSH with new diagnosis of\n Burkitt\ns lymphoma and tumor lysis syndrome. Presented to OSH with LDH\n > 20,000 and WBC 22. CT of chest/abdomen showed retroperitoneal nodes\n and hydronephrosis on the left. UA showed bacteria and a few WBC's with\n which pt was started on ceftriaxone.\n While in the MICU pt has been on CVVHD since for treatment of\n tumor lysis and as well as fluid removal. She has completed a 5 day\n course of Cytoxan along with a dose of Vincristin and Doxorubicin. She\n has been on CBI since admission---hematuria was present at admission\n and resolved with CBI and CBI remained for prevention of hemorrhagic\n cystitis.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt\ns last chemo . pt tolerated chemo well, CBI stopped .\n urine clear, dk yellow . No signs of tumor lysis. Denies pain, poor\n appetite, abd soft with + bowel sounds. Pt passed loose stool, brown.\n Lungs, clear, diminished at bases. On RA with O2 sats 100%\n Neutropenic.\n Action:\n Labs q 6 hrs, OOB to chair during the day, enc ambulation, enc po\n intake. Pt unable to sleep received 25 mg po Trazadone and 1 mg IV\n ativan a few hours later\n pt able to sleep most of the night.\n Response:\n No signs of tumor lysis, remains comfortable, hemodynamically stable\n Plan:\n Pt called out to the floor\n no beds. No chemo for one week, follow\n labs, transfuse if Hct <21, plts <50 Maintain chemo/neutropenic\n precautions.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt off CVVHD since 6 AM. Off CBI, making adequate amounts of\n urine\n Action:\n Labs as ordered, Magnesium repleted\n Response:\n No signs of tumor lysis, UO remains adequate 100 cc/hr.\n Plan:\n Check labs as ordered, monitor urine output\n SKIN: bruising/petechia noted lower back. Multiple bruising on both\n arms, no breakdown on coccyx, pt turned frequ. Skin care done.\n Pneumoboots on\n ------ Protected Section ------\n THIS AM patient alert oriented follows commands. Denies pain or any\n other discomfort. PT consult ordered\n patient will be seen today. On\n RA w/sats at high 90\ns-100%. L/S clear, RRR, unlabored breathing.\n Denies any SOB or CP. Normotensive, HR in 70\ns SR no ectopy noted. PIV\n placed by IV nurse. Renal to D/C Dialysis cath. On assessment abd soft\n non tender, positive for BS, no BM this shift. Regular diet\n tolerates\n well, denies nausea/vomiting. Dark yellow\n amber color urine via foley\n adequate amnt. In addition this am patient was repleted with 60meq\n KCL for K-3.5, 4gr of magnesium for Mg-1.6 and needs 4gr of calcium of\n Ca-7.1. Continue w/labs q12hr.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n LYMPHOMA\n Code status:\n Full code\n Height:\n 61 Inch\n Admission weight:\n 92.2 kg\n Daily weight:\n 87.8 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Hyperlipidemia, hypothyroidism\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:124\n D:55\n Temperature:\n 97.6\n Arterial BP:\n S:140\n D:64\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 75 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 24h total in:\n 590 mL\n 24h total out:\n 980 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 05:13 AM\n Potassium:\n 3.5 mEq/L\n 05:13 AM\n Chloride:\n 112 mEq/L\n 05:13 AM\n CO2:\n 23 mEq/L\n 05:13 AM\n BUN:\n 9 mg/dL\n 05:13 AM\n Creatinine:\n 0.4 mg/dL\n 05:13 AM\n Glucose:\n 109 mg/dL\n 05:13 AM\n Hematocrit:\n 21.5 %\n 05:13 AM\n Finger Stick Glucose:\n 143\n 05:00 AM\n Valuables / Signature\n Patient valuables: sent w/patient\n Transferred from: \n Transferred to: 7F 785\n Date & time of Transfer: \n ------ Protected Section Addendum Entered By: , RN\n on: 09:45 ------\n" }, { "category": "Nursing", "chartdate": "2133-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616539, "text": "Significant Events:\n --- CVVHD clotted @ 8 AM, renal notified and conclusion was to stop\n CVVHD and re-evaluate need for dialysis according to labs and UO\n ---Later in day, BMT ordered CVVHD to be continued through night as pt\n receiving new chemo regimen again toninght which could cause further\n damage to kidneys\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2133-12-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616604, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade burkits lymphoma. Transferred\n for further management from . Admitted to the ICU for CVVH\n for tumor lysis syndrome.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Burkitts lymphoma.\n Action:\n Pt received chemo last night. Remains on CVVH. Currently pt receiving\n platlets for level of 55, the site of HD cath is oozing. Will also\n receive a unit of Prbc for hct of 22.1, this has been trending down.\n Response:\n Plan:\n Cont with cvvh until the bmt clears the pt to stop.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Remains on CVVH but may stop it in the am since the chemo is finished.\n Response:\n CBI was stopped last evening as it was past 24 hours since the cytoxin\n was finished. Urine in the foley is now red in color which is due to\n the chemo received last evening.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2133-12-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 617202, "text": "62 year old woman transferred to from OSH with new diagnosis of\n Burkitt\ns lymphoma and tumor lysis syndrome. Presented to OSH with LDH\n > 20,000 and WBC 22. CT of chest/abdomen showed retroperitoneal nodes\n and hydronephrosis on the left. UA showed bacteria and a few WBC's with\n which pt was started on ceftriaxone.\n While in the MICU pt has been on CVVHD since for treatment of\n tumor lysis and as well as fluid removal. She has completed a 5 day\n course of Cytoxan along with a dose of Vincristin and Doxorubicin. She\n has been on CBI since admission---hematuria was present at admission\n and resolved with CBI. Off CBI and CVVHD last \n Pt stable hemodynamically, NSR and BP in the 110\n 120\n No c/o SOB or discomfort, O2 sats >95% at room air\n Oriented x 3, OOB with 1 assist, steady on her feet. Pt given trazadone\n and ativan for sleep with very positive results. Pt sleeping in long\n naps and states that she is feeling better because of it.\n Non-tender abdomen, on regular diet. Appetite improving. + bowel\n movement this am.\n Chemo precaution and neutropenic precaution maintained. WBC 0.3 this am\n UO adequate\n clear yellow with sediment intermittently\n Skin intact with some old bruise in her extremties and back area.\n Dilaysis line pulled out last night, PIV guage 20 at R basilic vein\n Repleted with magnesium for mg of 1.4; Postassium repletion 40 mEq for\n K of 3.5;need calcium repletion of Ca of 7.7\n Hct down to 21.2 this am, needs 1 unit of PRBC, goal hct\n 21 and\n platelet of 10 as goal current;y 39 with am labs\n Patient\ns husband called this am, aware of transfer once bed is\n available.\n" }, { "category": "Physician ", "chartdate": "2133-12-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 615996, "text": "Chief Complaint: Burkitt's lymphoma, acute renal failure, tumor lysis\n 24 Hour Events:\n - day 2 cytoxan and decadron, tolerating well\n - CVVH continues, evidence of TLS on labs\n - no evidence of DIC or hemorrhage\n - goal Is/Os even to (-) one liter\n - CVVH intermittently stopped overnight air infiltrate\n - c/o bladder spasm\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:33 PM\n Lorazepam (Ativan) - 12:00 AM\n Morphine Sulfate - 04:20 AM\n Other medications:\n Changes to medical and family history:\n sleeping this morning, denies pain, bladder spasm improving\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Genitourinary: Foley\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.3\nC (97.3\n HR: 85 (76 - 109) bpm\n BP: 123/64(85) {91/47(63) - 172/92(124)} mmHg\n RR: 15 (12 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 5,210 mL\n 1,176 mL\n PO:\n TF:\n IVF:\n 5,210 mL\n 1,176 mL\n Blood products:\n Total out:\n 6,113 mL\n 1,855 mL\n Urine:\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n -903 mL\n -679 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.45///21/\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: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 60 K/uL\n 6.9 g/dL\n 171 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 4.5 mEq/L\n 39 mg/dL\n 96 mEq/L\n 132 mEq/L\n 20.1 %\n 6.5 K/uL\n [image002.jpg]\n 12:39 PM\n 02:26 PM\n 05:35 PM\n 09:55 PM\n 11:49 PM\n 04:36 AM\n 09:59 AM\n 03:51 PM\n 08:42 PM\n 04:13 AM\n WBC\n 19.8\n 29.0\n 34.5\n 16.9\n 6.5\n Hct\n 22.9\n 23.5\n 25.3\n 22.1\n 20.1\n Plt\n 86\n 88\n 97\n 80\n 60\n Cr\n 2.0\n 2.2\n 1.8\n 1.6\n 1.4\n 1.0\n 1.0\n Glucose\n 143\n 161\n 197\n 134\n 116\n 112\n 114\n 171\n Other labs: PT / PTT / INR:13.5/21.3/1.2, CK / CKMB / Troponin-T:331//,\n ALT / AST:35/109, Alk Phos / T Bili:280/1.4, D-dimer:510 ng/mL,\n Fibrinogen:333 mg/dL, Lactic Acid:1.8 mmol/L, LDH: IU/L, Ca++:7.4\n mg/dL, Mg++:2.3 mg/dL, PO4:8.3 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n > Hct\n > Thrombocytopenia\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Tumour Lysis\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n TACHYCARDIA, OTHER\n HYPOTHYROIDISM\n URINARY TRACT INFECTION (UTI)\n HYPERCALCEMIA (HIGH CALCIUM)\n HYPERPHOSPHATEMIA (HIGH PHOSPHATE)\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and spontaneous tumor lysis\n syndrome. Received Rasburicase for uric acid converion. Pt intiated\n CVVH and CODOX yesterday. Labs remained stable. Today day 3 of cytoxan\n and decadron, continues on CVVH\n - cont dexa 40 mg IV daily, CODOX per heme/onc orders\n - cont allopurinol 100 mg daily\n - appreciate heme/onc recs -> ? to heme onc and renal re: risk of\n hemorrhagic cystitis, possibility of converting to HD\n - will check TLS labs Q6hrs (K, Cr, Ca, Mg, Ph, LDH)\n - DIC labs q6h\n - f/u EBV, CMV (-), HIV viral loads, antibody panels\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Has renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD. Had marginal urine output. Pt on CVVH given the anticipation\n of possible TLS from tumour response to dexamethasone. Could have\n component of hydroureter retroperitoneal disease\n - on CVVH, will readdress goal fluid balance with renal and BMT and\n possibility of converting to HD\n - currently would run her even given decreased BP and tachycardia with\n aggressive diuresis overnight, our goal is to maintain adequate\n hydration in setting of TLS and risk of hemorrhagic cystitis\n - f/u renal recs\n - trend Creatinine\n .\n ##. COAGULOPATHY: Pt had profuse oozing from HD site, with associated\n Hct drop. Also had hematuria, requiring CBI with 3way Foley. No\n evidence of coagulopathy by PTT/INR. Received 2 U FFP despite normal\n INR. Cryo\ns pending. Pt is not receiving anticoagulation in CVVH.\n Likely has platelet qualitative dysfunction. Hct and plt count cont to\n trend down, likely to recent hemorrhage and CVVH ->\n thrombocytopenia.\n - monitor Foley output, hematuria, concern for hemorrhagic cystitis\n - consider repeat CT for obstruction prior to urology consult\n - monitor q6h coags for r/o DIC\n - 2 units PRBCs for Hct, can give DDAVP for thrombocytopenia\n .\n URINARY TRACT INFECTION (UTI)/HEMATURIA\n Pt was given IV Ceftriaxone for ?UTI however U/A was notable for\n several epi cells in addition to bacteria. Patient complained of\n bladder discomfort with Foley in place, improved with pyridium. Repeat\n UA may suggest infection, although urine cx still pending. Leukocytosis\n and fever are difficult to follow in this patient given lymphoma and\n CVVH.\n - review OSH imaging for perinephric stranding\n - follow up Urine culture OSH and here and consider treatment\n - hematuria management as above\n .\n ##. Anion Gap Acidosis: Pt noted to have an anion gap acidosis on\n admission, likely lactic acidosis given her aggressive lymphoma. AG 20\n today. On CVVH.\n - trend lactate level\n - trend chemistry panel\n .\n ## Pain/discomfort\n morphine PRN\n .\n ## Nutrition- encourage PO intake, careful of aspiration\n .\n ## Fluid goal- even until speaking with Renal/BMT\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n -\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact to reconcile Furosemide, dosing.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer : famotidine\n VAP: none\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: \n" }, { "category": "Nursing", "chartdate": "2133-12-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616774, "text": "62 year old woman transferred to from OSH with new diagnosis of\n Burkitt\ns lymphoma and tumor lysis syndrome. Presented to OSH with LDH\n > 20,000 and WBC 22. CT of chest/abdomen showed retroperitoneal nodes\n and hydronephrosis on the left. UA showed bacteria and a few WBC's with\n which pt was started on ceftriaxone.\n While in the MICU pt has been on CVVHD since for treatment of\n tumor lysis and as well as fluid removal. She has completed a 5 day\n course of Cytoxan along with a dose of Vincristin and Doxorubicin. She\n has been on CBI since admission---hematuria was present at admission\n and resolved with CBI and CBI remained for prevention of hemorrhagic\n cystitis.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Received doses of vincristine and doxurobucin last night. Pt has\n tolerated chemo very well. CBI stopped last night. Urine clear, \n from chemo. No signs of tumor lysis. Denies pain. Poor appetite,\n abdomen soft with good bowel sounds. Lungs clear, diminished at bases.\n On RA with Sp02 100%. Neutropenic\n Action:\n Labs q6h. OOB to chair, walked in room. Encouraged PO intake.\n Neutropenic/chemo precautions\n Response:\n Pt ate\n today; weak on feet; no signs of tumor lysis; remains\n comfortable.\n Plan:\n Pt called out but there are no beds; NO chemo for one week; follow\n labs, transfuse for hct <21, plts <50. Maintain chemo/neutropenic\n precautions\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt taken off CVVHD at 6 AM; Off CBI, making adequate amounts of \n urine.\n Action:\n Labs q6h. Repleted K, Phos, and calcium\n Response:\n No signs of tumor lysis; UO remains adequate 100-200 cc/hr, urine now\n light yellow and clear. Cr 0.4; 1800 labs pending\n Plan:\n Follow labs q6h and UO qh, replete as needed\n" }, { "category": "Physician ", "chartdate": "2133-12-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 616914, "text": "Chief Complaint: Burkitt's lymphoma, acute renal failure, tumor lysis\n syndrome\n 24 Hour Events:\n ARTERIAL LINE - STOP 03:30 PM\n - stopped CVVH, labs all stable and urine output 100-200cc/hr\n - BMT recs: decrease to DIC labs\n - called out\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo 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 sleeping this morning, (-) n/v/d/f/c, (-) SOB, (-) abdominal pain, (-)\n chest pain\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Genitourinary: Foley\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 67 (65 - 110) bpm\n BP: 118/55(71) {104/52(64) - 143/123(128)} mmHg\n RR: 15 (14 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.8 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 1,866 mL\n 319 mL\n PO:\n 480 mL\n 200 mL\n TF:\n IVF:\n 908 mL\n 119 mL\n Blood products:\n 478 mL\n Total out:\n 3,912 mL\n 700 mL\n Urine:\n 2,865 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,046 mL\n -381 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, clear oropharynx\n Cardiovascular: (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: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x 3, Movement: Not assessed, Tone: Normal\n Labs / Radiology\n 68 K/uL\n 7.6 g/dL\n 109 mg/dL\n 0.4 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 112 mEq/L\n 143 mEq/L\n 21.5 %\n 0.4 K/uL\n [image002.jpg]\n 06:28 AM\n 12:08 PM\n 12:36 PM\n 05:57 PM\n 06:08 PM\n 11:21 PM\n 05:47 AM\n 11:51 AM\n 05:24 PM\n 05:13 AM\n WBC\n 0.7\n 0.5\n 0.5\n 0.4\n Hct\n 23.5\n 22.7\n 22.1\n 26.9\n 25.1\n 23.3\n 21.5\n Plt\n 76\n 71\n 55\n 98\n 84\n 87\n 68\n Cr\n 0.4\n 0.3\n 0.3\n 0.3\n 0.4\n 0.3\n 0.4\n TCO2\n 22\n 22\n 21\n Glucose\n 117\n 108\n 107\n 98\n 127\n 104\n 109\n Other labs: PT / PTT / INR:13.1/23.6/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:38/48, Alk Phos / T Bili:222/1.2, Differential-Neuts:62.0 %,\n Band:2.0 %, Lymph:22.0 %, Mono:8.0 %, Eos:6.0 %, D-dimer:510 ng/mL,\n Fibrinogen:229 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.2 g/dL,\n LDH:2335 IU/L, Ca++:7.1 mg/dL, Mg++:1.6 mg/dL, PO4:3.3 mg/dL\n Fluid analysis / Other labs: CHROMOSOME ANALYSIS-BONE\n MARROW-----------------------\n KARYOTYPE: SEE BELOW\n INTERPRETATION:\n 46,XX,t(8;14)(q24.1;q32)[10]/\n 46,idem,t(X;11)(p22.1;p11.2)[6]/47,idem,+[3]/\n 47,idem,t(X;11)(p22.1;p11.2),+[1]\n All metaphases showed a translocation of chromosomes 8 and 14. This\n translocation is associated with IGH/MYC fusion and is a characteristic\n finding in Burkitt lymphoma.\n The clone with the t(8;14) is the stemline. Three additional abnormal\n subclones are identified. The first\n subclone, represented by metaphases, has a translocation of\n chromosomes X at band Xp22.1 and 11 at band 11p11.2. The second\n subclone, represented by \n metaphases, has a marker chromsome. The third subclone, represented by\n metaphases, has the translocation of chromosomes X and 11 and the\n marker chromosome.\n Small chromosome anomalies may not be detectable using the standard\n methods employed.\n FISH evaluation for a MYC rearrangement was performed on nuclei with\n the LSI MYC Dual Dual Color, Break Apart Rearrangement Probe (\n Molecular) at 8q24 and is interpreted as ABNORMAL. Rearrangement was\n observed in\n 74/100 nuclei, which exceeds the normal range (up to 4%\n rearrangement) established for this probe in the Cytogenetics\n Laboratory at . MYC rearrangement is\n found in more than 90% of Burkitt lymphomas, but can also be found\n occasionally in other histologies of\n non-Hodgkin's lymphoma. The MYC rearrangements in Burkitt lymphomas\n result in MYC overexpression, generally by juxtaposition with an\n immunoglobulin gene.\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Tumor Lysis\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n TACHYCARDIA, OTHER\n HYPOTHYROIDISM\n URINARY TRACT INFECTION (UTI)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 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": "2133-12-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 616918, "text": "Chief Complaint: Burkitt's lymphoma, acute renal failure, tumor lysis\n syndrome\n 24 Hour Events:\n ARTERIAL LINE - STOP 03:30 PM\n - stopped CVVH, labs all stable and urine output 100-200cc/hr\n - BMT recs: decrease to DIC labs\n - called out\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo 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 sleeping this morning, (-) n/v/d/f/c, (-) SOB, (-) abdominal pain, (-)\n chest pain\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Genitourinary: Foley\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 67 (65 - 110) bpm\n BP: 118/55(71) {104/52(64) - 143/123(128)} mmHg\n RR: 15 (14 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.8 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 1,866 mL\n 319 mL\n PO:\n 480 mL\n 200 mL\n TF:\n IVF:\n 908 mL\n 119 mL\n Blood products:\n 478 mL\n Total out:\n 3,912 mL\n 700 mL\n Urine:\n 2,865 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,046 mL\n -381 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, clear oropharynx\n Cardiovascular: (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: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x 3, Movement: Not assessed, Tone: Normal\n Labs / Radiology\n 68 K/uL\n 7.6 g/dL\n 109 mg/dL\n 0.4 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 112 mEq/L\n 143 mEq/L\n 21.5 %\n 0.4 K/uL\n [image002.jpg]\n 06:28 AM\n 12:08 PM\n 12:36 PM\n 05:57 PM\n 06:08 PM\n 11:21 PM\n 05:47 AM\n 11:51 AM\n 05:24 PM\n 05:13 AM\n WBC\n 0.7\n 0.5\n 0.5\n 0.4\n Hct\n 23.5\n 22.7\n 22.1\n 26.9\n 25.1\n 23.3\n 21.5\n Plt\n 76\n 71\n 55\n 98\n 84\n 87\n 68\n Cr\n 0.4\n 0.3\n 0.3\n 0.3\n 0.4\n 0.3\n 0.4\n TCO2\n 22\n 22\n 21\n Glucose\n 117\n 108\n 107\n 98\n 127\n 104\n 109\n Other labs: PT / PTT / INR:13.1/23.6/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:38/48, Alk Phos / T Bili:222/1.2, Differential-Neuts:62.0 %,\n Band:2.0 %, Lymph:22.0 %, Mono:8.0 %, Eos:6.0 %, D-dimer:510 ng/mL,\n Fibrinogen:229 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.2 g/dL,\n LDH:2335 IU/L, Ca++:7.1 mg/dL, Mg++:1.6 mg/dL, PO4:3.3 mg/dL\n Fluid analysis / Other labs: CHROMOSOME ANALYSIS-BONE\n MARROW-----------------------\n KARYOTYPE: SEE BELOW\n INTERPRETATION:\n 46,XX,t(8;14)(q24.1;q32)[10]/\n 46,idem,t(X;11)(p22.1;p11.2)[6]/47,idem,+[3]/\n 47,idem,t(X;11)(p22.1;p11.2),+[1]\n All metaphases showed a translocation of chromosomes 8 and 14. This\n translocation is associated with IGH/MYC fusion and is a characteristic\n finding in Burkitt lymphoma.\n The clone with the t(8;14) is the stemline. Three additional abnormal\n subclones are identified. The first\n subclone, represented by metaphases, has a translocation of\n chromosomes X at band Xp22.1 and 11 at band 11p11.2. The second\n subclone, represented by \n metaphases, has a marker chromsome. The third subclone, represented by\n metaphases, has the translocation of chromosomes X and 11 and the\n marker chromosome.\n Small chromosome anomalies may not be detectable using the standard\n methods employed.\n FISH evaluation for a MYC rearrangement was performed on nuclei with\n the LSI MYC Dual Dual Color, Break Apart Rearrangement Probe (\n Molecular) at 8q24 and is interpreted as ABNORMAL. Rearrangement was\n observed in\n 74/100 nuclei, which exceeds the normal range (up to 4%\n rearrangement) established for this probe in the Cytogenetics\n Laboratory at . MYC rearrangement is\n found in more than 90% of Burkitt lymphomas, but can also be found\n occasionally in other histologies of\n non-Hodgkin's lymphoma. The MYC rearrangements in Burkitt lymphomas\n result in MYC overexpression, generally by juxtaposition with an\n immunoglobulin gene.\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Tumor Lysis\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n TACHYCARDIA, OTHER\n HYPOTHYROIDISM\n URINARY TRACT INFECTION (UTI)\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and spontaneous tumor lysis\n syndrome. Received Rasburicase for uric acid converion. Pt had e/o TL,\n now labs continue to be stable. Received doxorubicin and vincristine\n yesterday (day 1), next dose day 8. CVVH stopped yesterday, continues\n to have excellent UOP, renal function normal.\n - cont allopurinol 100 mg daily, cont to monitor renal fxn\n - BMT said no bactrim, inhaled pentamidine at some point\n - neutropenic precautions, normal\n goals off CVVH\n - Cryo for fibrinogen less than 100, Plts for less than 50 because of\n oozing, Hct>21\n - appreciate heme/onc recs\n - will check TLS labs, DIC labs, electrolytes \n - EBV -> IgG (+), IgM (-), CMV and HIV (-)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Has renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD in retroperitoneum. Had marginal urine output. Pt on CVVH so\n creatinine improved. Urine output continues to improve, possibly\n passed stone or tumor burden reduced. Stopped CBI and CVVH\n - electrolytes\n - Monitor for hematuria\n - f/u renal recs\n .\n ##. COAGULOPATHY/PANCYTOPENIA: Pt has had profuse oozing from HD site,\n with associated Hct drop. Also had hematuria, requiring CBI with 3way\n Foley. Both are now improving. No evidence of coagulopathy. Pt is not\n receiving anticoagulation in CVVH. Hct, white count, and plt count\n cont to trend down, likely to chemo.\n - transfusion goals as above.\n - monitor q12 coags for r/o DIC\n - transfuse for goal Hct>21, plt>50 since bleeding\n .\n URINARY TRACT INFECTION (UTI)/HEMATURIA: Pt had bladder pain and\n hematuria, now resolved.\n Ucx neg x 2.\n .\n ##. Anion Gap Acidosis: normalized.\n .\n ## Pain/discomfort\n morphine PRN\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: call out\n" }, { "category": "Physician ", "chartdate": "2133-12-16 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 616524, "text": "Chief Complaint: Respiratory distress\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 Overall, states to feel improved.\n Maintained on CVVH, tolerated net negative fluid balance over past 24\n hrs. CVVH clotted this AM --> now off CVVH.\n Poor appetite.\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 Famotidine (Pepcid) - 07:50 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, 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, 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, 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, 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 10:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 78 (54 - 106) bpm\n BP: 145/66(94) {123/59(84) - 169/88(120)} mmHg\n RR: 18 (12 - 19) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.4 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 4,980 mL\n 1,563 mL\n PO:\n 200 mL\n TF:\n IVF:\n 4,308 mL\n 1,514 mL\n Blood products:\n 473 mL\n 49 mL\n Total out:\n 6,789 mL\n 2,490 mL\n Urine:\n 1,875 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,809 mL\n -927 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: 7.50/27/99./22/0\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, Appears more\n comfortable today\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: 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: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) 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: Normal\n Labs / Radiology\n 8.0 g/dL\n 82 K/uL\n 118 mg/dL\n 0.4 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 10 mg/dL\n 107 mEq/L\n 136 mEq/L\n 23.0 %\n 0.9 K/uL\n [image002.jpg]\n 09:13 AM\n 09:29 AM\n 02:49 PM\n 03:04 PM\n 09:22 PM\n 09:36 PM\n 12:34 AM\n 12:51 AM\n 05:55 AM\n 06:28 AM\n WBC\n 1.3\n 0.9\n Hct\n 24.1\n 24.7\n 23.9\n 23.0\n Plt\n 63\n 48\n 79\n 82\n Cr\n 0.5\n 0.4\n TCO2\n 25\n 23\n 23\n 23\n 22\n Glucose\n 126\n 118\n Other labs: PT / PTT / INR:12.9/22.7/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:35/44, Alk Phos / T Bili:247/1.4, Differential-Neuts:78.0 %,\n Band:1.0 %, Lymph:16.0 %, Mono:5.0 %, Eos:0.0 %, D-dimer:510 ng/mL,\n Fibrinogen:154 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.2 g/dL,\n LDH:5379 IU/L, Ca++:7.6 mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n RESPIRATORY DISTRESS -- concern for evolving pulmonary edema secondary\n to volume resussitation (tumor lysis syndrome, acute renal failure).\n Monitor RR, SaO2. Aim for net diuresis.\n LYMPHOMA -- Burkitt's Lymphoma, high tumor burden, spontaneous tumor\n lysis syndrome. To complete cytoxan and decadron. Heme/Onc service\n following.\n RENAL FAILURE, ACUTE -- attributed to tumour lysis and urate\n nephropathy. Evidence for right renal stones (likely uric acid), and\n left hydronephrosis (possible external compression by\n lymphadenopathy). Continue CVVH if poor urine output. (Experienced\n difficulty with HD line and air infiltration). Monitor urine output,\n BUN, creatininine. Consider HD if requires resumption of renal\n replacement therapy.\n FLUIDS -- hypervolemia (net balance ~ 10 L since admission). Tolerated\n net negative fluid balance overnight. Desire net negative balance,\n aiming for additional 1-2 L net negative for next 24 hrs if tolerated\n by BP. Urine output may be difficult to determine/innacurate while\n receiving continous bladder irrigation. Monitor off CVVH today.\n COAGULOPATHY -- Pt had profuse oozing from HD site, hematuria, with\n associated Hct drop. Possible DIC? Monitor coagulopathy. Monitor q6h\n coags for r/o DIC\n ANEMIA -- transfuse for goal Hct>21\n THROMBOCYTOPENIA -- transfuse for plt <50 since bleeding\n NEUTROPENIA\n neutroppenic precautions, counts continue to fall.\n HEMATURIA -- attributed in part to chemotherapy. No evidence for UTI.\n TACHYCARDIA -- resolved.\n HYPOTHYROIDISM -- Continue on home regimen.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 03:17 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: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2133-12-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616765, "text": "62 year old woman transferred to from OSH with new diagnosis of\n Burkitt\ns lymphoma and tumor lysis syndrome. Presented to OSH with LDH\n > 20,000 and WBC 22. CT of chest/abdomen showed retroperitoneal nodes\n and hydronephrosis on the left. UA showed bacteria and a few WBC's with\n which pt was started on ceftriaxone.\n While in the MICU pt has been on CVVHD since for treatment of\n tumor lysis and as well as fluid removal. She has completed a 5 day\n course of Cytoxan along with a dose of Vincristin and Doxorubicin. She\n has been on CBI since admission---hematuria was present at admission\n and resolved with CBI and CBI remained for prevention of hemorrhagic\n cystitis.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Received doses of vincristine and doxurobucin last night. Pt has\n tolerated chemo very well. CBI stopped last night. Urine clear, \n from chemo. No signs of tumor lysis. Denies pain. Poor appetite,\n abdomen soft with good bowel sounds. Lungs clear, diminished at bases.\n On RA with Sp02 100%. Neutropenic\n Action:\n Labs q6h. OOB to chair, walked in room. Encouraged PO intake.\n Neutropenic/chemo precautions\n Response:\n Pt ate\n today; weak on feet; no signs of tumor lysis; remains\n comfortable.\n Plan:\n Pt called out but there are no beds; NO chemo for one week; follow\n labs, transfuse for hct <21, plts <50. Maintain chemo/neutropenic\n precautions\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt taken off CVVHD at 6 AM; Off CBI, making adequate amounts of \n urine.\n Action:\n Labs q6h. Repleted K, Phos, and calcium\n Response:\n No signs of tumor lysis; UO remains adequate 100-200 cc/hr, urine now\n light yellow and clear. Cr 0.4; 1800 labs pending\n Plan:\n Follow labs q6h and UO qh, replete as needed\n" }, { "category": "Physician ", "chartdate": "2133-12-19 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 617194, "text": "Chief Complaint: Burkitt's Lymphoma and Tumor Lysis Syndrome\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 Please see H&P for full details.\n 24 Hour Events:\n - Called out, no bed available.\n - Stable off of CVVH\n - Neutropenic\n - Improved appetite\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:14 AM\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.8\nC (98.3\n HR: 71 (64 - 93) bpm\n BP: 121/78(86) {109/50(66) - 142/78(93)} mmHg\n RR: 16 (13 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.8 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 891 mL\n PO:\n 380 mL\n TF:\n IVF:\n 511 mL\n Blood products:\n Total out:\n 2,920 mL\n 760 mL\n Urine:\n 2,920 mL\n 760 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,029 mL\n -760 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\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: 2+ DP bilat\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear ,\n soft crackles at base that clear with deep breaths)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to):\n Person, Place, Time, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 7.5 g/dL\n 39 K/uL\n 113 mg/dL\n 0.4 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 105 mEq/L\n 135 mEq/L\n 21.2 %\n 0.3 K/uL\n [image002.jpg]\n 05:57 PM\n 06:08 PM\n 11:21 PM\n 05:47 AM\n 11:51 AM\n 05:24 PM\n 05:13 AM\n 10:32 AM\n 04:34 PM\n 05:04 AM\n WBC\n 0.7\n 0.5\n 0.5\n 0.4\n 0.3\n Hct\n 22.7\n 22.1\n 26.9\n 25.1\n 23.3\n 21.5\n 22.6\n 21.2\n Plt\n 71\n 55\n 98\n 84\n 87\n 68\n 57\n 39\n Cr\n 0.3\n 0.3\n 0.3\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 21\n Glucose\n 108\n 107\n 98\n 127\n 104\n 109\n 113\n Other labs: PT / PTT / INR:13.2/23.2/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:26/22, Alk Phos / T Bili:196/1.1, Differential-Neuts:62.0 %,\n Band:2.0 %, Lymph:22.0 %, Mono:8.0 %, Eos:6.0 %, D-dimer:510 ng/mL,\n Fibrinogen:344 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.2 g/dL,\n LDH:1547 IU/L, Ca++:7.7 mg/dL, Mg++:1.4 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n BURKITT'S LYMPHOMA\n Now s/p cytoxan, doxirubicin, vincristine, and\n steroids. Is now neutropenic, on neutropenic precautions, afebrile.\n - Follow counts, transfuse Plt to >10, Hct >25 as needed.\n - Further chemotherapy per BMT service\n - Appreciate BMT input\n TUMOR LYSIS SYNDROME\n Required CVVH, now resolved, still following\n labs.\n - Improved UOP, Cr, stable electrolytes\n RENAL FAILURE, ACUTE\n Now improved.\n - Off of CVVH, stable electrolytes.\n HYPOTHYROIDISM\n Continue synthroid.\n ICU Care\n Nutrition: Oral diet\n Glycemic Control: follow chem-7\n Lines:\n Dialysis Catheter - 12:00 AM\n Now d/c\n 20 Gauge - 07:49 AM\n Prophylaxis:\n DVT: P-boots\n Stress ulcer: famotodine\n VAP: N/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : To BMT when bed available\n Total time spent: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2133-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616329, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade burkits lymphoma. Transferred\n for further management from . Admitted to the ICU for CVVH\n for tumor lysis syndrome.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with ? UTI dx in OSH; known renal calculi with hydronephrosis.\n creatinine high at 3.0/ BUN of 39; Started on CVVH for tumor lysis\n syndrome and while she is on chemotherapy; CVVH machine alarming air in\n the system and filter changed twice overnight; 10L positive I/O had\n 1100cc of urine out 17 hrs after 3L NS ( CBI) hang yesterday; reversed\n ( access port switched with return port)\n Action:\n CVVHD initiated 12noon, replacement fluid changed to K4 running at 4200\n ml/hr ( 4000 PBP) and dialysate at 1000ml/hr with goal to keep patient\n 50cc/hr negative; negative but per oncology and ICU team we can run\n patient 1-2 liters negative since she is almost 11L positive for LOS\n and desatted down 87-88% this am calculated urine output at 80cc/hr in\n reference to 1000 output via CBI for 12hrs; ports\n Response:\n 1000 cc urine out from CBI at 1800 ( for 9hrs from 0900-1800 that\n about 100cc/hr);\n Plan:\n Continue with CVVH with goal to keep her 50cc/hr; urine output of\n 100cc/hr is goal while on cytoxan\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n + burkits lymphoma, continues on CBI in the setting of hematuria\n previous days but kept her on CBI to flush kidney while getting\n chemotherapy; urine and clear;\n Action:\n TLS labs q6h includingcoags and fibrinogen. Pre-medicated for chemo, 40\n mg IV decadron and Zofran. 1 mg ativan given for anxiety/restlessness.\n Allopurinol 100mgs daily; received decadron and zofran pre chemo; last\n dose of cytoxan given this afternoon\n Response:\n K 3.6 this pm, phos down to 3.2, ionized calcium 0.96\n on KCL and\n Calcium gluconate repletion, uric acid down to 5.6 form 8.0 this am;\n Coags stable FDP 10-40;\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and\n Fibrinogen.\n" }, { "category": "Physician ", "chartdate": "2133-12-16 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 616488, "text": "Chief Complaint: Respiratory distress\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 Overall, states to feel improved.\n Maintained on CVVH, tolerated net negative fluid balance over past 24\n hrs. CVVH clotted this AM --> now off CVVH.\n Poor appetite.\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 Famotidine (Pepcid) - 07:50 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, 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, 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, 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, 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 10:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 78 (54 - 106) bpm\n BP: 145/66(94) {123/59(84) - 169/88(120)} mmHg\n RR: 18 (12 - 19) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.4 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 4,980 mL\n 1,563 mL\n PO:\n 200 mL\n TF:\n IVF:\n 4,308 mL\n 1,514 mL\n Blood products:\n 473 mL\n 49 mL\n Total out:\n 6,789 mL\n 2,490 mL\n Urine:\n 1,875 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,809 mL\n -927 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: 7.50/27/99./22/0\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, Appears more\n comfortable today\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: 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: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) 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: Normal\n Labs / Radiology\n 8.0 g/dL\n 82 K/uL\n 118 mg/dL\n 0.4 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 10 mg/dL\n 107 mEq/L\n 136 mEq/L\n 23.0 %\n 0.9 K/uL\n [image002.jpg]\n 09:13 AM\n 09:29 AM\n 02:49 PM\n 03:04 PM\n 09:22 PM\n 09:36 PM\n 12:34 AM\n 12:51 AM\n 05:55 AM\n 06:28 AM\n WBC\n 1.3\n 0.9\n Hct\n 24.1\n 24.7\n 23.9\n 23.0\n Plt\n 63\n 48\n 79\n 82\n Cr\n 0.5\n 0.4\n TCO2\n 25\n 23\n 23\n 23\n 22\n Glucose\n 126\n 118\n Other labs: PT / PTT / INR:12.9/22.7/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:35/44, Alk Phos / T Bili:247/1.4, Differential-Neuts:78.0 %,\n Band:1.0 %, Lymph:16.0 %, Mono:5.0 %, Eos:0.0 %, D-dimer:510 ng/mL,\n Fibrinogen:154 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.2 g/dL,\n LDH:5379 IU/L, Ca++:7.6 mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n RESPIRATORY DISTRESS -- concern for evolving pulmonary edema secondary\n to volume resussitation (tumor lysis syndrome, acute renal failure).\n Monitor RR, SaO2. Aim for net diuresis.\n LYMPHOMA -- Burkitt's Lymphoma, high tumor burden, spontaneous tumor\n lysis syndrome. To complete cytoxan and decadron. Heme/Onc service\n following.\n RENAL FAILURE, ACUTE -- attributed to tumour lysis and urate\n nephropathy. Evidence for right renal stones (likely uric acid), and\n left hydronephrosis (possible external compression by\n lymphadenopathy). Continue CVVH if poor urine output. (Experienced\n difficulty with HD line and air infiltration). Monitor urine output,\n BUN, creatininine. Consider HD if requires resumption of renal\n replacement therapy.\n FLUIDS -- hypervolemia (net balance ~ 10 L since admission). Tolerated\n net negative fluid balance overnight. Desire net negative balance,\n aiming for additional 1-2 L net negative for next 24 hrs if tolerated\n by BP. Urine output may be difficult to determine/innacurate while\n receiving continous bladder irrigation. Monitor off CVVH today.\n COAGULOPATHY -- Pt had profuse oozing from HD site, hematuria, with\n associated Hct drop. Possible DIC? Monitor coagulopathy. Monitor q6h\n coags for r/o DIC\n ANEMIA -- transfuse for goal Hct>21\n THROMBOCYTOPENIA -- transfuse for plt <50 since bleeding\n NEUTROPENIA\n neutroppenic precautions, counts continue to fall.\n HEMATURIA -- attributed in part to chemotherapy. No evidence for UTI.\n TACHYCARDIA -- resolved.\n HYPOTHYROIDISM -- Continue on home regimen.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 03:17 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: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2133-12-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 616490, "text": "TITLE:\n Chief Complaint:\n No complaints, no CP/SOB, no ab pain, no dysuria. +BM few days ago.\n Eating only juice/jello, no N/V but poor appetite.\n 24 Hour Events:\n - Hemeonc recs last dose of cytoxan tonight. get AM transaminases and\n t.bili in anticipation of adriamycin\n - fluid status -> will run slightly negative to avoid fluid further\n fluid overload\n - no evidence of DIC or TLS on Q6 checks\n - one bag of plts overnight for plt count 48\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 2 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:50 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 54 (54 - 106) bpm\n BP: 135/63(88) {123/54(80) - 171/94(125)} mmHg\n RR: 14 (12 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 94.4 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 4,980 mL\n 985 mL\n PO:\n 200 mL\n TF:\n IVF:\n 4,308 mL\n 936 mL\n Blood products:\n 473 mL\n 49 mL\n Total out:\n 6,789 mL\n 1,966 mL\n Urine:\n 1,875 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,809 mL\n -981 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: 7.50/27/99./20/0\n Physical Examination\n General Appearance: Well nourished, No acute distress, awake and alert\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: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Follows commands, alert and appropriate\n Labs / Radiology\n 79 K/uL\n 8.4 g/dL\n 126 mg/dL\n 0.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 106 mEq/L\n 136 mEq/L\n 23.9 %\n 1.3 K/uL\n [image002.jpg]\n 03:30 AM\n 09:13 AM\n 09:29 AM\n 02:49 PM\n 03:04 PM\n 09:22 PM\n 09:36 PM\n 12:34 AM\n 12:51 AM\n 06:28 AM\n WBC\n 1.2\n 1.3\n Hct\n 23.6\n 24.1\n 24.7\n 23.9\n Plt\n 65\n 63\n 48\n 79\n Cr\n 0.4\n 0.5\n TCO2\n 25\n 23\n 23\n 23\n 22\n Glucose\n 144\n 126\n Other labs: PT / PTT / INR:12.3/21.6/1.0, CK / CKMB / Troponin-T:331//,\n ALT / AST:28/51, Alk Phos / T Bili:221/1.7, Differential-Neuts:80.0 %,\n Band:5.0 %, Lymph:10.0 %, Mono:5.0 %, Eos:0.0 %, D-dimer:510 ng/mL,\n Fibrinogen:169 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.0 g/dL,\n LDH:5379 IU/L, Ca++:7.5 mg/dL, Mg++:1.9 mg/dL, PO4:1.5 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and spontaneous tumor lysis\n syndrome. Received Rasburicase for uric acid converion. Pt had e/o TL,\n now labs continue to be stable. Completed cytoxan last night, continues\n on CVVH and CBI prophylactically. To receive vincristine and\n doxorubicin today.\n - discuss coming off CVVH since no TL and completed cytoxan\n - cont allopurinol 100 mg daily, check renal dosing if off CVVH\n - discuss ppx (Bactrim) with BMT team\n - neutropenic precautions\n - Cryo for fibrinogen less than 100, Plts for less than 50 because of\n oozing, Hct>21\n - appreciate heme/onc recs\n - will check TLS labs Q6hrs (K, Cr, Ca, Mg, Ph, LDH)\n - DIC labs q6h\n - f/u EBV, antibody panels\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Has renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD in retroperitoneum. Had marginal urine output. Pt on CVVH so\n creatinine improved, 2.5L neg overnight. Urine output apparently\n improving, possibly passed stone or tumor burden reduced.\n - goal on CVVH 1-2L neg/day\n - consider stopping CVVH or transition to HD if pt euvolemic and good\n UOP\n - d/c CBI and monitor urine output.\n - repeat U/S for obstruction and consider urology consult\n - f/u renal recs\n .\n ##. COAGULOPATHY/PANCYTOPENIA: Pt has had profuse oozing from HD site,\n with associated Hct drop. Also had hematuria, requiring CBI with 3way\n Foley. Both are now improving. No evidence of coagulopathy. Pt is not\n receiving anticoagulation in CVVH. Hct and plt count cont to trend\n down, likely to chemo.\n - transfusion goals as above.\n - monitor q6h coags for r/o DIC\n - transfuse for goal Hct>21, plt>50 since bleeding\n .\n URINARY TRACT INFECTION (UTI)/HEMATURIA: Pt had bladder pain and\n hematuria, now resolved.\n Ucx neg x 2.\n .\n ##. Anion Gap Acidosis: normalized.\n .\n ## Pain/discomfort\n morphine PRN\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n -\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact to reconcile Furosemide, dosing.\n ICU Care\n Nutrition: regular, supplment with Boost/ensure\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer : famotidine\n VAP: none\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: until off CVVH and stable\n" }, { "category": "Nutrition", "chartdate": "2133-12-16 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 616494, "text": "Subjective\n Patient with poor appetite, only takes ginger ale, juice, jello, no n/v\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 155 cm\n 92 kg\n 94.4 kg ( 06:00 AM)\n 38\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 48 kg\n 192%\n 59 kg\n kg\n %\n Diagnosis: lymphoma\n PMHx: hypothyroid, hyperlipidemia, c-section\n Food allergies and intolerances: none noted\n Pertinent medications: humalog insulin sliding scale, others noted\n Labs:\n Value\n Date\n Glucose\n 118 mg/dL\n 05:55 AM\n Glucose Finger Stick\n 196\n 12:34 AM\n BUN\n 10 mg/dL\n 05:55 AM\n Creatinine\n 0.4 mg/dL\n 05:55 AM\n Sodium\n 136 mEq/L\n 05:55 AM\n Potassium\n 4.0 mEq/L\n 05:55 AM\n Chloride\n 107 mEq/L\n 05:55 AM\n TCO2\n 22 mEq/L\n 05:55 AM\n Albumin\n 3.2 g/dL\n 05:55 AM\n Calcium non-ionized\n 7.6 mg/dL\n 05:55 AM\n Phosphorus\n 1.3 mg/dL\n 05:55 AM\n Ionized Calcium\n 1.09 mmol/L\n 06:28 AM\n Magnesium\n 1.8 mg/dL\n 05:55 AM\n Current diet order / nutrition support: Regular diet\n GI: Abdomen soft with positive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: Low po intake\n Estimated Nutritional Needs\n Calories: 1200-1500 (BEE x or / 20-25 cal/kg)\n Protein: 70-90 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Specifics:\n 62 year old female with new diagnosis of high grade Burkitt\ns Lymphoma.\n Patient was started on CRRT and chemotherapy. Patient with poor PO\n intake, unable to take much intake and has poor appetite. Patient may\n benefit from nutritional supplement. If poor PO intake continues, may\n need to consider nutrition support to ensure that patient meets needs.\n Will provide recommendations as needed.\n Medical Nutrition Therapy Plan - Recommend the Following\n Continue with regular diet\n Provide Ensure Plus with meals\n Will follow closely for plan of care, please consult if plan\n for tube feedings or TPN\n 11:02 AM\n" }, { "category": "Physician ", "chartdate": "2133-12-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 617180, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n :\n - had bed and lost it, waiting for a new one\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.8\nC (98.3\n HR: 71 (64 - 93) bpm\n BP: 121/78(86) {109/50(66) - 142/78(93)} mmHg\n RR: 16 (13 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.8 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 891 mL\n PO:\n 380 mL\n TF:\n IVF:\n 511 mL\n Blood products:\n Total out:\n 2,920 mL\n 760 mL\n Urine:\n 2,920 mL\n 760 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,029 mL\n -760 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\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 39 K/uL\n 7.5 g/dL\n 113 mg/dL\n 0.4 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 105 mEq/L\n 135 mEq/L\n 21.2 %\n 0.3 K/uL\n [image002.jpg]\n 05:57 PM\n 06:08 PM\n 11:21 PM\n 05:47 AM\n 11:51 AM\n 05:24 PM\n 05:13 AM\n 10:32 AM\n 04:34 PM\n 05:04 AM\n WBC\n 0.7\n 0.5\n 0.5\n 0.4\n 0.3\n Hct\n 22.7\n 22.1\n 26.9\n 25.1\n 23.3\n 21.5\n 22.6\n 21.2\n Plt\n 71\n 55\n 98\n 84\n 87\n 68\n 57\n 39\n Cr\n 0.3\n 0.3\n 0.3\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 21\n Glucose\n 108\n 107\n 98\n 127\n 104\n 109\n 113\n Other labs: PT / PTT / INR:13.2/23.2/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:26/22, Alk Phos / T Bili:196/1.1, Differential-Neuts:62.0 %,\n Band:2.0 %, Lymph:22.0 %, Mono:8.0 %, Eos:6.0 %, D-dimer:510 ng/mL,\n Fibrinogen:344 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.2 g/dL,\n LDH:1547 IU/L, Ca++:7.7 mg/dL, Mg++:1.4 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and spontaneous tumor lysis\n syndrome. Received Rasburicase for uric acid converion. Pt had e/o TL,\n now labs continue to be stable. Received doxorubicin and vincristine\n (day 1), next dose day 8 . CVVH stopped yesterday, continues\n to have excellent UOP, renal function normal.\n - cont allopurinol 100 mg daily, cont to monitor renal fxn\n - BMT said no bactrim, inhaled pentamidine at some point\n - neutropenic precautions, normal\n goals off CVVH\n - Cryo for fibrinogen less than 100, Plts for less than 50 because of\n oozing, Hct>21\n - appreciate heme/onc recs\n - will check TLS labs, DIC labs, electrolytes \n - EBV -> IgG (+), IgM (-), CMV and HIV (-)\n .\n NEUTROPENIA\n WBC .3 today, await diff.\n - continue neutropenic precautions, no fevers yet\n .\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Had renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD in retroperitoneum. Had marginal urine output. Pt on CVVH so\n creatinine improved. Urine output continues to improve, possibly\n passed stone or tumor burden reduced. Stopped CBI and CVVH\n - electrolytes\n - Monitor for hematuria\n - f/u renal recs\n .\n ##. COAGULOPATHY/PANCYTOPENIA/NEUTROPENIA: Pt has had profuse oozing\n from HD site, with associated Hct drop. Also had hematuria, requiring\n CBI with 3way Foley. Both are now improving. No evidence of\n coagulopathy. Pt is not receiving anticoagulation in CVVH. Hct, white\n count, and plt count cont to trend down, likely to chemo.\n - transfusion goals as above.\n - monitor q12 coags for r/o DIC\n - transfuse for goal Hct>21, plt>10 now that bleeding has resolved\n .\n URINARY TRACT INFECTION (UTI)/HEMATURIA: Pt had bladder pain and\n hematuria, now resolved.\n Ucx neg x 2.\n .\n ##. Anion Gap Acidosis: normalized.\n .\n ## Pain/discomfort\n morphine PRN\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: call out\n" }, { "category": "Physician ", "chartdate": "2133-12-19 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 617190, "text": "Chief Complaint: Burkitt's Lymphoma and Tumor Lysis Syndrome\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 Please see H&P for full details.\n 24 Hour Events:\n - Called out, no bed available.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.8\nC (98.3\n HR: 71 (64 - 93) bpm\n BP: 121/78(86) {109/50(66) - 142/78(93)} mmHg\n RR: 16 (13 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.8 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 891 mL\n PO:\n 380 mL\n TF:\n IVF:\n 511 mL\n Blood products:\n Total out:\n 2,920 mL\n 760 mL\n Urine:\n 2,920 mL\n 760 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,029 mL\n -760 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\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\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to):\n Person, Place, Time, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 7.5 g/dL\n 39 K/uL\n 113 mg/dL\n 0.4 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 105 mEq/L\n 135 mEq/L\n 21.2 %\n 0.3 K/uL\n [image002.jpg]\n 05:57 PM\n 06:08 PM\n 11:21 PM\n 05:47 AM\n 11:51 AM\n 05:24 PM\n 05:13 AM\n 10:32 AM\n 04:34 PM\n 05:04 AM\n WBC\n 0.7\n 0.5\n 0.5\n 0.4\n 0.3\n Hct\n 22.7\n 22.1\n 26.9\n 25.1\n 23.3\n 21.5\n 22.6\n 21.2\n Plt\n 71\n 55\n 98\n 84\n 87\n 68\n 57\n 39\n Cr\n 0.3\n 0.3\n 0.3\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 21\n Glucose\n 108\n 107\n 98\n 127\n 104\n 109\n 113\n Other labs: PT / PTT / INR:13.2/23.2/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:26/22, Alk Phos / T Bili:196/1.1, Differential-Neuts:62.0 %,\n Band:2.0 %, Lymph:22.0 %, Mono:8.0 %, Eos:6.0 %, D-dimer:510 ng/mL,\n Fibrinogen:344 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.2 g/dL,\n LDH:1547 IU/L, Ca++:7.7 mg/dL, Mg++:1.4 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n BURKITT'S LYMPHOMA\n TUMOR LYSIS SYNDROME\n RENAL FAILURE, ACUTE\n HYPOTHYROIDISM\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n 20 Gauge - 07:49 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2133-12-15 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 616334, "text": "Chief Complaint: Acute renal 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 Tolerating CVVH.\n Continues with bladder irrigation.\n Continues to exhibit oozing of blood from venous and arterial catheter\n sites.\n States to feel \"swollen\" in arms and legs.\n Appears somewhat dyspneic while lying supine, although denies. Speech\n with mild respiratory distress.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 2 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Lorazepam (Ativan) - 12:00 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, 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, 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, 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 03:39 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.4\nC (95.7\n HR: 59 (49 - 91) bpm\n BP: 136/63(91) {112/50(74) - 171/94(125)} mmHg\n RR: 12 (11 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 61 Inch\n Total In:\n 4,729 mL\n 3,575 mL\n PO:\n 250 mL\n 200 mL\n TF:\n IVF:\n 3,679 mL\n 3,100 mL\n Blood products:\n 800 mL\n 275 mL\n Total out:\n 4,382 mL\n 2,509 mL\n Urine:\n 2,100 mL\n 975 mL\n NG:\n Stool:\n Drains:\n Balance:\n 347 mL\n 1,066 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.46/32/114/22/0\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: 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: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, 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): ox3, Movement: Not assessed, No(t) Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 8.4 g/dL\n 63 K/uL\n 144 mg/dL\n 0.4 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 16 mg/dL\n 100 mEq/L\n 133 mEq/L\n 24.1 %\n 1.3 K/uL\n [image002.jpg]\n 04:13 AM\n 08:40 AM\n 08:54 AM\n 02:53 PM\n 03:20 PM\n 09:56 PM\n 03:30 AM\n 09:13 AM\n 09:29 AM\n 03:04 PM\n WBC\n 2.2\n 1.7\n 1.7\n 1.1\n 1.2\n 1.3\n Hct\n 22.8\n 20.2\n 23.9\n 21.5\n 23.6\n 24.1\n Plt\n 26\n 84\n 86\n 66\n 65\n 63\n Cr\n 0.5\n 0.6\n 0.5\n 0.4\n TCO2\n 23\n 25\n 25\n 23\n Glucose\n 156\n 133\n 164\n 144\n Other labs: PT / PTT / INR:13.1/23.4/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:28/51, Alk Phos / T Bili:221/1.7, Differential-Neuts:80.0 %,\n Band:5.0 %, Lymph:10.0 %, Mono:5.0 %, Eos:0.0 %, D-dimer:510 ng/mL,\n Fibrinogen:180 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.0 g/dL,\n LDH:5379 IU/L, Ca++:7.3 mg/dL, Mg++:1.5 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n RESPIRATORY DISTRESS -- concern for evolving pulmonary edema secondary\n to volume resussitation (tumor lysis syndrome, acute renal failure).\n Monitor RR, SaO2. Aim for net diuresis.\n LYMPHOMA -- Burkitt's Lymphoma, high tumor burden, spontaneous tumor\n lysis syndrome. To complete cytoxan and decadron. Heme/Onc service\n following.\n RENAL FAILURE, ACUTE -- attributed to tumour lysis and urate\n nephropathy. Evidence for right renal stones (likely uric acid), and\n left hydronephrosis (possible external compression by\n lymphadenopathy). Continue CVVH. (Experienced difficulty with HD\n line and air infiltration). Monitor urine output, BUN, creatininine.\n FLUIDS -- hypervolemia (net balance > 10 L since admission). Desire\n net negative balance, aiming for 2 L net negative for next 24 hrs if\n tolerated by BP.\n COAGULOPATHY -- Pt had profuse oozing from HD site, hematuria, with\n associated Hct drop. Possible DIC? Monitor coagulopathy. Monitor q6h\n coags for r/o DIC\n ANEMIA -- transfuse for goal Hct>21\n THROMBOCYTOPENIA -- transfuse for plt <50 since bleeding\n HEMATURIA -- attributed in part to chemotherapy. No evidence for UTI.\n TACHYCARDIA -- resolved.\n HYPOTHYROIDISM -- Continue on home regimen.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 03:17 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: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2133-12-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 616452, "text": "TITLE:\n Chief Complaint: - Hemeonc recs last dose of cytoxan tonight. get AM\n transaminases and t.bili in anticipation of adriamycin\n - fluid status -> will run slightly negative to avoid fluid further\n fluid overload\n - no evidence of DIC or TLS on Q6 checks\n - one bag of plts overnight for plt count 48\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 2 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:50 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 54 (54 - 106) bpm\n BP: 135/63(88) {123/54(80) - 171/94(125)} mmHg\n RR: 14 (12 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 94.4 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 4,980 mL\n 985 mL\n PO:\n 200 mL\n TF:\n IVF:\n 4,308 mL\n 936 mL\n Blood products:\n 473 mL\n 49 mL\n Total out:\n 6,789 mL\n 1,966 mL\n Urine:\n 1,875 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,809 mL\n -981 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: 7.50/27/99./20/0\n Physical Examination\n General Appearance: Well nourished, No acute distress, awake and alert\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: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Follows commands, alert and appropriate\n Labs / Radiology\n 79 K/uL\n 8.4 g/dL\n 126 mg/dL\n 0.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 106 mEq/L\n 136 mEq/L\n 23.9 %\n 1.3 K/uL\n [image002.jpg]\n 03:30 AM\n 09:13 AM\n 09:29 AM\n 02:49 PM\n 03:04 PM\n 09:22 PM\n 09:36 PM\n 12:34 AM\n 12:51 AM\n 06:28 AM\n WBC\n 1.2\n 1.3\n Hct\n 23.6\n 24.1\n 24.7\n 23.9\n Plt\n 65\n 63\n 48\n 79\n Cr\n 0.4\n 0.5\n TCO2\n 25\n 23\n 23\n 23\n 22\n Glucose\n 144\n 126\n Other labs: PT / PTT / INR:12.3/21.6/1.0, CK / CKMB / Troponin-T:331//,\n ALT / AST:28/51, Alk Phos / T Bili:221/1.7, Differential-Neuts:80.0 %,\n Band:5.0 %, Lymph:10.0 %, Mono:5.0 %, Eos:0.0 %, D-dimer:510 ng/mL,\n Fibrinogen:169 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.0 g/dL,\n LDH:5379 IU/L, Ca++:7.5 mg/dL, Mg++:1.9 mg/dL, PO4:1.5 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and spontaneous tumor lysis\n syndrome. Received Rasburicase for uric acid converion. Pt had e/o TL,\n now labs continue to be stable. Completed cytoxan last night, continues\n on CVVH and CBI prophylactically. To receive vincristine and\n doxorubicin today.\n - discuss coming off CVVH since no TL and completed cytoxan\n - cont allopurinol 100 mg daily, check renal dosing if off CVVH\n - not neutropenic yet\n - Cryo for fibrinogen less than 100, Plts for less than 50 because of\n oozing, Hct>21\n - appreciate heme/onc recs\n - will check TLS labs Q6hrs (K, Cr, Ca, Mg, Ph, LDH)\n - DIC labs q6h\n - f/u EBV, antibody panels\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Has renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD in retroperitoneum. Had marginal urine output. Pt on CVVH so\n creatinine improved, 2.5L neg overnight. Urine output apparently\n improving, possibly passed stone or tumor burden reduced.\n - goal on CVVH 1-2L neg/day\n - consider stopping CVVH or transition to HD if pt euvolemic and good\n UOP\n - d/c CBI and monitor urine output.\n - if poor UOP, consider repeat CT for obstruction and urology consult\n - f/u renal recs\n .\n ##. COAGULOPATHY/PANCYTOPENIA: Pt has had profuse oozing from HD site,\n with associated Hct drop. Also had hematuria, requiring CBI with 3way\n Foley. Both are now improving. No evidence of coagulopathy. Pt is not\n receiving anticoagulation in CVVH. Hct and plt count cont to trend\n down, likely to chemo.\n - transfusion goals as above.\n - monitor q6h coags for r/o DIC\n - transfuse for goal Hct>21, plt>50 since bleeding\n .\n URINARY TRACT INFECTION (UTI)/HEMATURIA: Pt had bladder pain and\n hematuria, now resolved.\n Ucx neg x 2.\n .\n ##. Anion Gap Acidosis: normalized.\n .\n ## Pain/discomfort\n morphine PRN\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n -\n ##. Med Reconciliation: Pt unfortunately cannot remember all of her\n meds. She states that she is on Furosemide but it is unclear as to why\n given lack of edema or heart failure history. son has medication\n list, will contact to reconcile Furosemide, dosing.\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer : famotidine\n VAP: none\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: until off CVVH\n" }, { "category": "Nursing", "chartdate": "2133-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616568, "text": "Significant Events:\n --- CVVHD clotted @ 8 AM, renal notified and conclusion was to stop\n CVVHD and re-evaluate need for dialysis according to labs and UO\n ---Later in day, BMT ordered CVVHD to be continued through night as pt\n receiving new chemo regimen again toninght which could cause further\n damage to kidneys\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Finished last dose of cytotoxan last night. On CVVHD for tumor lysis\n syndrome. Neutropenic now with WBC 0.9, Plts 76, hct stable at 23. CBI\n to protect bladder from cytotoxan a/e\n Action:\n Stopped CVVHD for a 7 hours today, labs stable. CVVHD restarted @ 1500.\n Labs with lytes, uric acid, LD, Hct, coags, and fibrinogen q6h. Placed\n on neutropenic precautions.\n Response:\n 1800 labs pending. CBI draining yellow urine, no bloots or clots\n Plan:\n To start vincristine and doxyrubicin tonight. Will re-evalute need for\n CVVHD tomorrow pending night\ns course of events. Transfuse for Hct <21\n and plts <50. Maintain neutropenic/chemo precautions. CBI can be\n stopped tomorrow if output stays the same\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CVVHD, replacement K4 B22 @ 4200 cc/hr, dialysate K4 B22 @ 1000 cc/hr.\n Plenty of BP to work with, SBP 120-170; NSR 60-70\ns, in the high 90\n off CVVHD. Did have a 10 beat run of HR up to 180\ns, EKG with no\n changes and pt denied any CP or SOB. UO difficult to assess due to CBI,\n ? 50 cc/hr, urine is yellow in bag with no blood/clots\n Action:\n CVVHD q6h. Running pt even 100 to 200 cc/hr, as BP tolerates with goal\n of (-) 1 to 2 L\n Response:\n Pt tolerating CVVHD; 1800 labs pending\n Plan:\n CVVHD with q6h labs; Fluid goal of (-) 1 to 2 L\n" }, { "category": "Nursing", "chartdate": "2133-12-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616752, "text": "62 year old woman transferred to from OSH with new diagnosis of\n Burkitt\ns lymphoma and tumor lysis syndrome. Presented to OSH with LDH\n > 20,000 and WBC 22. CT of chest/abdomen showed retroperitoneal nodes\n and hydronephrosis on the left. UA showed bacteria and a few WBC's with\n which pt was started on ceftriaxone.\n While in the MICU pt has been on CVVHD since for treatment of\n tumor lysis and as well as fluid removal. She has completed a 5 day\n course of Cytoxan as well as a dose of\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2133-12-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616753, "text": "62 year old woman transferred to from OSH with new diagnosis of\n Burkitt\ns lymphoma and tumor lysis syndrome. Presented to OSH with LDH\n > 20,000 and WBC 22. CT of chest/abdomen showed retroperitoneal nodes\n and hydronephrosis on the left. UA showed bacteria and a few WBC's with\n which pt was started on ceftriaxone.\n While in the MICU pt has been on CVVHD since for treatment of\n tumor lysis and as well as fluid removal. She has completed a 5 day\n course of Cytoxan along with a dose of Vincristin and Doxorubicin. She\n has been on CBI since admission---hematuria was present at admission\n and resolved with CBI and CBI remained for prevention of hemorrhagic\n cystitis.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2133-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616565, "text": "Significant Events:\n --- CVVHD clotted @ 8 AM, renal notified and conclusion was to stop\n CVVHD and re-evaluate need for dialysis according to labs and UO\n ---Later in day, BMT ordered CVVHD to be continued through night as pt\n receiving new chemo regimen again toninght which could cause further\n damage to kidneys\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Finished last dose of cytotoxan last night. On CVVHD for tumor lysis\n syndrome. Neutropenic now with WBC 0.9, Plts 76, hct stable at 23\n Action:\n Stopped CVVHD for a 7 hours today, labs stable. CVVHD restarted @ 1500.\n Labs with lytes, uric acid, LD, Hct, coags, and fibrinogen q6h. Placed\n on neutropenic precautions.\n Response:\n 1800 labs pending.\n Plan:\n To start vincristine and doxyrubicin tonight. Will re-evalute need for\n CVVHD tomorrow pending night\ns course of events. Transfuse for Hct <21\n and plts <50. Maintain neutropenic/chemo precautions.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CVVHD, replacement K4 B22 @ 4200 cc/hr, dialysate K4 B22 @ 1000 cc/hr.\n Plenty of BP to work with, SBP 120-170; NSR 60-70\ns, in the high 90\n off CVVHD. Did have a 10 beat run of HR up to 180\ns, EKG with no\n changes and pt denied any CP or SOB.\n Action:\n CVVHD q6h. Running pt even 100 to 200 cc/hr, as BP tolerates.\n Response:\n Plan:\n Fluid goal if (-) 1-2 L\n" }, { "category": "Nursing", "chartdate": "2133-12-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616638, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade burkits lymphoma. Transferred\n for further management from . Admitted to the ICU for CVVH\n for tumor lysis syndrome.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Burkitts lymphoma.\n Action:\n Pt received chemo last night. Remains on CVVH. Currently pt receiving\n platlets for level of 55, the site of HD cath is oozing. Will also\n receive a unit of Prbc for hct of 22.1, this has been trending down.\n Response:\n Will check the labs as soon as the prbc finish.\n Plan:\n Cont with cvvh until the bmt clears the pt to stop. Bmt will evaluate\n pt and decide if further CVVH is needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt has been on Cvvh and the bun and creat will be accurate after\n treatment is stopped. Pt has been putting out urine this shift in good\n amts of red urine due to the chemo.\n Action:\n Remains on CVVH but may stop it in the am since the chemo is finished.\n Response:\n CBI was stopped last evening as it was past 24 hours since the cytoxin\n was finished. Urine in the foley is now red in color which is due to\n the chemo received last evening.\n Plan:\n Will stop the cvvh when the bmt team has decided it is no longer\n needed. Will draw labs as soon as the blood is finished infusing. Pt\n may be called out to 7F as soon as the cvvh stops.\n" }, { "category": "Nursing", "chartdate": "2133-12-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616888, "text": "62 year old woman transferred to from OSH with new diagnosis of\n Burkitt\ns lymphoma and tumor lysis syndrome. Presented to OSH with LDH\n > 20,000 and WBC 22. CT of chest/abdomen showed retroperitoneal nodes\n and hydronephrosis on the left. UA showed bacteria and a few WBC's with\n which pt was started on ceftriaxone.\n While in the MICU pt has been on CVVHD since for treatment of\n tumor lysis and as well as fluid removal. She has completed a 5 day\n course of Cytoxan along with a dose of Vincristin and Doxorubicin. She\n has been on CBI since admission---hematuria was present at admission\n and resolved with CBI and CBI remained for prevention of hemorrhagic\n cystitis.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt\ns last chemo . pt tolerated chemo well, CBI stopped .\n urine clear, dk yellow . No signs of tumor lysis. Denies pain, poor\n appetite, abd soft with + bowel sounds. Pt passed loose stool, brown.\n Lungs, clear, diminished at bases. On RA with O2 sats 100%\n Neutropenic.\n Action:\n Labs q 6 hrs, OOB to chair during the day, enc ambulation, enc po\n intake. Pt unable to sleep received 25 mg po Trazadone and 1 mg IV\n ativan a few hours later\n pt able to sleep most of the night.\n Response:\n No signs of tumor lysis, remains comfortable, hemodynamically stable\n Plan:\n Pt called out to the floor\n no beds. No chemo for one week, follow\n labs, transfuse if Hct <21, plts <50 Maintain chemo/neutropenic\n precautions.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt off CVVHD since 6 AM. Off CBI, making adequate amounts of\n urine\n Action:\n Labs as ordered, Magnesium repleted\n Response:\n No signs of tumor lysis, UO remains adequate 100 cc/hr.\n Plan:\n Check labs as ordered, monitor urine output\n SKIN: bruising/petechia noted lower back. Multiple bruising on both\n arms, no breakdown on coccyx, pt turned frequ. Skin care done.\n Pneumoboots on\n" }, { "category": "Nursing", "chartdate": "2133-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616431, "text": "62 y.o. F w/ PMH hypothyroidism presented initially at OSH w/ fatigue/\n insomnia and was found to have high grade burkits lymphoma. Transferred\n from to for further management. Her course has been\n complicated by tumor lysis syndrome for which she has been on CVVHDF\n since starting cytoxan on the 15^th.\n Overnight Events:\n 2mg PO ativan x 2 for anxiety/sleeplessness with good effect\n Removed approx 2.5 liters overnight goal 1-2 liters/day.\n Transfused 1 unit Plts for plts <50\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinine peaked at 3.0/ BUN of 39. Started on CVVHDF for tumor\n lysis syndrome. Cytoxan dose calculated based on creatinine clearance\n while on CVVHD. On CBI as pt had cytoxan induced hematuria. U/O\n appears to be 70-80cc/hr and there was no evidence of hematuria\n overnight.\n Action:\n CVVHDF maintained throughout shift, ran approx 200cc negative/hr, lytes\n monitored q 6hrs, titrated Ca and K gtts as necessary.\n Response:\n 2.5 liters negative overnight.\n Plan:\n Cont CRRT if filter clots contact renal as pt finished cytoxan last\n night and is hemodynamically stable possible transition to HD, fluid\n removal goal 1-2 liters/day.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt with burkits lymphoma,\n Action:\n TLS labs q6hrs including coags and fibrinogen. Pre-medicated 40 mg IV\n decadron and Zofran. 1 mg ativan PO given this am for\n anxiety/restlessness. Allopurinol 100mgs daily; last dose of cytoxan\n given this evening\n Response:\n K 3.3 this pm, phos down to 1.9 ionized calcium 1.02\n on KCL and\n Calcium gluconate repletion, uric acid down to 2.6; Coags stable FDP\n 10-40;\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and Fibrinogen\n with CVVH labs but can be done Q8hrs; will receive vincristine and\n doxorubicin ; run CBI to finish in 6hrs period\n Oriented x 3, denies any pain. Moving all extremties but weak due to\n edema; feels heavy with lifting and moving in bed; movement limited by\n CVVH and dialysis line which is very positional\n" }, { "category": "Nursing", "chartdate": "2133-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616432, "text": "62 y.o. F w/ PMH hypothyroidism presented initially at OSH w/ fatigue/\n insomnia and was found to have high grade burkits lymphoma. Transferred\n from to for further management. Her course has been\n complicated by tumor lysis syndrome for which she has been on CVVHDF\n since starting cytoxan on the 15^th.\n Overnight Events:\n 2mg PO ativan x 2 for anxiety/sleeplessness with good effect\n Removed approx 2.5 liters overnight goal 1-2 liters/day.\n Transfused 1 unit Plts for plts <50\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinine peaked at 3.0/ BUN of 39. Started on CVVHDF for tumor\n lysis syndrome. Cytoxan dose calculated based on creatinine clearance\n while on CVVHD. On CBI as pt had cytoxan induced hematuria. U/O\n appears to be 70-80cc/hr and there was no evidence of hematuria\n overnight.\n Action:\n CVVHDF maintained throughout shift, ran approx 200cc negative/hr, lytes\n monitored q 6hrs, titrated Ca and K gtts as necessary.\n Response:\n 2.5 liters negative overnight.\n Plan:\n Cont CRRT if filter clots contact renal as pt finished cytoxan last\n night and is hemodynamically stable possible transition to HD, fluid\n removal goal 1-2 liters/day.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt with burkits lymphoma, finished 5 day course of cytoxan, most recent\n WBC 1.3 down from\n Action:\n TLS labs q6hrs including coags and fibrinogen. Pre-medicated 40 mg IV\n decadron and Zofran. 1 mg ativan PO given this am for\n anxiety/restlessness. Allopurinol 100mgs daily; last dose of cytoxan\n given this evening\n Response:\n K 3.3 this pm, phos down to 1.9 ionized calcium 1.02\n on KCL and\n Calcium gluconate repletion, uric acid down to 2.6; Coags stable FDP\n 10-40;\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and Fibrinogen\n with CVVH labs but can be done Q8hrs; will receive vincristine and\n doxorubicin ; run CBI to finish in 6hrs period\n Oriented x 3, denies any pain. Moving all extremties but weak due to\n edema; feels heavy with lifting and moving in bed; movement limited by\n CVVH and dialysis line which is very positional\n" }, { "category": "Nursing", "chartdate": "2133-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616433, "text": "62 y.o. F w/ PMH hypothyroidism presented initially at OSH w/ fatigue/\n insomnia and was found to have high grade burkits lymphoma. Transferred\n from to for further management. Her course has been\n complicated by tumor lysis syndrome for which she has been on CVVHDF\n since starting cytoxan on the 15^th.\n Overnight Events:\n 2mg PO ativan x 2 for anxiety/sleeplessness with good effect\n Removed approx 2.5 liters overnight goal 1-2 liters/day.\n Transfused 1 unit Plts for plts <50\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinine peaked at 3.0/ BUN of 39. Started on CVVHDF for tumor\n lysis syndrome. Cytoxan dose calculated based on creatinine clearance\n while on CVVHD. On CBI as pt had cytoxan induced hematuria. U/O\n appears to be 70-80cc/hr and there was no evidence of hematuria\n overnight.\n Action:\n CVVHDF maintained throughout shift, ran approx 200cc negative/hr, lytes\n monitored q 6hrs, titrated Ca and K gtts as necessary.\n Response:\n 2.5 liters negative overnight.\n Plan:\n Cont CRRT if filter clots contact renal as pt finished cytoxan last\n night and is hemodynamically stable possible transition to HD, fluid\n removal goal 1-2 liters/day.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt with burkits lymphoma, finished 5 day course of cytoxan, most recent\n WBC 1.3 down from 28\n Action:\n Finished last dose of cytoxan overnight, q 6hr coags and CRRT labs.\n Response:\n Clinical presentation unchanged from above, coags stable\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and Fibrinogen\n with CVVH labs but can be done Q8hrs; will receive vincristine and\n doxorubicin ; run CBI to finish in 6hrs period\n Oriented x 3, denies any pain. Moving all extremties but weak due to\n edema; feels heavy with lifting and moving in bed; movement limited by\n CVVH and dialysis line which is very positional\n" }, { "category": "Nursing", "chartdate": "2133-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616435, "text": "62 y.o. F w/ PMH hypothyroidism presented initially at OSH w/ fatigue/\n insomnia and was found to have high grade burkits lymphoma. Transferred\n from to for further management. Her course has been\n complicated by tumor lysis syndrome for which she has been on CVVHDF\n since starting cytoxan on the 15^th.\n Overnight Events:\n 2mg PO ativan x 2 for anxiety/sleeplessness with good effect\n Removed approx 2.5 liters overnight goal 1-2 liters/day.\n Transfused 1 unit Plts for plts <50\n Slightly more alkalotic then on previous nights pH 7.50 up\n from 7.48\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinine peaked at 3.0/ BUN of 39. Started on CVVHDF for tumor\n lysis syndrome. Cytoxan dose calculated based on creatinine clearance\n while on CVVHD. On CBI as pt had cytoxan induced hematuria. U/O\n appears to be 70-80cc/hr and there was no evidence of hematuria\n overnight.\n Action:\n CVVHDF maintained throughout shift, ran approx 200cc negative/hr, lytes\n monitored q 6hrs, titrated Ca and K gtts as necessary.\n Response:\n 2.5 liters negative overnight.\n Plan:\n Cont CRRT if filter clots contact renal as pt finished cytoxan last\n night and is hemodynamically stable possible transition to HD, fluid\n removal goal 1-2 liters/day. Attempt to run CBI so that it finishes q\n 6hrs\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt with burkits lymphoma, finished 5 day course of cytoxan, most recent\n WBC 1.3 down from 28\n Action:\n Finished last dose of cytoxan overnight, q 6hr coags and CRRT labs.\n Response:\n Clinical presentation unchanged from above, coags stable\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and Fibrinogen\n with CVVHDF labs. To start vincristine and doxyrubicin today.\n Oriented x 3, denies any pain. Moving all extremties but weak due to\n edema; feels heavy with lifting and moving in bed; movement limited by\n CVVH and dialysis line which is very positional\n" }, { "category": "Physician ", "chartdate": "2133-12-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 616723, "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 Tolerated net negative 7 L fliuid balance over past 24 hrs.\n Completed CVVH this AM, remains off CVVH, with good urine output.\n Completed continuous bladder irrigation.\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 Famotidine (Pepcid) - 08:00 PM\n Lorazepam (Ativan) - 10:00 PM\n Morphine Sulfate - 12:00 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, 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, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.8\nC (96.5\n HR: 85 (60 - 121) bpm\n BP: 151/71(100) {113/50(74) - 170/85(117)} mmHg\n RR: 21 (12 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.8 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 3,275 mL\n 962 mL\n PO:\n TF:\n IVF:\n 3,225 mL\n 484 mL\n Blood products:\n 49 mL\n 478 mL\n Total out:\n 8,626 mL\n 1,972 mL\n Urine:\n 3,850 mL\n 925 mL\n NG:\n Stool:\n Drains:\n Balance:\n -5,351 mL\n -1,010 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: 7.45/28/141/20/0\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: , Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: 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): ox3, Movement: Not assessed, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 9.5 g/dL\n 98 K/uL\n 98 mg/dL\n 0.3 mg/dL\n 20 mEq/L\n 4.2 mEq/L\n 5 mg/dL\n 110 mEq/L\n 136 mEq/L\n 26.9 %\n 0.7 K/uL\n [image002.jpg]\n 12:34 AM\n 12:51 AM\n 05:55 AM\n 06:28 AM\n 12:08 PM\n 12:36 PM\n 05:57 PM\n 06:08 PM\n 11:21 PM\n 05:47 AM\n WBC\n 0.9\n 0.7\n Hct\n 23.0\n 23.5\n 22.7\n 22.1\n 26.9\n Plt\n 79\n 82\n 76\n 71\n 55\n 98\n Cr\n 0.4\n 0.4\n 0.3\n 0.3\n 0.3\n TCO2\n 23\n 22\n 22\n 21\n Glucose\n 118\n 117\n 108\n 107\n 98\n Other labs: PT / PTT / INR:13.4/23.7/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:38/48, Alk Phos / T Bili:222/1.4, Differential-Neuts:62.0 %,\n Band:2.0 %, Lymph:22.0 %, Mono:8.0 %, Eos:6.0 %, D-dimer:510 ng/mL,\n Fibrinogen:190 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.2 g/dL,\n LDH:2658 IU/L, Ca++:7.1 mg/dL, Mg++:1.9 mg/dL, PO4:1.5 mg/dL\n Assessment and Plan\n RESPIRATORY DISTRESS -- much improved. Monitor RR, SaO2. Provide\n supplimental oxygen as needed. Aim for net diuresis.\n LYMPHOMA -- Burkitt's Lymphoma, high tumor burden, spontaneous tumor\n lysis syndrome. To continue chemotherapy as per Heme/Onc service.\n RENAL FAILURE, ACUTE -- attributed to tumour lysis and urate\n nephropathy. Evidence for right renal stones (likely uric acid), and\n left hydronephrosis (possible external compression by\n lymphadenopathy). Hold CVVH and monitor urine output. Monitor urine\n output, BUN, creatininine, electrolytes while off CVVH. Consider HD if\n requires resumption of renal replacement therapy.\n FLUIDS -- hypervolemia, Tolerated net negative fluid balance\n overnight. Desire continued net negative balance, aiming for\n additional 1-2 L net negative for next 24 hrs if tolerated by BP.\n Monitor off CVVH today.\n COAGULOPATHY -- Pt had profuse oozing from HD site, hematuria, with\n associated Hct drop. Monitor coagulopathy. Monitor q6h coags for r/o\n DIC\n ANEMIA -- transfuse for goal Hct>21\n THROMBOCYTOPENIA -- transfuse for plt <50 since bleeding\n NEUTROPENIA\n neutroppenic precautions, PMN counts continue to fall.\n HEMATURIA -- attributed in part to chemotherapy. No evidence for UTI.\n TACHYCARDIA -- resolved.\n HYPOTHYROIDISM -- Continue on home regimen.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 03:17 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: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2133-12-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 616728, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Got vincristin, doxorubicin\n - Stopped CBI\n - got 1 unit of plts, 1 unit prbc\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Lorazepam (Ativan) - 10:00 PM\n Morphine Sulfate - 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 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.8\nC (96.5\n HR: 60 (60 - 121) bpm\n BP: 124/59(84) {113/50(74) - 170/85(117)} mmHg\n RR: 13 (12 - 28) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.8 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 3,275 mL\n 994 mL\n PO:\n TF:\n IVF:\n 3,225 mL\n 516 mL\n Blood products:\n 49 mL\n 478 mL\n Total out:\n 8,626 mL\n 1,672 mL\n Urine:\n 3,850 mL\n 625 mL\n NG:\n Stool:\n Drains:\n Balance:\n -5,351 mL\n -677 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.45/28/141/20/0\n Physical Examination\n General Appearance: Well nourished, No acute distress, awake and alert\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: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Follows commands, alert and appropriate\n Labs / Radiology\n 98 K/uL\n 9.5 g/dL\n 98 mg/dL\n 0.3 mg/dL\n 20 mEq/L\n 4.2 mEq/L\n 5 mg/dL\n 110 mEq/L\n 136 mEq/L\n 26.9 %\n 0.7 K/uL\n [image002.jpg]\n 12:34 AM\n 12:51 AM\n 05:55 AM\n 06:28 AM\n 12:08 PM\n 12:36 PM\n 05:57 PM\n 06:08 PM\n 11:21 PM\n 05:47 AM\n WBC\n 0.9\n 0.7\n Hct\n 23.0\n 23.5\n 22.7\n 22.1\n 26.9\n Plt\n 79\n 82\n 76\n 71\n 55\n 98\n Cr\n 0.4\n 0.4\n 0.3\n 0.3\n 0.3\n TCO2\n 23\n 22\n 22\n 21\n Glucose\n 118\n 117\n 108\n 107\n 98\n Other labs: PT / PTT / INR:13.4/23.7/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:38/48, Alk Phos / T Bili:222/1.4, Differential-Neuts:78.0 %,\n Band:1.0 %, Lymph:16.0 %, Mono:5.0 %, Eos:0.0 %, D-dimer:510 ng/mL,\n Fibrinogen:190 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.2 g/dL,\n LDH:3095 IU/L, Ca++:7.1 mg/dL, Mg++:1.9 mg/dL, PO4:1.5 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and spontaneous tumor lysis\n syndrome. Received Rasburicase for uric acid converion. Pt had e/o TL,\n now labs continue to be stable. Completed cytoxan last night, continues\n on CVVH and CBI prophylactically. Received vincristine and doxorubicin\n yesterday.\n - Stopped CVVH this AM at 6:30\n - cont allopurinol 100 mg daily, check renal dosing if off CVVH\n - BMT said no bactrim, inhaled pentamidine at some point\n - neutropenic precautions, normal\n goals off CVVH\n - Cryo for fibrinogen less than 100, Plts for less than 50 because of\n oozing, Hct>21\n - appreciate heme/onc recs\n - will check TLS labs, DIC labs, electrolytes q6h\n - f/u EBV, antibody panels\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Has renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD in retroperitoneum. Had marginal urine output. Pt on CVVH so\n creatinine improved, 2.5L neg overnight. Urine output apparently\n improving, possibly passed stone or tumor burden reduced.\n - Stopping CVVH today\n - Stopped CBI overnight\n - q6h electrolytes\n - Monitor for hematuria\n - f/u renal recs\n .\n ##. COAGULOPATHY/PANCYTOPENIA: Pt has had profuse oozing from HD site,\n with associated Hct drop. Also had hematuria, requiring CBI with 3way\n Foley. Both are now improving. No evidence of coagulopathy. Pt is not\n receiving anticoagulation in CVVH. Hct and plt count cont to trend\n down, likely to chemo.\n - transfusion goals as above.\n - monitor q6h coags for r/o DIC\n - transfuse for goal Hct>21, plt>50 since bleeding\n .\n URINARY TRACT INFECTION (UTI)/HEMATURIA: Pt had bladder pain and\n hematuria, now resolved.\n Ucx neg x 2.\n .\n ##. Anion Gap Acidosis: normalized.\n .\n ## Pain/discomfort\n morphine PRN\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n ICU Care\n Nutrition: regular, supplment with Boost/ensure\n ENCOURAGE PO\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer : famotidine\n VAP: none\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: until off CVVH and stable\n" }, { "category": "Social Work", "chartdate": "2133-12-17 00:00:00.000", "description": "Social Work Progress Note", "row_id": 616741, "text": "Family Note:\n Throughout this admission, this writer has briefly met with pt\ns family\n re short-term disability benefits, as well as providing support. Ms.\n \ns claim will be considered on the 25^th. She states that her\n spirits are\ngood,\n and that she is doing well, as is her son, ,\n and her husband.\n Plans:\n 1. There are no F/U plans as pt is being transferred to the medical\n floor.\n , PhD, LICSW\n PAGE \n" }, { "category": "Physician ", "chartdate": "2133-12-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 616742, "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 Tolerated net negative 7 L fliuid balance over past 24 hrs.\n Completed CVVH this AM, remains off CVVH, with good urine output.\n Completed continuous bladder irrigation.\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 Famotidine (Pepcid) - 08:00 PM\n Lorazepam (Ativan) - 10:00 PM\n Morphine Sulfate - 12:00 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, 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, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.8\nC (96.5\n HR: 85 (60 - 121) bpm\n BP: 151/71(100) {113/50(74) - 170/85(117)} mmHg\n RR: 21 (12 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.8 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 3,275 mL\n 962 mL\n PO:\n TF:\n IVF:\n 3,225 mL\n 484 mL\n Blood products:\n 49 mL\n 478 mL\n Total out:\n 8,626 mL\n 1,972 mL\n Urine:\n 3,850 mL\n 925 mL\n NG:\n Stool:\n Drains:\n Balance:\n -5,351 mL\n -1,010 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: 7.45/28/141/20/0\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: , Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: 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): ox3, Movement: Not assessed, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 9.5 g/dL\n 98 K/uL\n 98 mg/dL\n 0.3 mg/dL\n 20 mEq/L\n 4.2 mEq/L\n 5 mg/dL\n 110 mEq/L\n 136 mEq/L\n 26.9 %\n 0.7 K/uL\n [image002.jpg]\n 12:34 AM\n 12:51 AM\n 05:55 AM\n 06:28 AM\n 12:08 PM\n 12:36 PM\n 05:57 PM\n 06:08 PM\n 11:21 PM\n 05:47 AM\n WBC\n 0.9\n 0.7\n Hct\n 23.0\n 23.5\n 22.7\n 22.1\n 26.9\n Plt\n 79\n 82\n 76\n 71\n 55\n 98\n Cr\n 0.4\n 0.4\n 0.3\n 0.3\n 0.3\n TCO2\n 23\n 22\n 22\n 21\n Glucose\n 118\n 117\n 108\n 107\n 98\n Other labs: PT / PTT / INR:13.4/23.7/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:38/48, Alk Phos / T Bili:222/1.4, Differential-Neuts:62.0 %,\n Band:2.0 %, Lymph:22.0 %, Mono:8.0 %, Eos:6.0 %, D-dimer:510 ng/mL,\n Fibrinogen:190 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.2 g/dL,\n LDH:2658 IU/L, Ca++:7.1 mg/dL, Mg++:1.9 mg/dL, PO4:1.5 mg/dL\n Assessment and Plan\n RESPIRATORY DISTRESS -- much improved. Monitor RR, SaO2. Provide\n supplimental oxygen as needed. Aim for net diuresis.\n LYMPHOMA -- Burkitt's Lymphoma, high tumor burden, spontaneous tumor\n lysis syndrome. To continue chemotherapy as per Heme/Onc service.\n RENAL FAILURE, ACUTE -- attributed to tumour lysis and urate\n nephropathy. Evidence for right renal stones (likely uric acid), and\n left hydronephrosis (possible external compression by\n lymphadenopathy). Hold CVVH and monitor urine output. Monitor urine\n output, BUN, creatininine, electrolytes while off CVVH. Consider HD if\n requires resumption of renal replacement therapy.\n FLUIDS -- hypervolemia, Tolerated net negative fluid balance\n overnight. Desire continued net negative balance, aiming for\n additional 1-2 L net negative for next 24 hrs if tolerated by BP.\n Monitor off CVVH today.\n COAGULOPATHY -- Pt had profuse oozing from HD site, hematuria, with\n associated Hct drop. Monitor coagulopathy. Monitor q6h coags for r/o\n DIC\n ANEMIA -- transfuse for goal Hct>21\n THROMBOCYTOPENIA -- transfuse for plt <50 since bleeding\n NEUTROPENIA\n neutroppenic precautions, PMN counts continue to fall.\n HEMATURIA -- attributed in part to chemotherapy. No evidence for UTI.\n TACHYCARDIA -- resolved.\n HYPOTHYROIDISM -- Continue on home regimen.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 03:17 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: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2133-12-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 616680, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Got vincristin, doxorubicin\n - Stopped CBI\n - got 1 unit of plts, 1 unit prbc\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Lorazepam (Ativan) - 10:00 PM\n Morphine Sulfate - 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 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.8\nC (96.5\n HR: 60 (60 - 121) bpm\n BP: 124/59(84) {113/50(74) - 170/85(117)} mmHg\n RR: 13 (12 - 28) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.8 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 3,275 mL\n 994 mL\n PO:\n TF:\n IVF:\n 3,225 mL\n 516 mL\n Blood products:\n 49 mL\n 478 mL\n Total out:\n 8,626 mL\n 1,672 mL\n Urine:\n 3,850 mL\n 625 mL\n NG:\n Stool:\n Drains:\n Balance:\n -5,351 mL\n -677 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.45/28/141/20/0\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 98 K/uL\n 9.5 g/dL\n 98 mg/dL\n 0.3 mg/dL\n 20 mEq/L\n 4.2 mEq/L\n 5 mg/dL\n 110 mEq/L\n 136 mEq/L\n 26.9 %\n 0.7 K/uL\n [image002.jpg]\n 12:34 AM\n 12:51 AM\n 05:55 AM\n 06:28 AM\n 12:08 PM\n 12:36 PM\n 05:57 PM\n 06:08 PM\n 11:21 PM\n 05:47 AM\n WBC\n 0.9\n 0.7\n Hct\n 23.0\n 23.5\n 22.7\n 22.1\n 26.9\n Plt\n 79\n 82\n 76\n 71\n 55\n 98\n Cr\n 0.4\n 0.4\n 0.3\n 0.3\n 0.3\n TCO2\n 23\n 22\n 22\n 21\n Glucose\n 118\n 117\n 108\n 107\n 98\n Other labs: PT / PTT / INR:13.4/23.7/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:38/48, Alk Phos / T Bili:222/1.4, Differential-Neuts:78.0 %,\n Band:1.0 %, Lymph:16.0 %, Mono:5.0 %, Eos:0.0 %, D-dimer:510 ng/mL,\n Fibrinogen:190 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.2 g/dL,\n LDH:3095 IU/L, Ca++:7.1 mg/dL, Mg++:1.9 mg/dL, PO4:1.5 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Tumour Lysis\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n TACHYCARDIA, OTHER\n HYPOTHYROIDISM\n URINARY TRACT INFECTION (UTI)\n HYPERCALCEMIA (HIGH CALCIUM)\n HYPERPHOSPHATEMIA (HIGH PHOSPHATE)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 03:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2133-12-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 616682, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Got vincristin, doxorubicin\n - Stopped CBI\n - got 1 unit of plts, 1 unit prbc\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Lorazepam (Ativan) - 10:00 PM\n Morphine Sulfate - 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 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.8\nC (96.5\n HR: 60 (60 - 121) bpm\n BP: 124/59(84) {113/50(74) - 170/85(117)} mmHg\n RR: 13 (12 - 28) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.8 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 3,275 mL\n 994 mL\n PO:\n TF:\n IVF:\n 3,225 mL\n 516 mL\n Blood products:\n 49 mL\n 478 mL\n Total out:\n 8,626 mL\n 1,672 mL\n Urine:\n 3,850 mL\n 625 mL\n NG:\n Stool:\n Drains:\n Balance:\n -5,351 mL\n -677 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.45/28/141/20/0\n Physical Examination\n General Appearance: Well nourished, No acute distress, awake and alert\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: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Follows commands, alert and appropriate\n Labs / Radiology\n 98 K/uL\n 9.5 g/dL\n 98 mg/dL\n 0.3 mg/dL\n 20 mEq/L\n 4.2 mEq/L\n 5 mg/dL\n 110 mEq/L\n 136 mEq/L\n 26.9 %\n 0.7 K/uL\n [image002.jpg]\n 12:34 AM\n 12:51 AM\n 05:55 AM\n 06:28 AM\n 12:08 PM\n 12:36 PM\n 05:57 PM\n 06:08 PM\n 11:21 PM\n 05:47 AM\n WBC\n 0.9\n 0.7\n Hct\n 23.0\n 23.5\n 22.7\n 22.1\n 26.9\n Plt\n 79\n 82\n 76\n 71\n 55\n 98\n Cr\n 0.4\n 0.4\n 0.3\n 0.3\n 0.3\n TCO2\n 23\n 22\n 22\n 21\n Glucose\n 118\n 117\n 108\n 107\n 98\n Other labs: PT / PTT / INR:13.4/23.7/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:38/48, Alk Phos / T Bili:222/1.4, Differential-Neuts:78.0 %,\n Band:1.0 %, Lymph:16.0 %, Mono:5.0 %, Eos:0.0 %, D-dimer:510 ng/mL,\n Fibrinogen:190 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.2 g/dL,\n LDH:3095 IU/L, Ca++:7.1 mg/dL, Mg++:1.9 mg/dL, PO4:1.5 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and spontaneous tumor lysis\n syndrome. Received Rasburicase for uric acid converion. Pt had e/o TL,\n now labs continue to be stable. Completed cytoxan last night, continues\n on CVVH and CBI prophylactically. Received vincristine and doxorubicin\n yesterday.\n - Stopped CVVH this AM at 6:30\n - cont allopurinol 100 mg daily, check renal dosing if off CVVH\n - BMT said no bactrim, inhaled pentamidine at some point\n - neutropenic precautions, normal\n goals off CVVH\n - Cryo for fibrinogen less than 100, Plts for less than 50 because of\n oozing, Hct>21\n - appreciate heme/onc recs\n - will check TLS labs, DIC labs, electrolytes q8h\n - f/u EBV, antibody panels\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Has renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD in retroperitoneum. Had marginal urine output. Pt on CVVH so\n creatinine improved, 2.5L neg overnight. Urine output apparently\n improving, possibly passed stone or tumor burden reduced.\n - Stopping CVVH today\n - Stopped CBI overnight\n - TID electrolytes\n - Monitor for hematuria\n - f/u renal recs\n .\n ##. COAGULOPATHY/PANCYTOPENIA: Pt has had profuse oozing from HD site,\n with associated Hct drop. Also had hematuria, requiring CBI with 3way\n Foley. Both are now improving. No evidence of coagulopathy. Pt is not\n receiving anticoagulation in CVVH. Hct and plt count cont to trend\n down, likely to chemo.\n - transfusion goals as above.\n - monitor q6h coags for r/o DIC\n - transfuse for goal Hct>21, plt>50 since bleeding\n .\n URINARY TRACT INFECTION (UTI)/HEMATURIA: Pt had bladder pain and\n hematuria, now resolved.\n Ucx neg x 2.\n .\n ##. Anion Gap Acidosis: normalized.\n .\n ## Pain/discomfort\n morphine PRN\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism.\n ICU Care\n Nutrition: regular, supplment with Boost/ensure\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer : famotidine\n VAP: none\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: until off CVVH and stable\n" }, { "category": "Physician ", "chartdate": "2133-12-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 617000, "text": "Chief Complaint: Burkitt's lymphoma, acute renal failure, tumor lysis\n syndrome\n 24 Hour Events:\n ARTERIAL LINE - STOP 03:30 PM\n - stopped CVVH, labs all stable and urine output 100-200cc/hr\n - BMT recs: decrease to DIC labs\n - called out\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo 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 sleeping this morning, (-) n/v/d/f/c, (-) SOB, (-) abdominal pain, (-)\n chest pain\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Genitourinary: Foley\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 67 (65 - 110) bpm\n BP: 118/55(71) {104/52(64) - 143/123(128)} mmHg\n RR: 15 (14 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.8 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 1,866 mL\n 319 mL\n PO:\n 480 mL\n 200 mL\n TF:\n IVF:\n 908 mL\n 119 mL\n Blood products:\n 478 mL\n Total out:\n 3,912 mL\n 700 mL\n Urine:\n 2,865 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,046 mL\n -381 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, clear oropharynx\n Cardiovascular: (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: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x 3, Movement: Not assessed, Tone: Normal\n Labs / Radiology\n 68 K/uL\n 7.6 g/dL\n 109 mg/dL\n 0.4 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 112 mEq/L\n 143 mEq/L\n 21.5 %\n 0.4 K/uL\n [image002.jpg]\n 06:28 AM\n 12:08 PM\n 12:36 PM\n 05:57 PM\n 06:08 PM\n 11:21 PM\n 05:47 AM\n 11:51 AM\n 05:24 PM\n 05:13 AM\n WBC\n 0.7\n 0.5\n 0.5\n 0.4\n Hct\n 23.5\n 22.7\n 22.1\n 26.9\n 25.1\n 23.3\n 21.5\n Plt\n 76\n 71\n 55\n 98\n 84\n 87\n 68\n Cr\n 0.4\n 0.3\n 0.3\n 0.3\n 0.4\n 0.3\n 0.4\n TCO2\n 22\n 22\n 21\n Glucose\n 117\n 108\n 107\n 98\n 127\n 104\n 109\n Other labs: PT / PTT / INR:13.1/23.6/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:38/48, Alk Phos / T Bili:222/1.2, Differential-Neuts:62.0 %,\n Band:2.0 %, Lymph:22.0 %, Mono:8.0 %, Eos:6.0 %, D-dimer:510 ng/mL,\n Fibrinogen:229 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.2 g/dL,\n LDH:2335 IU/L, Ca++:7.1 mg/dL, Mg++:1.6 mg/dL, PO4:3.3 mg/dL\n Fluid analysis / Other labs: CHROMOSOME ANALYSIS-BONE\n MARROW-----------------------\n KARYOTYPE: SEE BELOW\n INTERPRETATION:\n 46,XX,t(8;14)(q24.1;q32)[10]/\n 46,idem,t(X;11)(p22.1;p11.2)[6]/47,idem,+[3]/\n 47,idem,t(X;11)(p22.1;p11.2),+[1]\n All metaphases showed a translocation of chromosomes 8 and 14. This\n translocation is associated with IGH/MYC fusion and is a characteristic\n finding in Burkitt lymphoma.\n The clone with the t(8;14) is the stemline. Three additional abnormal\n subclones are identified. The first\n subclone, represented by metaphases, has a translocation of\n chromosomes X at band Xp22.1 and 11 at band 11p11.2. The second\n subclone, represented by \n metaphases, has a marker chromsome. The third subclone, represented by\n metaphases, has the translocation of chromosomes X and 11 and the\n marker chromosome.\n Small chromosome anomalies may not be detectable using the standard\n methods employed.\n FISH evaluation for a MYC rearrangement was performed on nuclei with\n the LSI MYC Dual Dual Color, Break Apart Rearrangement Probe (\n Molecular) at 8q24 and is interpreted as ABNORMAL. Rearrangement was\n observed in\n 74/100 nuclei, which exceeds the normal range (up to 4%\n rearrangement) established for this probe in the Cytogenetics\n Laboratory at . MYC rearrangement is\n found in more than 90% of Burkitt lymphomas, but can also be found\n occasionally in other histologies of\n non-Hodgkin's lymphoma. The MYC rearrangements in Burkitt lymphomas\n result in MYC overexpression, generally by juxtaposition with an\n immunoglobulin gene.\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Tumor Lysis\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n TACHYCARDIA, OTHER\n HYPOTHYROIDISM\n URINARY TRACT INFECTION (UTI)\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and spontaneous tumor lysis\n syndrome. Received Rasburicase for uric acid converion. Pt had e/o TL,\n now labs continue to be stable. Received doxorubicin and vincristine\n yesterday (day 1), next dose day 8. CVVH stopped yesterday, continues\n to have excellent UOP, renal function normal.\n - cont allopurinol 100 mg daily, cont to monitor renal fxn\n - BMT said no bactrim, inhaled pentamidine at some point\n - neutropenic precautions, normal\n goals off CVVH\n - Cryo for fibrinogen less than 100, Plts for less than 50 because of\n oozing, Hct>21\n - appreciate heme/onc recs\n - will check TLS labs, DIC labs, electrolytes \n - EBV -> IgG (+), IgM (-), CMV and HIV (-)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Has renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD in retroperitoneum. Had marginal urine output. Pt on CVVH so\n creatinine improved. Urine output continues to improve, possibly\n passed stone or tumor burden reduced. Stopped CBI and CVVH\n - electrolytes\n - Monitor for hematuria\n - f/u renal recs\n .\n ##. COAGULOPATHY/PANCYTOPENIA/NEUTROPENIA: Pt has had profuse oozing\n from HD site, with associated Hct drop. Also had hematuria, requiring\n CBI with 3way Foley. Both are now improving. No evidence of\n coagulopathy. Pt is not receiving anticoagulation in CVVH. Hct, white\n count, and plt count cont to trend down, likely to chemo.\n - transfusion goals as above.\n - monitor q12 coags for r/o DIC\n - transfuse for goal Hct>21, plt>50 since bleeding\n .\n URINARY TRACT INFECTION (UTI)/HEMATURIA: Pt had bladder pain and\n hematuria, now resolved.\n Ucx neg x 2.\n .\n ##. Anion Gap Acidosis: normalized.\n .\n ## Pain/discomfort\n morphine PRN\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: call out\n" }, { "category": "Nursing", "chartdate": "2133-12-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616800, "text": "62 year old woman transferred to from OSH with new diagnosis of\n Burkitt\ns lymphoma and tumor lysis syndrome. Presented to OSH with LDH\n > 20,000 and WBC 22. CT of chest/abdomen showed retroperitoneal nodes\n and hydronephrosis on the left. UA showed bacteria and a few WBC's with\n which pt was started on ceftriaxone.\n While in the MICU pt has been on CVVHD since for treatment of\n tumor lysis and as well as fluid removal. She has completed a 5 day\n course of Cytoxan along with a dose of Vincristin and Doxorubicin. She\n has been on CBI since admission---hematuria was present at admission\n and resolved with CBI and CBI remained for prevention of hemorrhagic\n cystitis.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Received doses of vincristine and doxurobucin last night. Pt has\n tolerated chemo very well. CBI stopped last night. Urine clear, \n from chemo. No signs of tumor lysis. Denies pain. Poor appetite,\n abdomen soft with good bowel sounds. Lungs clear, diminished at bases.\n On RA with Sp02 100%. Neutropenic\n Action:\n Labs q6h. OOB to chair, walked in room. Encouraged PO intake.\n Neutropenic/chemo precautions\n Response:\n Pt ate\n today; weak on feet; no signs of tumor lysis; remains\n comfortable.\n Plan:\n Pt called out but there are no beds; NO chemo for one week; follow\n labs, transfuse for hct <21, plts <50. Maintain chemo/neutropenic\n precautions\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt taken off CVVHD at 6 AM; Off CBI, making adequate amounts of \n urine.\n Action:\n Labs q6h. Repleted K, Phos, and calcium\n Response:\n No signs of tumor lysis; UO remains adequate 100-200 cc/hr, urine now\n light yellow and clear. Cr 0.4; 1800 labs pending\n Plan:\n Follow labs q6h and UO qh, replete as needed\n" }, { "category": "Physician ", "chartdate": "2133-12-18 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 617001, "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 off renal replacement therapy (no CVVH required).\n No hematuria.\n Remains neutropenic.\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 Famotidine (Pepcid) - 08:14 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, 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, 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, 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: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:33 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.1\nC (96.9\n HR: 71 (65 - 110) bpm\n BP: 116/51(66) {104/51(64) - 143/123(128)} mmHg\n RR: 16 (14 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.8 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 1,866 mL\n 751 mL\n PO:\n 480 mL\n 380 mL\n TF:\n IVF:\n 908 mL\n 371 mL\n Blood products:\n 478 mL\n Total out:\n 3,912 mL\n 1,600 mL\n Urine:\n 2,865 mL\n 1,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,046 mL\n -849 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\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: 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: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: 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, No(t) Oriented (to): , Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 7.6 g/dL\n 68 K/uL\n 109 mg/dL\n 0.4 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 112 mEq/L\n 143 mEq/L\n 22.6 %\n 0.4 K/uL\n [image002.jpg]\n 12:08 PM\n 12:36 PM\n 05:57 PM\n 06:08 PM\n 11:21 PM\n 05:47 AM\n 11:51 AM\n 05:24 PM\n 05:13 AM\n 10:32 AM\n WBC\n 0.7\n 0.5\n 0.5\n 0.4\n Hct\n 23.5\n 22.7\n 22.1\n 26.9\n 25.1\n 23.3\n 21.5\n 22.6\n Plt\n 76\n 71\n 55\n 98\n 84\n 87\n 68\n Cr\n 0.4\n 0.3\n 0.3\n 0.3\n 0.4\n 0.3\n 0.4\n TCO2\n 22\n 21\n Glucose\n 117\n 108\n 107\n 98\n 127\n 104\n 109\n Other labs: PT / PTT / INR:13.1/23.6/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:38/48, Alk Phos / T Bili:222/1.2, Differential-Neuts:62.0 %,\n Band:2.0 %, Lymph:22.0 %, Mono:8.0 %, Eos:6.0 %, D-dimer:510 ng/mL,\n Fibrinogen:229 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.2 g/dL,\n LDH:2335 IU/L, Ca++:7.1 mg/dL, Mg++:1.6 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n RESPIRATORY DISTRESS -- much improved. Monitor RR, SaO2. Provide\n supplimental oxygen as needed. Aim for net diuresis.\n LYMPHOMA -- Burkitt's Lymphoma, high tumor burden, spontaneous tumor\n lysis syndrome. To continue chemotherapy as per Heme/Onc service.\n RENAL FAILURE, ACUTE -- attributed to tumour lysis and urate\n nephropathy. Resolved. Consider HD if requires resumption of renal\n replacement therapy.\n FLUIDS -- hypervolemia, Tolerated net negative fluid balance\n overnight. Desire continued net negative balance, aiming for\n additional 1-2 L net negative for next 24 hrs if tolerated by BP.\n Monitor off CVVH today.\n COAGULOPATHY -- Pt had profuse oozing from HD site, hematuria, with\n associated Hct drop. Monitor coagulopathy. Monitor q6h coags for r/o\n DIC\n ANEMIA -- transfuse for goal Hct>21\n THROMBOCYTOPENIA -- transfuse for plt <50 since bleeding\n NEUTROPENIA\n neutroppenic precautions, PMN counts continue to fall.\n HEMATURIA -- attributed in part to chemotherapy. No evidence for UTI.\n HYPOTHYROIDISM -- Continue on home regimen.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n 20 Gauge - 07:49 AM\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 :Transfer to floor\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2133-12-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616873, "text": "62 year old woman transferred to from OSH with new diagnosis of\n Burkitt\ns lymphoma and tumor lysis syndrome. Presented to OSH with LDH\n > 20,000 and WBC 22. CT of chest/abdomen showed retroperitoneal nodes\n and hydronephrosis on the left. UA showed bacteria and a few WBC's with\n which pt was started on ceftriaxone.\n While in the MICU pt has been on CVVHD since for treatment of\n tumor lysis and as well as fluid removal. She has completed a 5 day\n course of Cytoxan along with a dose of Vincristin and Doxorubicin. She\n has been on CBI since admission---hematuria was present at admission\n and resolved with CBI and CBI remained for prevention of hemorrhagic\n cystitis.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt\ns last chemo . pt tolerated chemo well, CBI stopped .\n urine clear, dk yellow . No signs of tumor lysis. Denies pain, poor\n appetite, abd soft with + bowel sounds. Pt passed loose stool, brown.\n Lungs, clear, diminished at bases. On RA with O2 sats 100%\n Neutropenic.\n Action:\n Labs q 6 hrs, OOB to chair during the day, enc ambulation, enc po\n intake. Pt unable to sleep received 25 mg po Trazadone and 1 mg IV\n ativan a few hours later\n pt able to sleep most of the night.\n Response:\n No signs of tumor lysis, remains comfortable, hemodynamically stable\n Plan:\n Pt called out to the floor\n no beds. No chemo for one week, follow\n labs, transfuse if Hct <21, plts <50 Maintain chemo/neutropenic\n precautions.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt off CVVHD since 6 AM. Off CBI, making adequate amounts of\n urine\n Action:\n Labs as ordered, Magnesium repleted\n Response:\n No signs of tumor lysis, UO remains adequate 100 cc/hr.\n Plan:\n Check labs as ordered, monitor urine output\n" }, { "category": "Nursing", "chartdate": "2133-12-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 617056, "text": "62 year old woman transferred to from OSH with new diagnosis of\n Burkitt\ns lymphoma and tumor lysis syndrome. Presented to OSH with LDH\n > 20,000 and WBC 22. CT of chest/abdomen showed retroperitoneal nodes\n and hydronephrosis on the left. UA showed bacteria and a few WBC's with\n which pt was started on ceftriaxone.\n While in the MICU pt has been on CVVHD since for treatment of\n tumor lysis and as well as fluid removal. She has completed a 5 day\n course of Cytoxan along with a dose of Vincristin and Doxorubicin. She\n has been on CBI since admission---hematuria was present at admission\n and resolved with CBI and CBI remained for prevention of hemorrhagic\n cystitis.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt\ns last chemo . pt tolerated chemo well, CBI stopped .\n urine clear, dk yellow . No signs of tumor lysis. Denies pain, poor\n appetite, abd soft with + bowel sounds. Pt passed loose stool, brown.\n Lungs, clear, diminished at bases. On RA with O2 sats 100%\n Neutropenic.\n Action:\n Labs q 6 hrs, OOB to chair during the day, enc ambulation, enc po\n intake. Pt unable to sleep received 25 mg po Trazadone and 1 mg IV\n ativan a few hours later\n pt able to sleep most of the night.\n Response:\n No signs of tumor lysis, remains comfortable, hemodynamically stable\n Plan:\n Pt called out to the floor\n no beds. No chemo for one week, follow\n labs, transfuse if Hct <21, plts <50 Maintain chemo/neutropenic\n precautions.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt off CVVHD since 6 AM. Off CBI, making adequate amounts of\n urine\n Action:\n Labs as ordered, Magnesium repleted\n Response:\n No signs of tumor lysis, UO remains adequate 100 cc/hr.\n Plan:\n Check labs as ordered, monitor urine output\n SKIN: bruising/petechia noted lower back. Multiple bruising on both\n arms, no breakdown on coccyx, pt turned frequ. Skin care done.\n Pneumoboots on\n ------ Protected Section ------\n THIS AM patient alert oriented follows commands. Denies pain or any\n other discomfort. PT consult ordered\n patient will be seen today. On\n RA w/sats at high 90\ns-100%. L/S clear, RRR, unlabored breathing.\n Denies any SOB or CP. Normotensive, HR in 70\ns SR no ectopy noted. PIV\n placed by IV nurse. Renal to D/C Dialysis cath. On assessment abd soft\n non tender, positive for BS, no BM this shift. Regular diet\n tolerates\n well, denies nausea/vomiting. Dark yellow\n amber color urine via foley\n adequate amnt. In addition this am patient was repleted with 60meq\n KCL for K-3.5, 4gr of magnesium for Mg-1.6 and needs 4gr of calcium of\n Ca-7.1. Continue w/labs q12hr.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n LYMPHOMA\n Code status:\n Full code\n Height:\n 61 Inch\n Admission weight:\n 92.2 kg\n Daily weight:\n 87.8 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Hyperlipidemia, hypothyroidism\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:124\n D:55\n Temperature:\n 97.6\n Arterial BP:\n S:140\n D:64\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 75 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 24h total in:\n 590 mL\n 24h total out:\n 980 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 05:13 AM\n Potassium:\n 3.5 mEq/L\n 05:13 AM\n Chloride:\n 112 mEq/L\n 05:13 AM\n CO2:\n 23 mEq/L\n 05:13 AM\n BUN:\n 9 mg/dL\n 05:13 AM\n Creatinine:\n 0.4 mg/dL\n 05:13 AM\n Glucose:\n 109 mg/dL\n 05:13 AM\n Hematocrit:\n 21.5 %\n 05:13 AM\n Finger Stick Glucose:\n 143\n 05:00 AM\n Valuables / Signature\n Patient valuables: sent w/patient\n Transferred from: \n Transferred to: 7F 785\n Date & time of Transfer: \n ------ Protected Section Addendum Entered By: , RN\n on: 09:45 ------\n No change from previous note. Patient remains alert oriented, denies\n pain. Seen by PT\n patient in the chair. Denies SOB, CP or any other\n discofort. VSS. Awaiting bed on 7 F again.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:20 ------\n" }, { "category": "Physician ", "chartdate": "2133-12-18 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 617064, "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 off renal replacement therapy (no CVVH required).\n No hematuria.\n Remains neutropenic.\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 Famotidine (Pepcid) - 08:14 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, 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, 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, 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: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:33 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.1\nC (96.9\n HR: 71 (65 - 110) bpm\n BP: 116/51(66) {104/51(64) - 143/123(128)} mmHg\n RR: 16 (14 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.8 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 1,866 mL\n 751 mL\n PO:\n 480 mL\n 380 mL\n TF:\n IVF:\n 908 mL\n 371 mL\n Blood products:\n 478 mL\n Total out:\n 3,912 mL\n 1,600 mL\n Urine:\n 2,865 mL\n 1,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,046 mL\n -849 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\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: 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: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: 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, No(t) Oriented (to): , Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 7.6 g/dL\n 68 K/uL\n 109 mg/dL\n 0.4 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 112 mEq/L\n 143 mEq/L\n 22.6 %\n 0.4 K/uL\n [image002.jpg]\n 12:08 PM\n 12:36 PM\n 05:57 PM\n 06:08 PM\n 11:21 PM\n 05:47 AM\n 11:51 AM\n 05:24 PM\n 05:13 AM\n 10:32 AM\n WBC\n 0.7\n 0.5\n 0.5\n 0.4\n Hct\n 23.5\n 22.7\n 22.1\n 26.9\n 25.1\n 23.3\n 21.5\n 22.6\n Plt\n 76\n 71\n 55\n 98\n 84\n 87\n 68\n Cr\n 0.4\n 0.3\n 0.3\n 0.3\n 0.4\n 0.3\n 0.4\n TCO2\n 22\n 21\n Glucose\n 117\n 108\n 107\n 98\n 127\n 104\n 109\n Other labs: PT / PTT / INR:13.1/23.6/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:38/48, Alk Phos / T Bili:222/1.2, Differential-Neuts:62.0 %,\n Band:2.0 %, Lymph:22.0 %, Mono:8.0 %, Eos:6.0 %, D-dimer:510 ng/mL,\n Fibrinogen:229 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.2 g/dL,\n LDH:2335 IU/L, Ca++:7.1 mg/dL, Mg++:1.6 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n RESPIRATORY DISTRESS -- much improved. Monitor RR, SaO2. Provide\n supplimental oxygen as needed. Aim for net diuresis.\n LYMPHOMA -- Burkitt's Lymphoma, high tumor burden, spontaneous tumor\n lysis syndrome. To continue chemotherapy as per Heme/Onc service.\n RENAL FAILURE, ACUTE -- attributed to tumour lysis and urate\n nephropathy. Resolved. Consider HD if requires resumption of renal\n replacement therapy.\n FLUIDS -- hypervolemia, Tolerated net negative fluid balance\n overnight. Desire continued net negative balance, aiming for\n additional 1-2 L net negative for next 24 hrs if tolerated by BP.\n Monitor off CVVH today.\n COAGULOPATHY -- Pt had profuse oozing from HD site, hematuria, with\n associated Hct drop. Monitor coagulopathy. Monitor q6h coags for r/o\n DIC\n ANEMIA -- transfuse for goal Hct>21\n THROMBOCYTOPENIA -- transfuse for plt <50 since bleeding\n NEUTROPENIA\n neutroppenic precautions, PMN counts continue to fall.\n HEMATURIA -- attributed in part to chemotherapy. No evidence for UTI.\n HYPOTHYROIDISM -- Continue on home regimen.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n 20 Gauge - 07:49 AM\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 :Transfer to floor\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2133-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616426, "text": "62 y.o. F w/ PMH hypothyroidism presented initially at OSH w/ fatigue/\n insomnia and was found to have high grade burkits lymphoma. Transferred\n from to for further management. Her course has been\n complicated by tumor lysis syndrome for which she has been on CVVHDF\n since starting cytoxan on the 15^th.\n Overnight Events:\n 2mg PO ativan x 2 for anxiety/sleeplessness with good effect\n Removed approx 2.5 liters overnight goal 1-2 liters/day.\n Transfused 1 unit Plts for plts <50\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinine peaked at 3.0/ BUN of 39. Started on CVVHDF for tumor\n lysis syndrome. Cytoxan dose calculated based on creatinine clearance\n while on CVVHD. On CBI as pt had cytoxan induced hematuria. U/O\n appears to be 70-80cc/hr and there was no evidence of hematuria\n overnight.\n Action:\n CVVHDF maintained throughout shift, ran approx 200cc negative/hr, lytes\n monitored q 6hrs, titrated Ca and K gtts as necessary.\n Response:\n 2.5 liters negative overnight.\n Plan:\n Cont CRRT if filter clots contact renal as pt finished cytoxan last\n night and is hemodynamically stable possible transition to HD, fluid\n removal goal 1-2 liters/day.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n + burkits lymphoma, continues on CBI in the setting of hematuria\n previous days, hematuria resolved but kept her on CBI to flush kidney\n while getting chemotherapy; urine and clear; PTT 63\n patient no\n longer bleeding from RIJ and aline\n Action:\n TLS labs q6hrs including coags and fibrinogen. Pre-medicated 40 mg IV\n decadron and Zofran. 1 mg ativan PO given this am for\n anxiety/restlessness. Allopurinol 100mgs daily; last dose of cytoxan\n given this evening\n Response:\n K 3.3 this pm, phos down to 1.9 ionized calcium 1.02\n on KCL and\n Calcium gluconate repletion, uric acid down to 2.6; Coags stable FDP\n 10-40;\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and Fibrinogen\n with CVVH labs but can be done Q8hrs; will receive vincristine and\n doxorubicin ; run CBI to finish in 6hrs period\n Oriented x 3, denies any pain. Moving all extremties but weak due to\n edema; feels heavy with lifting and moving in bed; movement limited by\n CVVH and dialysis line which is very positional\n" }, { "category": "Nursing", "chartdate": "2133-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616427, "text": "62 y.o. F w/ PMH hypothyroidism presented initially at OSH w/ fatigue/\n insomnia and was found to have high grade burkits lymphoma. Transferred\n from to for further management. Her course has been\n complicated by tumor lysis syndrome for which she has been on CVVHDF\n since starting cytoxan on the 15^th.\n Overnight Events:\n 2mg PO ativan x 2 for anxiety/sleeplessness with good effect\n Removed approx 2.5 liters overnight goal 1-2 liters/day.\n Transfused 1 unit Plts for plts <50\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinine peaked at 3.0/ BUN of 39. Started on CVVHDF for tumor\n lysis syndrome. Cytoxan dose calculated based on creatinine clearance\n while on CVVHD. On CBI as pt had cytoxan induced hematuria. U/O\n appears to be 70-80cc/hr and there was no evidence of hematuria\n overnight.\n Action:\n CVVHDF maintained throughout shift, ran approx 200cc negative/hr, lytes\n monitored q 6hrs, titrated Ca and K gtts as necessary.\n Response:\n 2.5 liters negative overnight.\n Plan:\n Cont CRRT if filter clots contact renal as pt finished cytoxan last\n night and is hemodynamically stable possible transition to HD, fluid\n removal goal 1-2 liters/day.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n + burkits lymphoma,\n Action:\n TLS labs q6hrs including coags and fibrinogen. Pre-medicated 40 mg IV\n decadron and Zofran. 1 mg ativan PO given this am for\n anxiety/restlessness. Allopurinol 100mgs daily; last dose of cytoxan\n given this evening\n Response:\n K 3.3 this pm, phos down to 1.9 ionized calcium 1.02\n on KCL and\n Calcium gluconate repletion, uric acid down to 2.6; Coags stable FDP\n 10-40;\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and Fibrinogen\n with CVVH labs but can be done Q8hrs; will receive vincristine and\n doxorubicin ; run CBI to finish in 6hrs period\n Oriented x 3, denies any pain. Moving all extremties but weak due to\n edema; feels heavy with lifting and moving in bed; movement limited by\n CVVH and dialysis line which is very positional\n" }, { "category": "Nursing", "chartdate": "2133-12-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 615852, "text": "62 y.o. Female w/ h.o. HL, hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade lymphoma. Transferred for\n further management from . Admitted to the ICU for CVVH for\n tumor lysis syndrome.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with ? UTI dx in OSH; known renal calculi with hydronephrosis.. Cr\n 1.6. On CVVH---pt (-) 2.6 L at beginning of shift. Making little urine,\n however difficult to asses as pt on CBI\n Action:\n Replaced 1.5 L as pt became hypotensive to high 80\ns, pale and\n difficult to arouse. Discussed fluid goal with BMT and they would like\n the pt even to slightly negative, depending on how the pt\ns BP\n tolerates. They also added cont IVF @ 100 cc/hr but want pt even for\n day???? running fluid @ 100 cc/hr. Stopped CBI. Gave phenazopyridine\n for c/o bladder spasm.\n Response:\n Foley draining 15-25 cc/hr of amber urine. CVVH machine running great\n without problems. balance for day as of 1800 -------------\n Plan:\n Continue with CVVH with goal of even to slightly negative as BP\n tolerates, BMT will re-evaluate goal tomorrow.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Received pt with CBI\nurine yellow and clear. TLS labs WNL. Pt somnolent\n but arousable and alert and oriented x3. Intermittently crying with\n confused expressions. CBI draining clear, yellow urine.\n Action:\n TLS labs q6h with coags and fibrinogen q4h. Pre-medicated for chemo, 40\n mg IV decadron and Zofran\n Response:\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and Fibrinogen\n q4 hours. Cont with chemo and follow heme onc recs---chemo nurse will\n be by at 7:30. Provide emotional support to pt and to family.\n" }, { "category": "Nursing", "chartdate": "2133-12-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 617120, "text": "62 year old woman transferred to from OSH with new diagnosis of\n Burkitt\ns lymphoma and tumor lysis syndrome. Presented to OSH with LDH\n > 20,000 and WBC 22. CT of chest/abdomen showed retroperitoneal nodes\n and hydronephrosis on the left. UA showed bacteria and a few WBC's with\n which pt was started on ceftriaxone.\n While in the MICU pt has been on CVVHD since for treatment of\n tumor lysis and as well as fluid removal. She has completed a 5 day\n course of Cytoxan along with a dose of Vincristin and Doxorubicin. She\n has been on CBI since admission---hematuria was present at admission\n and resolved with CBI and CBI remained for prevention of hemorrhagic\n cystitis.\n Pt stable throughout the night hemodynamically.\n No c/o SOB or discomfort.\n Pt given trazadone and ativan for sleep with very positive results.\n Pt sleeping in long naps and states that she is feeling better because\n of it.\n UO adequate\n continues to contain some sediment.\n Pt to be transferred this morning to floor as soon as a bed is\n available.\n Transfer note completed.\n" }, { "category": "Nursing", "chartdate": "2133-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616542, "text": "Significant Events:\n --- CVVHD clotted @ 8 AM, renal notified and conclusion was to stop\n CVVHD and re-evaluate need for dialysis according to labs and UO\n ---Later in day, BMT ordered CVVHD to be continued through night as pt\n receiving new chemo regimen again toninght which could cause further\n damage to kidneys\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2133-12-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 617218, "text": "62 year old woman transferred to from OSH with new diagnosis of\n Burkitt\ns lymphoma and tumor lysis syndrome. Presented to OSH with LDH\n > 20,000 and WBC 22. CT of chest/abdomen showed retroperitoneal nodes\n and hydronephrosis on the left. UA showed bacteria and a few WBC's with\n which pt was started on ceftriaxone.\n While in the MICU pt has been on CVVHD since for treatment of\n tumor lysis and as well as fluid removal. She has completed a 5 day\n course of Cytoxan along with a dose of Vincristin and Doxorubicin. She\n has been on CBI since admission---hematuria was present at admission\n and resolved with CBI. Off CBI and CVVHD last \n Pt stable hemodynamically, NSR and BP in the 110\n 120\n No c/o SOB or discomfort, O2 sats >95% at room air\n Oriented x 3, OOB with 1 assist, steady on her feet. Pt given trazadone\n and ativan for sleep with very positive results. Pt sleeping in long\n naps and states that she is feeling better because of it.\n Non-tender abdomen, on regular diet. Appetite improving. + bowel\n movement this am.\n Chemo precaution and neutropenic precaution maintained. WBC 0.3 this am\n UO adequate\n clear yellow with sediment intermittently\n Skin intact with some old bruise in her extremties and back area.\n Dilaysis line pulled out last night, PIV guage 20 at R basilic vein\n Repleted with magnesium for mg of 1.4; Postassium repletion 40 mEq for\n K of 3.5;need calcium repletion of Ca of 7.7\n Hct down to 21.2 this am, needs 1 unit of PRBC, goal hct\n 21 and\n platelet of 10 as goal current;y 39 with am labs\n Patient\ns husband called this am, aware of transfer once bed is\n available.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n LYMPHOMA\n Code status:\n Full code\n Height:\n 61 Inch\n Admission weight:\n 92.2 kg\n Daily weight:\n 87.8 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Hyperlipidemia, hypothyroidism\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:134\n D:56\n Temperature:\n 98.8\n Arterial BP:\n S:140\n D:64\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 78 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 170 mL\n 24h total out:\n 1,080 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 05:04 AM\n Potassium:\n 3.5 mEq/L\n 05:04 AM\n Chloride:\n 105 mEq/L\n 05:04 AM\n CO2:\n 23 mEq/L\n 05:04 AM\n BUN:\n 9 mg/dL\n 05:04 AM\n Creatinine:\n 0.4 mg/dL\n 05:04 AM\n Glucose:\n 113 mg/dL\n 05:04 AM\n Hematocrit:\n 21.2 %\n 05:04 AM\n Finger Stick Glucose:\n 156\n 06:00 PM\n Additional pertinent labs:\n patient received magnesium, calcium and potassium repletion\n Lines / Tubes / Drains:\n PIV's\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": "2133-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616413, "text": "62 y.o. Female w/ h.o., hypothyroidism presented initially at OSH w/\n fatigue, insomnia found to be high grade burkits lymphoma. Transferred\n for further management from . Admitted to the ICU for CVVH\n tumor lysis syndrome.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with ? UTI dx in OSH; known renal calculi with hydronephrosis.\n creatinine high at 3.0/ BUN of 39; Started on CVVH for tumor lysis\n syndrome and while she is on chemotherapy; chemo drugs dose calculated\n based on creatinine clearance while on CVVHD; filter clotted at 0600,\n off CRRT for about 6hrs\n Action:\n CVVHD initiated 12noon, replacement fluid changed to K4 running at 4200\n ml/hr ( 4000 PBP) and dialysate at 1000ml/hr with goal to keep patient\n 50cc/hr negative per renal although ICU team prefers patient to be at\n least 1 liter negative by MN\n patient became symptomatic being 11L\n positive at start of shift - desatted down 87-88% @ room air;\n calculated urine output at 80cc/hr in reference to 1000 output per CBI\n for 12hrs\n Response:\n 500 cc urine out from CBI at 1800\n Plan:\n Continue with CVVH with goal to keep her negative 50cc/hr, restart\n patient on 150cc/hr NS continues - urine output of at least 100cc/hr\n is goal while on cytoxan per oncology\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n + burkits lymphoma, continues on CBI in the setting of hematuria\n previous days, hematuria resolved but kept her on CBI to flush kidney\n while getting chemotherapy; urine and clear; PTT 63\n patient no\n longer bleeding from RIJ and aline\n Action:\n TLS labs q6hrs including coags and fibrinogen. Pre-medicated 40 mg IV\n decadron and Zofran. 1 mg ativan PO given this am for\n anxiety/restlessness. Allopurinol 100mgs daily; last dose of cytoxan\n given this evening\n Response:\n K 3.3 this pm, phos down to 1.9 ionized calcium 1.02\n on KCL and\n Calcium gluconate repletion, uric acid down to 2.6; Coags stable FDP\n 10-40;\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and Fibrinogen\n with CVVH labs but can be done Q8hrs; will receive vincristine and\n doxorubicin ; run CBI to finish in 6hrs period\n Oriented x 3, denies any pain. Moving all extremties but weak due to\n edema; feels heavy with lifting and moving in bed; movement limited by\n CVVH and dialysis line which is very positional\n Hemodynamically stable, hypertensive in the >160 and tachycardic in the\n 120\ns when she cries\n Desatted down to 87-88% at room air, transiently uses O2 at 2 liters.\n IS use started, needs encouragement. Off O2 2hrs after of being on it;\n lung sounds dim at bases\n On regular diet but patient has poor appetite, drinks ginger ale and\n crackers. problem with swallowing. Bowel sounds present, non tender\n abdomen; on colace as bowel regimen\n Skin intact but bruises noted arms and back area\n Family visited today, ICU team updated them of plans of care. Social\n work follows patient.\n" }, { "category": "Nursing", "chartdate": "2133-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616421, "text": "62 y.o. F w/ PMH hypothyroidism presented initially at OSH w/ fatigue/\n insomnia and was found to have high grade burkits lymphoma. Transferred\n from to for further management. Her course has been\n complicated by tumor lysis syndrome for which she has been on CVVHDF\n since starting cytoxan on the 15^th.\n Overnight Events:\n 2mg PO ativan x 2 for anxiety/sleeplessness with good effect\n Removed approx 2.5 liters overnight goal 1-2 liters/day.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinine peaked at 3.0/ BUN of 39. Started on CVVHDF for tumor\n lysis syndrome. Cytoxan dose calculated based on creatinine clearance\n while on CVVHD.\n Action:\n CVVHD initiated 12noon, replacement fluid changed to K4 running at 4200\n ml/hr ( 4000 PBP) and dialysate at 1000ml/hr with goal to keep patient\n 50cc/hr negative per renal although ICU team prefers patient to be at\n least 1 liter negative by MN\n patient became symptomatic being 11L\n positive at start of shift - desatted down 87-88% @ room air;\n calculated urine output at 80cc/hr in reference to 1000 output per CBI\n for 12hrs\n Response:\n 500 cc urine out from CBI at 1800\n Plan:\n Continue with CVVH with goal to keep her negative 50cc/hr, restart\n patient on 150cc/hr NS continues - urine output of at least 100cc/hr\n is goal while on cytoxan per oncology\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n + burkits lymphoma, continues on CBI in the setting of hematuria\n previous days, hematuria resolved but kept her on CBI to flush kidney\n while getting chemotherapy; urine and clear; PTT 63\n patient no\n longer bleeding from RIJ and aline\n Action:\n TLS labs q6hrs including coags and fibrinogen. Pre-medicated 40 mg IV\n decadron and Zofran. 1 mg ativan PO given this am for\n anxiety/restlessness. Allopurinol 100mgs daily; last dose of cytoxan\n given this evening\n Response:\n K 3.3 this pm, phos down to 1.9 ionized calcium 1.02\n on KCL and\n Calcium gluconate repletion, uric acid down to 2.6; Coags stable FDP\n 10-40;\n Plan:\n Cont to monitor tumor lysis labs q6 hours with the coags and Fibrinogen\n with CVVH labs but can be done Q8hrs; will receive vincristine and\n doxorubicin ; run CBI to finish in 6hrs period\n Oriented x 3, denies any pain. Moving all extremties but weak due to\n edema; feels heavy with lifting and moving in bed; movement limited by\n CVVH and dialysis line which is very positional\n" }, { "category": "Nursing", "chartdate": "2133-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616543, "text": "Significant Events:\n --- CVVHD clotted @ 8 AM, renal notified and conclusion was to stop\n CVVHD and re-evaluate need for dialysis according to labs and UO\n ---Later in day, BMT ordered CVVHD to be continued through night as pt\n receiving new chemo regimen again toninght which could cause further\n damage to kidneys\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2133-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616544, "text": "Significant Events:\n --- CVVHD clotted @ 8 AM, renal notified and conclusion was to stop\n CVVHD and re-evaluate need for dialysis according to labs and UO\n ---Later in day, BMT ordered CVVHD to be continued through night as pt\n receiving new chemo regimen again toninght which could cause further\n damage to kidneys\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Finished last dose of cytotoxan last night. On CVVHD for tumor lysis\n syndrome. Pancytopenic now.\n Action:\n Stopped CVVHD for a 7 hours today, labs stable. CVVHD restarted @ 1500.\n Labs with lytes, uric acid, LD, Hct, coags, and fibrinogen q6h.\n Response:\n 1800 labs pending.\n Plan:\n To start vincristine and doxyrubicin tonight. Will re-evalute need for\n CVVHD tomorrow pending night\ns course of events.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2133-12-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 616007, "text": "Significant Events:\n ----BMT, renal, and MICU services discussed pt\ns fluid status and\n hydration for chemo today and have come to a goal of running pt even on\n CVVHD, not giving pre-chemo fluids but rather keeping CBI to protect\n bladder from hemorrhagic cystitis.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt received 2^nd dose of 5 cytotoxin doses. On CVVHD for txt tumor\n lysis.\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Running CVVHD, making little urine, 20-70 cc/hr. Urine appearing\n intermittently pink/red with NO clots. Cr down but this is due to\n CVVHD. Initally running pt slightly negative prior to fluid status\n convo.\n Action:\n Manually flushed foley q3h and then placed pt on CBI. CVVHD with q6h\n labs---Calcium sliding scale changed. Started to run pt even at around\n 1200. Frequent rescue flushes as filter pressure rising, 170-180\n from 160.\n Response:\n Pt\n :\n" }, { "category": "Nursing", "chartdate": "2133-12-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 617225, "text": "62 year old woman transferred to from OSH with new diagnosis of\n Burkitt\ns lymphoma and tumor lysis syndrome. Presented to OSH with LDH\n > 20,000 and WBC 22. CT of chest/abdomen showed retroperitoneal nodes\n and hydronephrosis on the left. UA showed bacteria and a few WBC's with\n which pt was started on ceftriaxone.\n While in the MICU pt has been on CVVHD since for treatment of\n tumor lysis and as well as fluid removal. She has completed a 5 day\n course of Cytoxan along with a dose of Vincristin and Doxorubicin. She\n has been on CBI since admission---hematuria was present at admission\n and resolved with CBI. Off CBI and CVVHD last \n Pt stable hemodynamically, NSR and BP in the 110\n 120\n No c/o SOB or discomfort, O2 sats >95% at room air\n Oriented x 3, OOB with 1 assist, steady on her feet. Pt given trazadone\n and ativan for sleep with very positive results. Pt sleeping in long\n naps and states that she is feeling better because of it.\n Non-tender abdomen, on regular diet. Appetite improving. + bowel\n movement this am.\n Chemo precaution and neutropenic precaution maintained. WBC 0.3 this am\n UO adequate\n clear yellow with sediment intermittently\n Skin intact with some old bruise in her extremties and back area.\n Dilaysis line pulled out last night, PIV guage 20 at R basilic vein\n Repleted with magnesium for mg of 1.4; Postassium repletion 40 mEq for\n K of 3.5;need calcium repletion of Ca of 7.7\n Hct down to 21.2 this am, needs 1 unit of PRBC, goal hct\n 21 and\n platelet of 10 as goal current;y 39 with am labs\n Patient\ns husband called this am, aware of transfer once bed is\n available.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n LYMPHOMA\n Code status:\n Full code\n Height:\n 61 Inch\n Admission weight:\n 92.2 kg\n Daily weight:\n 87.8 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Hyperlipidemia, hypothyroidism\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:134\n D:56\n Temperature:\n 98.8\n Arterial BP:\n S:140\n D:64\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 78 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 170 mL\n 24h total out:\n 1,080 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 05:04 AM\n Potassium:\n 3.5 mEq/L\n 05:04 AM\n Chloride:\n 105 mEq/L\n 05:04 AM\n CO2:\n 23 mEq/L\n 05:04 AM\n BUN:\n 9 mg/dL\n 05:04 AM\n Creatinine:\n 0.4 mg/dL\n 05:04 AM\n Glucose:\n 113 mg/dL\n 05:04 AM\n Hematocrit:\n 21.2 %\n 05:04 AM\n Finger Stick Glucose:\n 156\n 06:00 PM\n Additional pertinent labs:\n patient received magnesium, calcium and potassium repletion\n Lines / Tubes / Drains:\n PIV's\n Valuables / Signature\n Patient valuables: cellphone\n Other valuables:\n Clothes: Sent home with: family\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 401\n Transferred to: 7 \n Date & time of Transfer: 1200\n" }, { "category": "Physician ", "chartdate": "2133-12-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 617299, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n :\n - had bed and lost it, waiting for a new one\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.8\nC (98.3\n HR: 71 (64 - 93) bpm\n BP: 121/78(86) {109/50(66) - 142/78(93)} mmHg\n RR: 16 (13 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.8 kg (admission): 92.2 kg\n Height: 61 Inch\n Total In:\n 891 mL\n PO:\n 380 mL\n TF:\n IVF:\n 511 mL\n Blood products:\n Total out:\n 2,920 mL\n 760 mL\n Urine:\n 2,920 mL\n 760 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,029 mL\n -760 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\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 39 K/uL\n 7.5 g/dL\n 113 mg/dL\n 0.4 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 105 mEq/L\n 135 mEq/L\n 21.2 %\n 0.3 K/uL\n [image002.jpg]\n 05:57 PM\n 06:08 PM\n 11:21 PM\n 05:47 AM\n 11:51 AM\n 05:24 PM\n 05:13 AM\n 10:32 AM\n 04:34 PM\n 05:04 AM\n WBC\n 0.7\n 0.5\n 0.5\n 0.4\n 0.3\n Hct\n 22.7\n 22.1\n 26.9\n 25.1\n 23.3\n 21.5\n 22.6\n 21.2\n Plt\n 71\n 55\n 98\n 84\n 87\n 68\n 57\n 39\n Cr\n 0.3\n 0.3\n 0.3\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 21\n Glucose\n 108\n 107\n 98\n 127\n 104\n 109\n 113\n Other labs: PT / PTT / INR:13.2/23.2/1.1, CK / CKMB / Troponin-T:331//,\n ALT / AST:26/22, Alk Phos / T Bili:196/1.1, Differential-Neuts:62.0 %,\n Band:2.0 %, Lymph:22.0 %, Mono:8.0 %, Eos:6.0 %, D-dimer:510 ng/mL,\n Fibrinogen:344 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:3.2 g/dL,\n LDH:1547 IU/L, Ca++:7.7 mg/dL, Mg++:1.4 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n Burkitt's Lymphoma with high tumor burden and spontaneous tumor lysis\n syndrome. Received Rasburicase for uric acid converion. Pt had e/o TL,\n now labs continue to be stable. Received doxorubicin and vincristine\n (day 1), next dose day 8 . CVVH stopped yesterday, continues\n to have excellent UOP, renal function normal.\n - cont allopurinol 100 mg daily, cont to monitor renal fxn\n - BMT said no bactrim, inhaled pentamidine at some point\n - neutropenic precautions, normal\n goals off CVVH\n - Cryo for fibrinogen less than 100, Plts for less than 50 because of\n oozing, Hct>21\n - appreciate heme/onc recs\n - will check TLS labs, DIC labs, electrolytes \n - EBV -> IgG (+), IgM (-), CMV and HIV (-)\n .\n NEUTROPENIA\n WBC .3 today, await diff.\n - continue neutropenic precautions, no fevers yet\n .\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely due to tumour lysis and urate nephropathy given her prior labs\n from . Had renal stones, likely uric acid on right, and\n hydronephrosis on left possibly due to external compression by\n tumor/LAD in retroperitoneum. Had marginal urine output. Pt on CVVH so\n creatinine improved. Urine output continues to improve, possibly\n passed stone or tumor burden reduced. Stopped CBI and CVVH\n - electrolytes\n - Monitor for hematuria\n - f/u renal recs\n .\n ##. COAGULOPATHY/PANCYTOPENIA/NEUTROPENIA: Pt has had profuse oozing\n from HD site, with associated Hct drop. Also had hematuria, requiring\n CBI with 3way Foley. Both are now improving. No evidence of\n coagulopathy. Pt is not receiving anticoagulation in CVVH. Hct, white\n count, and plt count cont to trend down, likely to chemo.\n - transfusion goals as above.\n - monitor q12 coags for r/o DIC\n - transfuse for goal Hct>21, plt>10 now that bleeding has resolved\n .\n URINARY TRACT INFECTION (UTI)/HEMATURIA: Pt had bladder pain and\n hematuria, now resolved.\n Ucx neg x 2.\n .\n ##. Anion Gap Acidosis: normalized.\n .\n ## Pain/discomfort\n morphine PRN\n .\n TACHYCARDIA, OTHER\n On review of OSH records pt has been persistently sinus tachycardic,\n likely related to her underlying lymphoma.\n .\n HYPOTHYROIDISM\n Will continue on home regimen of Hypothyroidism\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:00 AM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: call out\n" }, { "category": "ECG", "chartdate": "2133-12-31 00:00:00.000", "description": "Report", "row_id": 231419, "text": "Artifact is present. Probable sinus rhythm. Low voltage in the precordial\nleads. If clinically indicated, repeat tracing may provide better diagnostic\nquality. Compared to the previous tracing ST-T wave changes may have resolved.\n\n" }, { "category": "ECG", "chartdate": "2133-12-25 00:00:00.000", "description": "Report", "row_id": 231420, "text": "Normal sinus rhythm, rate 94. Mild generalized non-specific repolarization\nchanges. Compared to the previous tracing of repolarization changes\nare new.\n\n" }, { "category": "ECG", "chartdate": "2133-12-16 00:00:00.000", "description": "Report", "row_id": 231421, "text": "Sinus rhythm. Low precordial lead QRS voltages are non-specific and\ntracing is otherwise within normal limits. Since the previous tracing\nof rate is slower, QTc interval may be shorter and low T wave\namplitude is improved.\n\n" }, { "category": "ECG", "chartdate": "2133-12-12 00:00:00.000", "description": "Report", "row_id": 231422, "text": "Sinus rhythm at upper limits of normal rate. Borderline low voltage. Minor\nT wave abnormalities. No previous tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2134-01-10 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1121436, "text": " 6:39 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Eval line position\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with burkitt's lymphoma s/p L IJ placement\n REASON FOR THIS EXAMINATION:\n Eval line position\n ______________________________________________________________________________\n WET READ: DLrc SUN 8:44 PM\n Left IJ malpositioned with tip coursing into L axillary. Small right\n effusion.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Line placement.\n\n FINDINGS: The left IJ catheter extends into the left axillary vein. This\n information was telephoned to Dr. by the resident on call, and a\n subsequent image shows proper placement of the central catheter.\n\n\n" }, { "category": "Radiology", "chartdate": "2134-01-10 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1121463, "text": " 11:25 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: correct line position\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with central line, moved back; need to assess location.\n REASON FOR THIS EXAMINATION:\n correct line position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central catheter position.\n\n FINDINGS: In comparison with the earlier study of this date, the central\n catheter has been pulled back so that the tip lies in the lower SVC or at the\n cavoatrial junction.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-12-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1116796, "text": " 6:23 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for complications and position of HD catheter.\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman s/p line placment.\n REASON FOR THIS EXAMINATION:\n assess for complications and position of HD catheter.\n ______________________________________________________________________________\n WET READ: CXWc 7:23 PM\n Right IJ HD catheter terminates in the right atrium. Low lung volumes. Hazy\n opacity at the left lung base could be due to small effusion, atelectasis or\n developing consolidation.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Check HD catheter placement.\n\n Exam AP radiograph compared to prior study from .\n\n A right IJ hemodialysis catheter tip is seen with the tip projecting at the\n cavoatrial junction. No pneumothorax is demonstrated. There are low lung\n volumes. A hazy opacity is seen at the left lung base, which may represent\n minimal atelectasis.\n\n IMPRESSION: Left lower lobe hazy opacity, likely representing atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2133-12-11 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1116791, "text": " 6:10 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: please assess liver/gallbladder\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lymphoma and elevated bili\n REASON FOR THIS EXAMINATION:\n please assess liver/gallbladder\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc 8:41 PM\n 1. No intra or extrahepatic biliary dilatation. CBD 2 mm.\n 2. No evidence of cholecystitis.\n 3. Several sub-cm nonobstructing right renal collecting system calculi, as\n seen on OSH CT.\n 4. Mild left hydronephrosis with no left renal calculi seen, as on OSH CT.\n 5. Enlarged uterus.\n PFI VERSION #1 CXWc 8:37 PM\n 1. No intra or extrahepatic biliary dilatation. CBD 2 mm.\n 2. No evidence of cholecystitis.\n 3. Several sub-cm nonobstructing right renal collecting system calculus.\n 4. Mild left hydronephrosis with no left renal calculi seen.\n 5. Enlarged uterus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old woman with lymphoma and elevated bilirubin.\n\n COMPARISON: CT torso obtained at .\n\n ABDOMINAL ULTRASOUND: The liver is normal in echotexture without focal\n abnormalities. There is no intra- or extra-hepatic biliary ductal dilatation.\n The common duct measures 2 mm. The main portal vein demonstrates normal\n hepatopetal flow. There is no ascites. The gallbladder is decompressed and\n normal in appearance.\n\n The abdominal midline is obscured by overlying bowel gas, and the pancreas is\n not visualized. The spleen is slightly enlarged, measuring 13.4 cm.\n\n The right kidney contains several hyperechoic foci with posterior shadowing,\n within the renal pelvis, consistent with calculi. There is no hydronephrosis.\n These nonobstructing calculi measure up to 6 mm. These are similar in size\n and distribution to the recent CT. The left kidney demonstrates mild\n hydronephrosis, as seen on CT. No left renal stones are noted.\n\n The urinary bladder is minimally distended. Incidentally noted while imaging\n the bladder is an enlarged uterus, as seen on recent CT.\n\n IMPRESSION:\n 1. No intra- or extra-hepatic biliary dilatation. CBD 2-mm. No evidence of\n cholecystitis.\n 2. As seen on recent outside hospital CT, several subcentimeter non-\n obstructing right renal calculi, and mild left hydronephrosis without left\n renal calculi. Hydronephrosis is likely related to extensive retroperitoneal\n (Over)\n\n 6:10 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: please assess liver/gallbladder\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n soft tissue density mass (likely nodes), seen on the outside hospital CT.\n 3. Mild splenomegaly\n 3. Incidentally noted, enlarged uterus.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2133-12-11 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1116792, "text": "2. No evidence of cholecystitis.\n 3. Several sub-cm nonobstructing right renal collecting system calculus.\n 4. Mild left hydronephrosis with no left renal calculi seen.\n 5. Enlarged uterus. Page: 3\n\n , M F 62 () \n , MED 6:10 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: please assess liver/gallbladder\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lymphoma and elevated bili\n REASON FOR THIS EXAMINATION:\n please assess liver/gallbladder\n ______________________________________________________________________________\n PFI REPORT\n 1. No intra or extrahepatic biliary dilatation. CBD 2 mm.\n 2. No evidence of cholecystitis.\n 3. Several sub-cm nonobstructing right renal collecting system calculi, as\n seen on OSH CT.\n 4. Mild left hydronephrosis with no left renal calculi seen, as on OSH CT.\n 5. Enlarged uterus.\n\n" }, { "category": "Radiology", "chartdate": "2133-12-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1116596, "text": " 3:37 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for acute path\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with new onset lymphoma\n REASON FOR THIS EXAMINATION:\n eval for acute path\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old woman with new onset of lymphoma. Evaluate for acute\n pathology.\n\n PA AND LATERAL CHEST RADIOGRAPH\n\n COMPARISON: None.\n\n FINDINGS: Lung volumes are low, accentuating interstitial markings. No focal\n consolidations are present. No pneumothorax, or pleural effusions present.\n The cardiac silhouette, hilar, mediastinal contours appear normal.\n\n IMPRESSION: No acute cardiopulmonary process. Low lung volumes.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-12-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1116650, "text": " 12:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: HD line placement\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with need for dialysis\n REASON FOR THIS EXAMINATION:\n HD line placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:43 A.M.\n\n HISTORY: Patient needs dialysis. Check dialysis catheter placement.\n\n IMPRESSION: AP chest compared to earlier on :\n\n Tip of the new right jugular dual-channel hemodialysis catheter projects over\n the mid SVC. No pneumothorax, pleural effusion, or mediastinal widening.\n Lungs clear. Heart size normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-12-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1116939, "text": " 4:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with newly diagnosed non-Hodgkins lymphoma, spontaneous tumor\n lysis, day 2 induction chemo on CVVH\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hodgkin's with spontaneous tumor lysis, on chemotherapy.\n\n FINDINGS: In comparison with study of , there is little overall change.\n Again there are relatively low lung volumes but no evidence of vascular\n congestion or pleural effusion. No acute focal pneumonia. Central catheter\n remains in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-12-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1118037, "text": " 1:06 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: R picc 45cm\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n lymphoma\n REASON FOR THIS EXAMINATION:\n R picc 45cm\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe MON 2:22 PM\n PICC within the distal SVC cavoatrial junction.\n\n This was discussed with IV nursing staff member on date of exam at\n approximately 1:35 p.m.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lymphoma and recent right PICC placement.\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH: Comparison is made to prior exams of\n and . In the interval, a right central venous line\n has been removed and a right PICC placed, terminating in the distal\n SVC/cavoatrial junction. Lung volumes are slightly improved with no focal\n opacity, edema, effusions, or pneumothorax. Cardiomediastinal silhouette is\n stable.\n\n IMPRESSION:\n\n PICC within the distal SVC/cavoatrial junction.\n\n This was discussed with IV nursing staff member on date of exam at\n approximately 1:35 p.m.\n\n" }, { "category": "Radiology", "chartdate": "2133-12-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1118038, "text": ", E. OMED 7F 1:06 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: R picc 45cm\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n lymphoma\n REASON FOR THIS EXAMINATION:\n R picc 45cm\n ______________________________________________________________________________\n PFI REPORT\n PICC within the distal SVC cavoatrial junction.\n\n This was discussed with IV nursing staff member on date of exam at\n approximately 1:35 p.m.\n\n" }, { "category": "Radiology", "chartdate": "2133-12-22 00:00:00.000", "description": "NECK,SOFT TISSUE US", "row_id": 1118281, "text": ", E. OMED 7F 6:36 PM\n NECK,SOFT TISSUE US Clip # \n Reason: hematoma, seroma\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with Burkitt lymphoma s/p Right IJ hemodialysis catheter\n removal with neck swelling\n REASON FOR THIS EXAMINATION:\n hematoma, seroma\n ______________________________________________________________________________\n PFI REPORT\n No evidence of hematoma or seroma.\n\n" }, { "category": "Radiology", "chartdate": "2133-12-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1117154, "text": " 4:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate interval change\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with new dx lymphoma on hemodialysis for tumor lysis\n REASON FOR THIS EXAMINATION:\n evaluate interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lymphoma on hemodialysis, to evaluate for change.\n\n FINDINGS: In comparison with the study of , there is little change.\n Again there are relatively low lung volumes with the cardiac silhouette at the\n upper limits of normal in size. The lungs are clear without vascular\n congestion or pleural effusion.\n\n Central catheter remains in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-12-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1118771, "text": " 12:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM:\n Findings were discussed with Dr. .\n\n\n\n 12:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with Burkitt lymphoma and fever neutropenia\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Lymphoma and neutropenic fever.\n\n Comparison is made with prior study performed on .\n\n Cardiomediastinal contours are normal. There is no pneumothorax or pleural\n effusion. Increased opacity in the right base is new. This could be due to\n lower lung volumes and atelectasis. A developing infection cannot be\n excluded. I recommend PA and lateral views of the chest to confirm or exclude\n the peristent abnormality.\n\n Right PICC catheter tip is in the right atrium.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-12-28 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1119228, "text": " 3:27 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: evaluate for progression of clot\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with recent RUE thrombosis\n REASON FOR THIS EXAMINATION:\n evaluate for progression of clot\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 62-year-old woman with recent right upper extremity\n thrombosis. Evaluate progression of clot.\n\n Comparison made to previous ultrasound dated .\n\n FINDINGS: Symmetrical venous waveforms with respiratory variation are seen in\n both subclavian veins.\n\n The right internal jugular vein, right axillary vein, right cephalic vein, and\n right brachial vein compress completely, and demonstrate adequate flow.\n\n A PICC line is in situ and is seen within the right basilic vein, which is\n completely occluded with thrombus, and so does not compress, and demonstrates\n no flow within it. There is no evidence of progression of clot.\n\n CONCLUSION: Persisting thrombosis within the right basilic vein, however, no\n evidence of progression of thrombosis.\n\n" }, { "category": "Radiology", "chartdate": "2133-12-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1117330, "text": " 4:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with newly diagnosed Burkitt's lymphoma, spontaneous tumor\n lysis on CVVH.\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tumor lysis, to evaluate for change.\n\n FINDINGS: In comparison with the study of , there is little change.\n Again there are relatively low lung volumes with the cardiac silhouette at the\n upper limits of normal in size. No vascular congestion or acute focal\n pneumonia. Central catheter remains in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-12-22 00:00:00.000", "description": "NECK,SOFT TISSUE US", "row_id": 1118280, "text": " 6:36 PM\n NECK,SOFT TISSUE US Clip # \n Reason: hematoma, seroma\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with Burkitt lymphoma s/p Right IJ hemodialysis catheter\n removal with neck swelling\n REASON FOR THIS EXAMINATION:\n hematoma, seroma\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc 7:09 PM\n No evidence of hematoma or seroma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 62-year-old female status post right internal\n jugular hemodialysis catheter removal, now with right-sided neck swelling.\n\n EXAMINATION: Focused ultrasound of the right side of the neck at site of\n abnormality.\n\n FINDINGS: A well-delineated rounded predominantly hypoechoic region,\n measuring less than 5 mm, can be traced to the superficial skin, likely\n reflecting prior right hemodialysis catheter tract site or tiny hematoma. No\n abnormal fluid collections are detected that would be concerning for a\n significant hematoma or seroma. Please note this was not performed as a DVT\n study.\n\n" }, { "category": "Radiology", "chartdate": "2133-12-25 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1118784, "text": " 2:21 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: Thrombosis\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with Burkitt lymphoma, now with RUE swelling\n REASON FOR THIS EXAMINATION:\n Thrombosis\n ______________________________________________________________________________\n WET READ: ENYa 3:18 PM\n Occlusive thrombosis in the R basilic and branchial V (PICC in branchial v).\n Clot does NOT extend to axillary or subclavian V.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old woman, with Burkitt lymphoma, status post PICC line\n placement, now with right upper extremity swelling.\n\n COMPARISON: None.\n\n Grayscale and color son were performed on the right upper extremity. A\n PICC line is noted inserted via the right brachial vein, and continued onto\n the axillary and subclavian veins. There are occlusive thrombi in the right\n brachial and basilic veins. The clots are confined to these two veins. No\n thrombosis is noted in the right subclavian, axillary, or internal jugular\n veins. The right cephalic vein is not well visualized.\n\n IMPRESSION: Occlusive thrombosis in the right brachial and basilic veins.\n Right axillary, subclavian and internal jugular veins remain patent.\n\n" }, { "category": "Radiology", "chartdate": "2133-12-30 00:00:00.000", "description": "CHEST (PA, LAT & OBLIQUES)", "row_id": 1119679, "text": " 9:41 PM\n CHEST (PA, LAT & OBLIQUES) Clip # \n Reason: Evaluate progression of right pleural effusion. Please get\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with Burkitt's lymphoma- on chemotherapy.\n REASON FOR THIS EXAMINATION:\n Evaluate progression of right pleural effusion. Please get PA, lateral and\n right lateral decubitis films.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the progression of the right pleural\n effusion.\n\n PA, lateral, oblique and right and left decubitus were obtained.\n\n Heart size is normal. The mediastinal contours are unchanged. Lungs are\n essentially clear. The pleural effusion better appreciated on the lateral\n view, small to moderate, mainly subpulmonic and also be seen in the decubitus\n projection.\n\n The right PICC line tip appears to be in the right atrium and potentially\n continuing towards the inferior vena cava and should be pulled back for at\n least 4 cm to secure its position in the SVC up to the level of the cavoatrial\n junction. There is no pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2133-12-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1118910, "text": " 1:35 PM\n CHEST (PA & LAT) Clip # \n Reason: PNA\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with Burkitt lymphoma, febrile neutopenia, ? infiltrate on\n portable CXR\n REASON FOR THIS EXAMINATION:\n PNA\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST\n\n HISTORY: Burkitt's lymphoma, febrile neutropenia. Question pneumonia.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Small right pleural effusion may have increased since . Lungs\n clear. Heart size normal. Right PIC line ends in the upper right atrium.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-12-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1118441, "text": " 5:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with Burkitt lymphoma w/ febrile neutropenia\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n WET READ: DLrc WED 9:00 PM\n No change from with no acute cardiopulmonary process and right PICC.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Burkitt lymphoma, febrile neutropenia. Questionable pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Unchanged appearance of the lung parenchyma, no evidence of focal\n parenchymal opacity suggesting pneumonia. Normal size of the cardiac\n silhouette, no evidence of pleural effusions. No hilar or mediastinal\n adenopathies. Unchanged course and position of the pre-placed right-sided\n PICC line.\n\n\n" }, { "category": "Radiology", "chartdate": "2134-01-10 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1121458, "text": " 9:44 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: evaluate line placement\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with Burkitt's lymphoma now s/p line placement.\n REASON FOR THIS EXAMINATION:\n evaluate line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Line placement.\n\n FINDINGS: There has been placement of a left IJ catheter that extends into\n the right atrium and should be pulled back about 4 cm. Lungs are otherwise\n clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2134-01-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1122404, "text": ", E. OMED 7F 11:52 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: HAND NUMBNESS, LYMPHOMA, EVALUATE FOR BLEED/LESION\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with Burkitts Lymphoma with hand numbness\n REASON FOR THIS EXAMINATION:\n please eval for bleed/lesion\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No acute intracranial abnormality or mass effect.\n\n\n" }, { "category": "Radiology", "chartdate": "2134-01-01 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 1119993, "text": " 1:37 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: evaluate for ascites.\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with Burkitt's lymphoma- concerned for ascites. (Patient\n already scheduled for bilateral LENI's today- it would be great to get both\n studies done on one trip, if possible. Thanks).\n REASON FOR THIS EXAMINATION:\n evaluate for ascites.\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 62-year-old woman with Burkitt's lymphoma. Query presence\n of ascites.\n\n TECHNIQUE: Limited abdominal ultrasound.\n FINDINGS: There is no ascites within the abdomen or pelvis. A moderate right\n sided pleural effusion is noted.\n\n CONCLUSION: No ascites seen. Moderate right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2134-01-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1120329, "text": " 12:06 AM\n CHEST (PA & LAT) Clip # \n Reason: line!\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with line\n REASON FOR THIS EXAMINATION:\n line!\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST \n\n COMPARISON: .\n\n INDICATION: Line assessment.\n\n FINDINGS: Right PICC terminates within the mid superior vena cava. Heart\n size is normal, and lungs are clear. Small right pleural effusion is noted.\n\n IMPRESSION:\n 1. Right PICC in standard position.\n\n 2. Small right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2134-01-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1121537, "text": " 1:45 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: evaluate central line placement\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with Burkitt's lymphoma\n REASON FOR THIS EXAMINATION:\n evaluate central line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement.\n\n FINDINGS: The left IJ catheter tip lies in the lower portion of the SVC.\n Needle is projected over the lower right chest, though its position is\n unclear. evidence of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2134-01-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1122403, "text": " 11:52 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: HAND NUMBNESS, LYMPHOMA, EVALUATE FOR BLEED/LESION\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with Burkitts Lymphoma with hand numbness\n REASON FOR THIS EXAMINATION:\n please eval for bleed/lesion\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg SUN 1:11 PM\n No acute intracranial abnormality or mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old female with history of Burkitt's lymphoma presents\n with hand numbness. Evaluate for bleed or lesion.\n\n COMPARISON: No prior study available for comparison.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without IV\n contrast.\n\n FINDINGS: There is no acute intracranial hemorrhage, major vascular territory\n infarction, mass effect, or edema. The -white matter differentiation is\n preserved. Age-appropriate prominence of ventricles and sulci is consistent\n with a mild degree of diffuse parenchymal volume loss. The visualized\n paranasal sinuses and mastoid air cells are well aerated. No osseous\n abnormality is identified. Globes and lenses are intact.\n\n IMPRESSION: No acute intracranial abnormality or evidence of mass effect.\n\n\n" }, { "category": "Radiology", "chartdate": "2134-01-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1119961, "text": " 11:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman s/p thoracentesis\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post thoracocentesis, rule out pneumothorax.\n\n FINDINGS: The radiograph is compared with . _____ status\n post thoracocentesis. No evidence for pneumothorax is present. Unchanged\n course of the right-sided PICC line. No interval appearance of focal\n parenchymal opacities suggesting pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2134-01-11 00:00:00.000", "description": "LP UNILAT UP EXT VEINS US LEFT PORT", "row_id": 1121535, "text": " 12:56 PM\n UNILAT UP EXT VEINS US LEFT PORT Clip # \n Reason: Evaluate for clot\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with leukemia, with recent manipulation of lines in her LUE,\n on chemo now with L>R upper extremity swelling\n REASON FOR THIS EXAMINATION:\n Evaluate for clot\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa MON 2:18 PM\n Slightly limited exam. No definite thrombus within the deep veins of the left\n upper extremity.\n ______________________________________________________________________________\n FINAL REPORT\n LEFT UPPER EXTREMITY VENOUS ULTRASOUND.\n\n COMPARISON: None.\n\n HISTORY: Left upper extremity swelling.\n\n FINDINGS: Exam was slightly limited due to overlying bandage within the neck\n and antecubital fossa. Grayscale and color Doppler son were performed of\n the left internal jugular, subclavian, axillary, basilic and brachial veins.\n These demonstrate normal color flow, compressibility and waveforms.\n Augmentation was not performed. A line within the left internal jugular vein\n was identified. There was no evidence of thrombus. The cephalic vein was not\n visualized.\n\n IMPRESSION: Slightly limited exam. No definite thrombus within the deep\n veins of the left upper extremity.\n\n" }, { "category": "Radiology", "chartdate": "2134-01-11 00:00:00.000", "description": "LP UNILAT UP EXT VEINS US LEFT PORT", "row_id": 1121536, "text": ", E. OMED 7F 12:56 PM\n UNILAT UP EXT VEINS US LEFT PORT Clip # \n Reason: Evaluate for clot\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with leukemia, with recent manipulation of lines in her LUE,\n on chemo now with L>R upper extremity swelling\n REASON FOR THIS EXAMINATION:\n Evaluate for clot\n ______________________________________________________________________________\n PFI REPORT\n Slightly limited exam. No definite thrombus within the deep veins of the left\n upper extremity.\n\n" }, { "category": "Radiology", "chartdate": "2134-01-03 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1120295, "text": " 4:26 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: LYMPHOMA, PAIN, ? IVC CLOT\n Admitting Diagnosis: LYMPHOMA\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with Burkitt's lymphoma now with LUQ abd pain an ivc clot\n REASON FOR THIS EXAMINATION:\n Pls eval for cause of pain an status of ivc clot\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc SUN 5:46 PM\n 1. Decrease in size of retroperitoneal lymphadenopathy with largest in left\n para-aortic region measuring 25 mm x 23 mm.\n 2. Right PICC line terminates in right ventricle, should be withdrawn.\n 3. Small to moderate right pleural effusion.\n 4. Suboptimal IVC evaluation secondary to suboptimal contrast timing, though\n no large IVC thrombus identified.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old female with Burkitt's lymphoma, now with left upper\n quadrant abdominal pain and an IVC clot, evaluate cause of pain as well as\n status of IVC clot.\n\n COMPARISON: , performed at .\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n symphysis pubis with the administration of intravenous contrast, obtained at a\n 180-second delay per CTV protocol. Coronal and sagittal reformations were\n obtained.\n\n CT OF THE CHEST WITH IV CONTRAST: A right-sided PICC terminates within the\n right ventricle. The heart and pericardium are otherwise unremarkable,\n without pericardial effusion. The great vessels are unremarkable. No\n pathologically enlarged mediastinal, hilar, or axillary lymph nodes are\n identified.\n\n There is a new small-to-moderate right-sided pleural effusion, with associated\n atelectasis of the adjacent lung. The lungs are otherwise clear.\n\n There is new skin thickening of the left breast.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The liver, gallbladder, spleen, pancreas,\n adrenal glands, and kidneys are unremarkable.\n\n Mild distal esophageal wall thickening is seen, which may indicate\n inflammation. There are scattered diverticula throughout the colon, without\n evidence of diverticulitis. The appendix is visualized and is normal in\n caliber, without evidence of appendicitis.\n\n Retroperitoneal lymphadenopathy is markedly improved compared to ,\n (Over)\n\n 4:26 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: LYMPHOMA, PAIN, ? IVC CLOT\n Admitting Diagnosis: LYMPHOMA\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n . The largest is within the left paraaortic region measuring 2.6 cm x 2.3\n cm. (Previously, a conglomerate of lymph nodes measured up to 5.0 cm x 5.0\n cm).\n\n The IVC opacifies homogeneously without no evidence of thrombosis.\n\n CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder, rectum and uterus are\n unremarkable. There is a small amount of free fluid within the pelvic\n cul-de-sac measuring about 25 Hounsfield units. Since the amount of fluid is\n small, the apparent intermediate density may be due to volume averaging.\n Lymph nodes along the bilateral iliac chains are also markedly smaller in\n size. A residual left pelvic side wall lymph node (2:95), measures 12 mm x 24\n mm (previously 28 mm x 18 mm). Additionally, there are scattered inguinal\n lymph nodes, the largest within the left inguinal region measuring 24 mm x 14\n mm.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is identified.\n\n IMPRESSION:\n 1. Improved retroperitoneal lymphadenopathy compared to ,\n with the largest lymph node along the left paraaortic region.\n 2. No evidence for venous thrombosis.\n 3. New small-to-moderate right-sided pleural effusion.\n 4. Right PICC terminating within the right ventricle, and should be\n withdrawn.\n 5. Mild distal esophageal wall thickening, which may be inflammatory.newbom\n 6. New left breast skin thickening, clinical correlation suggested.\n 7. Small amount of ascites, apparently of intermediate density, of uncertain\n signifance.\n\n" }, { "category": "Radiology", "chartdate": "2134-01-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1120322, "text": " 8:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: query position\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with reposition of picc line.\n REASON FOR THIS EXAMINATION:\n query position\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: \n\n INDICATION: PICC line.\n\n FINDINGS: PICC terminates just below the expected level of the cavoatrial\n junction. Cardiomediastinal contours are stable in appearance, and lungs\n remain clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2134-01-01 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1119991, "text": " 1:34 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: evaluate for DVTs\n Admitting Diagnosis: LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with Burkitt's lymphoma. On chemotherapy. Developed\n tachycardia. Concern for DVTs\n REASON FOR THIS EXAMINATION:\n evaluate for DVTs\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY VEIN\n\n MEDICAL HISTORY: 62-year-old woman with Burkitt's lymphoma. On chemotherapy.\n Developed tachycardia. Concern for DVT.\n\n FINDINGS: Normal venous waveforms are seen in both common femoral veins, with\n respiratory variation and augmentation. Both common femoral veins,\n superficial femoral veins, and popliteal veins compress completely and augment\n well. Flow is demonstrated within the posterior tibial and peroneal veins\n bilaterally.\n\n Note is made of edema of the soft tissues of the right calf region.\n\n CONCLUSION:\n 1. There is no ultrasound evidence of deep venous thrombosis of the lower\n extremities.\n 2. There is moderate edema of the soft tissues of the right calf region.\n\n" } ]

[ { "category": "ECG", "chartdate": "2125-01-20 00:00:00.000", "description": "Report", "row_id": 147089, "text": "Sinus tachycardia, rate 108. Since the previous tracing of the heart\nrate is faster. Increased ST-T wave abnormalities are seen particularly over\nthe inferior leads.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2125-01-20 00:00:00.000", "description": "Report", "row_id": 147090, "text": "Sinus rhythm, rate 81. Since the previous tracing of no significant\nchanges have occurred.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2125-01-19 00:00:00.000", "description": "Report", "row_id": 147091, "text": "Sinus rhythm, rate 67. Since the previous tracing of no changes have\noccurred.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2125-01-19 00:00:00.000", "description": "Report", "row_id": 147092, "text": "Sinus rhythm, rate 64. Small Q waves are present in the inferior leads.\nNo other abnormalities are seen. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2125-01-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 753395, "text": " 8:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p chest tube removal-R/O PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal-R/O PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n Status post CABG and chest tube removal, rule out pneumothorax.\n\n AP CHEST:\n There are no prior studies for comparison. Sternal wires and surgical clips\n are seen overlying the midchest. External pacing devices are present. No chest\n tube is identified. There is enlargement of the cardiac silhouette. There is\n bilateral lower lobe opaicities, the left being worse than the right. This\n likely reprepsents collapse/consolidation due to either atelectasis or\n aspiration. There is no definite pneumothorax seen. A small pleural effusion\n is present. Osseous structures are within normal limits.\n\n IMPRESSION:\n 1. Status post CABG with cardiomegaly.\n 2. Bilateral lower lobe collapse/consolidation. This may be related to\n atelectasis, also aspiration would have this appearance.\n 3. No definite pneumothorax noted after chest tube removal.\n\n" }, { "category": "Nursing/other", "chartdate": "2125-01-22 00:00:00.000", "description": "Report", "row_id": 1421150, "text": "Neuro: pt awake and alert, communicates needs weel.\nResp: o2 sats 98% on 3lnp. coughs and deep breaths with encouragement.\nChest tubes draining minimal amounts of sang fluid 50cc over 12 hours.\nC/V: heart rate in the 90's no ectopy seen. Neo weaned to off this am cuff pressure 100/50's.\nGI: pt tolerating liquids overnight.\nGU: urine outputs adequate.\nSkin: Incisions clean and dry no drainage Ace wrap reapplied to left leg.\nPain: pt taking 1 Percocet for mild pain at rest. When up to chair this am C/o more pain with movement pt encorarged to take 2 percocet during day with activity.\nPlan: Deline and transfer to floor this am if remains off neo.\n\n" }, { "category": "Nursing/other", "chartdate": "2125-01-22 00:00:00.000", "description": "Report", "row_id": 1421151, "text": "mobility~ambulated with assist of 1~approx 300 feet~slightly tachycardic but bp stable.\n" }, { "category": "Nursing/other", "chartdate": "2125-01-22 00:00:00.000", "description": "Report", "row_id": 1421152, "text": "TRANSFER NOTE~\n\nPT IS A 39 YEAR OLD CANTONESE SPEAKING GENTLEMAN~UNDERSTANDS AND SPEAKS SMALL AMT OF ENGLISGH. PT INTO COMMUNITY CENTER ON WITH C/O CHEST PAIN RADIATING TO L ARM. ADMITTED TO FOR C CATH~ON ~CNC RCA WIRH 100% MID OCCLUSION, STENT X3~ON WITHDRAWAL OF GUIDEWIRE IT BECAMED TRAPPED IN STENT PROXIMAL TO PDA AND COULD BE REMOVED WIRE FRACTURED WITH SEVERAL CM EXTENDING INTO ASCENDING AORTA. PT TO OR FOR EMERGENT CABGX1 AND REMOVAL OF WIRE.\n\nNKDA\n\n CABG X1 SVG TO PDA AND REMOVAL OF WIRE~UNEVENTFUL OR~EXTUBATED WITHOUT INCIDENT. NEO NEEDS REQUIRED EXTRA DAY IN CSRU.\n\nNEURO~ALERT AND ORIENTATED X3~PERCS FOR PAIN. MSO4 4SQ X1 PRIOR TO REMOVAL OF CHEST TUBES. PLEASANT AND COPPERATIVE~ABLE TO VERBALIZE NEEDS IN ENGLISH.\n\nCV~ST WITHOUT ECTOPY. NEO OFF AT 0600~BP STABLE. HCT OF 21.5~NO TRANSFUSION AT THIS TIME. PULSES PALPABLE. 2A/2V~VWIRES WITH INAPPROPRIATE SENSING~A WIRE ON ATRIAL DEMAND.\n\nRESP~LS DIMINSHED AT BASES~PT ENCOURAGE TO COUGH AND DEEP BREATH. CTS D/C'D BY PA. O2 @ 3L WITH STABLE SATS.\n\nGI~+BS TOLERATING PO'S WITHOUT N/V. NO BM TO DATE.\n\nGU~STABLE U/O.\n\nSKIN~STERNAL INCISION WITH STERIS. L LEG WITH ACE.\n\nENDO~SUGARS WNL. ID~FINISHED VANCO DOSING~SPIKE TEMP OVERNOC LAST EVENING~BC~PERIPHERAL/LINE, UA DONE. LOW GRADE TODAY.\n\nPLAN~TRANSFER TO 6 WHEN BED AVAILABLE.\n\n" }, { "category": "Nursing/other", "chartdate": "2125-01-20 00:00:00.000", "description": "Report", "row_id": 1421145, "text": "CSRU ADMISSION NOTE:\n\n39YO CANTONESE SPEAKING MAN PRESENTED TO HEALTH CENTER WITH COMPLAINTS OF CP WITH N/V. REFERRED TO FOR EVAL. EKG'S IN ER WITH NO EVIDENCE OF ISCHEMIA, BUT CK/MB/TROPI +. STARTED ON HEPARIN AND INTEGRELIN AND SENT TO CATH LAB.\n\nPMHX: HYPERLIPIDEMIA\n + HEPATITIS B\n\nALLG: NKDA\n\n: PT HAD COMPLETE HEART CATH WHICH SHOWED 100% OCCLUSION TO MID-RCA. HAD ANGIOJET AND 3 STENTS PLACED. FILLING PRESSURES LOW, TREATED WITH IVF. DID BECOME BRADYCARDIC REQUIRING PACING WIRE- THEN D/C'D. WHILE PLACING 3RD STENT, RCA PUNCTURED WITH GUIDE WIRE. HIWLE REMOVING GUIDE WIRE, WIRE BROKE, LEAVING PIECE BETWEEN RCA AND AORTA. UNSUCCESSFULLY ATTEMPTED TO RETRIEVE. PT BECAME HYPOTENSIVE REQUIRING DOPA GTT. PT THEN BEGAN VOMITING, RIGHT HEART CATH DONE, SHOWING NO OCCLUSIONS. TX TO ICU FOR MONITORING.\n\nON ARRIVAL TO CSRU: PT ALERT AND ORIENTED. FAMILY IN TO SEE PT AND HELPED TO TRANSLATE. PT DOES SPEAK SOME ENGLISH. ABLE TO FOLLOW COMMANDS, MOVING ALL EXTREMITIES.\n\nCV: PT DENIES CP, PALP, SOB. TELE: MP NSR. HR 60-80'S. BP 80-90'S ON 7.5 MCG/KG/MIN OF DOPA. PA PRESSURES LOW, REC'G IVF. HCT STABLE, REC'G 1U PRBC'S. DISTAL PULSES PALPABLE.\n\nRESP: LS CTA. STRONG NPC.\n\nGI: ABD SOFT, NONTENDER. +BS. PT DID HAVE ONE EPISODE OF VOMITING CLEAR EMESIS WITH RESIDENT ATTEMPTING TO PLACE NGT. NGT REMOVED. NO BM.\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE.\n\nINTEG: PT HAS PRESSURE DRSG TO FEM AREA FROM PREVIOUS ART SHEATH. DSD . NO FURTHER BLEEDING.\n\nPLAN: SURGICAL INTERVENTION TO REMOVE GUIDE WIRE IN AM. MONITOR HCT AND TELEMETRY. FAMILY AWARE AND IN AGREEMENT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2125-01-20 00:00:00.000", "description": "Report", "row_id": 1421146, "text": "extubated w/o incident post op. initially labile w brisk huo & low filling pressures.responded well to volume. toradol & mso4 for c/o incisional pain w good relief. sleeping in long naps. plan f6 in a.m.\n" }, { "category": "Nursing/other", "chartdate": "2125-01-20 00:00:00.000", "description": "Report", "row_id": 1421147, "text": "pain well relieved w toradol & percocets.sleeping in long naps. tol. clear liqs. neo started for hypotension w low filling pressures after volume. family in,questions answered. belongings(ring,necklace)given to wife.\n" }, { "category": "Nursing/other", "chartdate": "2125-01-21 00:00:00.000", "description": "Report", "row_id": 1421148, "text": "Neuro: pt awake alert following commands. need to use simple phrases secondary to language barrier.\nresp: o2 sats 98% on 2l np. breath sounds clear. chest tubes patent draining serous sang. drainage small to moderate amouints.\nC/V: heart rate in the 90's. pt requiring neo to maintain map>60. neo up as high as 2mcg/kg/min presently on 1.25. ho aware continue to tirtate neo.\ngi: tolerating clear liquids.\nGU: pt passing large amounts of urine 100-400cc/hr.\nID: Temp spike up to 101.4 treated with tylenol per ho no cultures done.\nPain: good pain relief with Torodol and intermittent percocets.\nPlan: wean off neo and transfer to floor later today or tomorrow when able.\n" }, { "category": "Nursing/other", "chartdate": "2125-01-21 00:00:00.000", "description": "Report", "row_id": 1421149, "text": "NEURO: AWAKE AND ALERT, FALLS OFF TO SLEEP EASILY BUT ALSO EASY TO ROUSE. OOB TO CHAIR WITH HELP, TOLERATED WELL.\nCV: HR SR WITHOUT, ABLE TO WEAN NEO TO 1 M/K/M TO KEEP MAP ^60. SWAN DC'D.\nRESP: C AND RAISING THICK TAN, STRONG COUGH.\nGU: URINE OUTPUT ADEQUATE, CLEAR YELLOW.\nPAIN: MEDICATED X 2 WITH PERCOCET FOR INCISIONAL PAIN. TORADOL GIVEN AS ORDERED.\nENDO: GLUCOSES WITHIN RANGE, NO TX NECESSARY.\nPLAN: CONTINUE TO ATTEMPT TO WEAN NEO, OOB NAD TX TO F6 WHEN OFF PRESSORS.\nFAMILY IN\n" } ]

[ { "category": "ECG", "chartdate": "2173-07-01 00:00:00.000", "description": "Report", "row_id": 300748, "text": "Sinus rhythm. Borderline low limb lead voltage. Compared to the previous\ntracing of no diagnostic interim change.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-07-03 00:00:00.000", "description": "Report", "row_id": 1428827, "text": " 4ICU NPN 0700-1900\nA&O X3. Ambulating around room. Magnesium repleted. VSS, Fentanyl patch 25mcg placed on 1300. Pt discharged to home. He was instructe to follow up with PCP this week. He stated he had an appt with Dr. on .\n" }, { "category": "Nursing/other", "chartdate": "2173-07-02 00:00:00.000", "description": "Report", "row_id": 1428823, "text": "Pt admitted from ew...s/p opiate OD found unresponsive at home. Given Narcan in ew and pt. woke up.Pt stated he used 4 fentanyl patches. None found.\nAdmitted to 4 icu for narcan gtt.\nneuro: awake and alert. Slurred speech c/o bilat leg pain.\nOriented x 3 follows commands. Slept well during the night but easily arousable on narcan gtt.\ncv/resp nsr no ectopy on room air with good o2 sats. clear lung sounds. bp low on admission to icu rx with 2 liters total of ivf bolus's.\ngi/gu c/o wanting to eat. given cookies and juice. foley q.s. uop clear yellow. incont. of loose liquid brown stool during his sleep. Fully bathed and mushroom cath placed.\ninteg. skin warm and dry. no rashes or broken areas.\nPlan. ? wean narcan gtt this am. If he tolerates this, c/o to floor.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-07-02 00:00:00.000", "description": "Report", "row_id": 1428824, "text": " 4 ICU NPN 0700-1900\nCalled out to the floor. Nsg transfer note done. Updated prior to transfer.\nNarcan gtt d/c'd at 1030. Dozing this afternoon. Easily arousable. Oriented.\nNo S&SX of ETOH or narcotic withdrawl.\nMagnesoim sulfate repleted.\nAppitite adequate.\nA/P: Stable\nCont to assess MS, withdrawl\n" }, { "category": "Nursing/other", "chartdate": "2173-07-03 00:00:00.000", "description": "Report", "row_id": 1428825, "text": "Nursing Assessment Note 1900-0700\nNEURO: Pt A&O x3, pleasant and cooperative, pt denies any SI at this time and does contract for safety, PERL, pt moves all extremities well without deficit, pt also denies headache or dizziness\n\nCV: Pt's vss, afebrile, pt denies pain at this time, Pt has #18 in left arm, which is patent and intact, skin is pale, warm, and dry, pp + & =, with trace edema, pt in nsr without ectopy,\n\nRESP: Pt's lung sounds are clear, but diminished in bases, pt denies cough or sob at this time, pt on R/A with sats 96-97%,\n\nGI: Pt tol po intake well without N/V, bowel sounds are positive, with soft abd, pt's iv fluids were heplocked as pt taking adequate po\n\nGU: Pt's foley draining clear yellow urine qs\n\nPLAN: Awaiting bed on floors at this time\n" }, { "category": "Nursing/other", "chartdate": "2173-07-03 00:00:00.000", "description": "Report", "row_id": 1428826, "text": "Addendum Note\nPt's am magnesium level was 1.4, repleated with 4 grams magnesium sulfate iv in 250 cc's NS, pt found standing at bedside trying to put his shorts on, pt verbalized feeling \"closed in\" and needed to put boxer shorts on, pt reminded to use call bell to get assistance with ambulating as it is a safety issue, pt verbalized understanding of importance of using call bell for assistance\n" } ]

[ { "category": "Radiology", "chartdate": "2157-07-29 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 966556, "text": " 3:18 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n bleed?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DBH FRI 4:28 PM\n No evidence of fracture or intracranial bleed. Left frontal scalp hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST.\n\n HISTORY: Status post fall. Question hemorrhage.\n\n Contiguous axial images were obtained through the brain. No contrast was\n administered. No prior brain imaging studies are available for comparison.\n\n FINDINGS: There is a left frontal scalp hematoma. There is no evidence of\n intracranial hemorrhage. No fractures are identified. There is no evidence\n of edema or mass effect.\n\n CONCLUSION: Left frontal scalp hematoma. Otherwise, normal study.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-07-29 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 966557, "text": " 3:18 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DBH FRI 4:42 PM\n No evidence of fracture or subluxation\n ______________________________________________________________________________\n FINAL REPORT\n CT CERVICAL SPINE \n\n HISTORY: Status post fall.\n\n Contiguous axial images were obtained through the cervical spine. No contrast\n was administered. No prior spine imaging studies are available for\n comparison.\n\n FINDINGS: Alignment of the cervical spine is normal. No fractures are\n identified. There is no evidence of prevertebral soft tissue swelling.\n Non-contrast CT has limited sensitivity for intraspinal soft tissue\n abnormalities such as disc protrusion or hematoma. Within the limits of this\n examination, no such abnormalities are detected. However, if this is a\n clinical concern, an MR examination would be required.\n\n CONCLUSION: Normal study. No evidence of fracture or subluxation.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-07-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 966554, "text": " 3:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Trauma.\n\n COMPARISON: There are no prior studies for comparison. The CT torso\n performed at the same time is reviewed.\n\n SUPINE AP CHEST: A trauma board obscures detail. The cardiac and mediastinal\n contours are within the range of normal for this supine patient. There are\n low lung volumes, though the lungs are clear. No pneumothorax is apparent. No\n fractures are appreciated.\n\n IMPRESSION: No evidence of acute traumatic injury of the chest.\n\n" }, { "category": "Radiology", "chartdate": "2157-07-29 00:00:00.000", "description": "L WRIST(3 + VIEWS) LEFT", "row_id": 966564, "text": " 4:00 PM\n WRIST(3 + VIEWS) LEFT; HAND (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n fracture\n ______________________________________________________________________________\n WET READ: PJHf FRI 4:46 PM\n Non-displaced intra-articular distal radius fracture. Fracture dislocation of\n the third PIP joint.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fall. Fracture.\n\n Six radiographs of the left hand and wrist are submitted.\n\n There is a nondisplaced intra-articular fracture involving the distal radius.\n There is 1 mm of positive ulnar variance. There are zero degrees of dorsal\n angulation of the articular surface of the distal radius. Mineralization is\n normal. Intercarpal spaces are unremarkable. The ulnar styloid is intact.\n There is ulnar dislocation of the base of the middle phalanx of the third\n digit relative to the head of the proximal phalanx of the third digit. There\n is an associated intra-articular fracture of the base of the middle phalanx of\n the third digit. There is swelling of the overlying soft tissues.\n\n IMPRESSION: Fracture dislocation of the third PIP joint.\n\n Nondisplaced intra-articular distal radius fracture.\n\n These findings were entered into the ED dashboard on at 4:45 p.m.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2157-07-30 00:00:00.000", "description": "Report", "row_id": 1667941, "text": "Nursing Admission Note 7p-7a\n Pt is a 27y/o roofer who fell from roof yesterday approx 25-30feet landing on left side in ground. He had no LOC, just abrasions on left side of head and left shoulder anterior chest area. Pt brought to our EW where head CT was negative and spine was cleared by CT however scans did reveal a grade III renal lac and grade II spleenic lac, x-ray showed displaced fx of third finger of left hand and nondisplaced fx of distal radius on left arm. Pt transferred to TSICU for q 4hr hct checks.\n Pt has no PMHx and is on no meds. No cigarettes/etoh, and \nPt is from Guatamala, has lived here six years, he is primarily Spanish speaking yet does speak some English.\n\nCurrent ROS\n\n pt alert and oriented, appropriate throughout the shift, follows commands to MAE's w/ good strengthes in all extremities as allowed by injuries ( left arm fx's slightly limiting). Pt oriented to person, place and event/date. C/O pain in left side slightly below his rib cage and lateral. also sore in left hand /wrist area. Pt medicated w/ 1mg dilaudid every 1-2 hours w/ good effect.\n\n pt in SR w/ rate 80-90 no ectopy, BP very stable at 115-125/55-65, easily palpable pulses in all extremities, all extremities warm and dry. Monitoring Hct every four hours, thus far values have been from 36.7, to 34.0, to 32.2 with repeat level pending for 6am. IVF of LR at 125cc's hr.\n\n pt on 2 liters NC w/ RR 16-20 nonlabored. Breath sounds clear bilaterally, pt does note increased pain w/ deep breath yet able to incentive spirometer from 500-600cc's. O2 sats from 97-100%, no cough noted.\n\nGI- abd firm yet not distended, bowel sounds hypoactive, Pt started on protonix IV. NGT w/ minimal aspirates so d/c's at midnight per Gold team. Pt c/o nausea once prior to d/c of NGT and med w/ 4mg zofran w/ good results.\n\n pt w/ u/o from 40-70cc's hr, clear yellow urine.\n\nID- t max 99.6, pt on no abx's at this time.\n\nEndo- Blood sugars from 154 to 134 covered per sliding scale.\n\n pt is a roofer, says he has never had an accident in six years of working here. Lives on / line w/ his wife and their one year old son, pt also has brother and in the area.\n\nSkin- abrasions on left face and head area as well as across left shoulder and anterior trunk. Backside intact.\n\nA/P- con't to monitor hemodynamics closely, follow hcts q four hours as ordered, 6am one pnd. ? advance diet to clear liqs as tolerated. Con't w/ pulmonary hygeine and ? possible transfer to floor later in day if hct remains stable.\n" }, { "category": "ECG", "chartdate": "2157-07-30 00:00:00.000", "description": "Report", "row_id": 228536, "text": "Sinus rhythm. Otherwise, within normal limits. No previous tracings for\ncomparison.\n\n" }, { "category": "Radiology", "chartdate": "2157-07-29 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 966558, "text": " 3:19 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: acute process\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ARHb FRI 4:22 PM\n Multiple left renal lacerations, grade III, without evidence of active\n extravasation. Multiple inferior pole splenic lacerations, likely Grade II.\n Possible proximal left ureteral injury though no extravasation of ureteral\n contents. Fluid and debris filled stomach.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27-year-old man status post fall.\n\n COMPARISON: None.\n\n TECHNIQUE: Contrast-enhanced axial images of the chest, abdomen and pelvis\n are obtained with multiplanar reformatted images.\n\n CT CHEST WITH CONTRAST: The heart and great vessels are unremarkable without\n evidence of traumatic injury. There is no evidence of pericardial or pleural\n effusion. The lung windows reveal no pneumothorax or evidence of pulmonary\n contusion. Bilateral dependant opacity likely represents atelectasis. A tiny\n calcified left perifissural nodule (2:20) likely represents sequelae of old\n granulomatous disease.\n\n CT ABDOMEN WITH CONTRAST: The liver, gallbladder, pancreas, adrenal glands,\n and right kidney appear unremarkable and demonstrate no evidence of traumatic\n injury. The left kidney demonstrates multiple lacerations, some of which\n extend to the hilum with a perirenal hematoma which extends along the proximal\n ureter. The remainder of the left kidney demonstrates normal perfusion. There\n is no evidence of traumatic injury to the ureter. The spleen demonstrates\n several lacerations inferiorly also without evidence of active extravasation.\n The stomach is filled with fluid and debris. Intra- abdominal loops of large\n and small bowel are unremarkable and there is no evidence of free air or\n pathologically enlarged mesenteric or retroperitoneal lymph nodes. The\n abdominal aorta is of normal caliber throughout and there is no evidence of an\n acute aortic injury.\n\n CT PELVIS WITH CONTRAST: The rectum, sigmoid colon, prostate, seminal\n vesicles, distal ureters and bladder are unremarkable. No pelvic free fluid\n or pathologically enlarged lymph nodes are identified.\n\n Bone windows reveal no fractures. No worrisome lytic or sclerotic lesions are\n identified.\n\n (Over)\n\n 3:19 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: acute process\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Grade III left renal laceration with surrounding hematoma and no evidence\n of active arterial extravasation.\n\n 2. Multiple inferior splenic lacerations, grade II.\n\n" }, { "category": "Radiology", "chartdate": "2157-07-30 00:00:00.000", "description": "L HAND (AP, LAT & OBLIQUE) LEFT", "row_id": 966656, "text": " 10:46 AM\n HAND (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: s/p reduction 3rd PIP dislocation; assess reduction\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man s/p fall\n\n REASON FOR THIS EXAMINATION:\n s/p reduction 3rd PIP dislocation; assess reduction\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Left hand.\n\n DATE: .\n\n CLINICAL HISTORY: 27-year-old man status post fall, post reduction of third\n PIP dislocation. Assess reduction.\n\n Comparison made to prior study dated .\n\n FINDINGS: PA, lateral and oblique views of the left hand were obtained. There\n has been interval reduction of a dislocated third left PIP joint, with good\n anatomic alignment. Evaluation is somewhat limited secondary to the presence\n of a splint which overlies the region of interest. An osseous fragment is at\n the lateral, volar aspect of the third PIP joint.\n\n IMPRESSION: Post reduction of third left PIP joint dislocation with near\n anatomic alignment. Small fracture fragment at lateral, volar aspect of the\n joint.\n\n" } ]

[ { "category": "Echo", "chartdate": "2163-05-06 00:00:00.000", "description": "Report", "row_id": 104563, "text": "PATIENT/TEST INFORMATION:\nIndication: EVALUATE CHF,PULMONARY HT\nHeight: (in) 69\nWeight (lb): 220\nBSA (m2): 2.15 m2\nBP (mm Hg): 112/79\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 14:37\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler. Normal IVC diameter (<=2.1cm) with <50%\ndecrease with sniff (estimated RA pressure (5-10 mmHg).\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. No VSD.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\nAbnormal septal motion/position.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No MS.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No TS. TR present - cannot\nbe quantified. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. The estimated right atrial pressure is 5-10 mmHg. Left\nventricular wall thickness, cavity size, and global systolic function are\nnormal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. There is no ventricular septal defect.\nThe right ventricular cavity is mildly dilated with normal free wall\ncontractility. There is abnormal septal motion/position. The diameters of\naorta at the sinus, ascending and arch levels are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic stenosis or aortic regurgitation. The mitral valve appears structurally\nnormal with trivial mitral regurgitation. There is no mitral valve prolapse.\nTricuspid regurgitation is present but cannot be quantified. There is moderate\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-06 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1235815, "text": " 11:12 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: ?PNA, other pulmonary process\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with hypoxia, possible PNA versus vasculitis\n REASON FOR THIS EXAMINATION:\n ?PNA, other pulmonary process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n COMPUTED TOMOGRAPHY OF THE THORAX\n\n INDICATION: Hypoxia, possible pneumonia, evaluation for abnormalities.\n\n COMPARISON: No comparison available at the time of dictation.\n\n TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,\n no administration of intravenous contrast material, multiplanar\n reconstructions.\n\n FINDINGS: No incidental thyroid findings.\n\n Multiple borderline size or slightly enlarged lymph nodes in the\n supraclavicular region bilaterally, in both axillary regions as well as in\n virtually all mediastinal compartments.\n\n The large mediastinal vessels are unremarkable, there is no evidence of\n substantial coronary calcifications.\n\n No pericardial effusion. Small hiatal hernia.\n\n Extensive bilateral pleural effusions.\n\n No visible abnormalities in the upper abdomen, moderate degenerative spine\n disease but no evidence of osteodestructive lesions.\n\n The lung parenchyma shows an overall increase in attenuation. There is a\n thickening of the interlobular septa, notably in the left upper lobe (4, 64)\n and at the right lung base (4, 159).\n\n The lung parenchyma overall shows extensive and bilateral combination of\n ground-glass opacities (4, 62), widespread parenchymal opacities (4, 77), and\n consolidations (4, 154). Whereas the consolidations are seen in the dependent\n lung regions, both ground-glass opacity and focal parenchymal opacities, while\n predominating in the right upper lobe, are relatively widespread and show no\n particular distribution pattern.\n\n There is no evidence of cavitations. Also, the airways are patent and there\n is no evidence of intrabronchial lesions.\n\n No other lung parenchymal changes.\n (Over)\n\n 11:12 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: ?PNA, other pulmonary process\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION: Extensive bilateral, predominantly right lung parenchymal\n changes, consisting of ground-glass opacities, parenchymal opacities and\n consolidations. The changes are accompanied by signs of predominantly\n interstitial fluid overload, as reflected by bilateral pleural effusions and\n thickening of the interlobular septa. Finally there is generalized\n mediastinal and extrathoracic lymphadenopathy.\n\n Overall, the morphological findings are nonspecific, although the absence of\n cavitary lesions would be indicative of an extensive infectious process rather\n than for vasculitis. Neither of the two diagnoses, however, can be excluded\n on the basis of the imaging findings alone.\n\n No airway wall lesions. No indications for osteolytic lesions, mild\n degenerative spinal changes.\n\n If bronchoscopy is intended, the right upper lobe would be a good target\n region,.\n\n" }, { "category": "Radiology", "chartdate": "2163-05-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1236124, "text": " 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with severe multifocal PNA\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Multifocal pneumonia. Comparison is made with prior study\n .\n\n Cardiac size is normal. Extensive multifocal bilateral consolidations\n consistent with multifocal pneumonia have minimally improved. Small bilateral\n pleural effusions are probably unchanged allowing the difference in\n positioning of the patient. There is no evident pneumothorax. Right PICC is\n in standard position. There are no new lung abnormalities.\n\n The component of pulmonary edema has almost resolved.\n\n" }, { "category": "Radiology", "chartdate": "2163-05-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1236031, "text": " 3:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with ?pneumonia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia, to assess for change.\n\n FINDINGS: In comparison with the study of , there is slightly improved\n aeration in the right upper zone. Indeed, the diffuse opacification\n bilaterally is generally slightly less prominent than on the previous study.\n The overall appearance again is consistent with some combination of severe\n pulmonary edema and multifocal pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1236210, "text": " 2:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with pneumonia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pneumonia, evaluation for interval change.\n\n COMPARISON: , 3:02 a.m.\n\n FINDINGS: As compared to the previous radiograph, there is improvement of the\n pre-existing predominantly right upper lobe pneumonia. The opacity\n preexistent in the left upper lobe is also slightly improved. Unchanged small\n pleural effusions, left more than right, unchanged moderate cardiomegaly with\n retrocardiac atelectasis.\n\n\n" }, { "category": "ECG", "chartdate": "2163-05-11 00:00:00.000", "description": "Report", "row_id": 305974, "text": "Sinus rhythm with slowing of the rate as compared with previous tracing\nof . The axis is more leftward. Otherwise, no diagnostic interim\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2163-05-06 00:00:00.000", "description": "Report", "row_id": 305975, "text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2163-05-08 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1236059, "text": " 10:01 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Pt. had a right sided picc line placed,44cm and needs tip co\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with PICC.\n REASON FOR THIS EXAMINATION:\n Pt. had a right sided picc line placed,44cm and needs tip confirmation please\n page at \n ______________________________________________________________________________\n WET READ: EHAb SUN 11:43 AM\n picc tip projects at approximate level of cavoatrial junction. discussed with\n by phone at 11:40 am on .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a right subclavian PICC line that projects to about the level of\n the cavoatrial junction. This information was discussed with the IV nurse,\n by the resident on call.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1235940, "text": " 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Worsening edema or effusions?\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with multifocal pneumonia and pulmonary edema with worsening\n hypoxia.\n REASON FOR THIS EXAMINATION:\n Worsening edema or effusions?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 49-year-old woman with multifocal pneumonia and pulmonary\n edema. Worsening hypoxia.\n\n FINDINGS: Comparison is made to prior study from .\n\n There is no interval change. There are again seen bilateral pleural effusions\n and extensive bilateral airspace opacities consistent with pulmonary edema or\n multifocal pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1235749, "text": " 2:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evidence of pneumonia?\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with ?pneumonia transferred from OSH\n REASON FOR THIS EXAMINATION:\n evidence of pneumonia?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: To look for any evidence of pneumonia.\n\n TECHNIQUE: Portable semi-erect chest view was reviewed in comparison with\n prior chest radiograph from . Concurrently, a chest CT from\n , done outside was reviewed.\n\n FINDINGS: Asymmetrically distributed confluent opacities (right side more\n than left side) have worsened over last 24 hours . On concurrent review of\n prior chest CT dated , lungs were clear and these opacities\n developed over short interval between and . Bilateral\n pleural effusions are small and stable. Heart size is normal. Mediastinal\n and hilar contours are unremarkable.\n\n IMPRESSION: Given the rapid appearance of the bilateral confluent lung\n opacities between and and worsening over last 24 hours\n reflects pulmonary edema. However, concurrently associated infection remains a\n possibility .\n\n" } ]

[ { "category": "Nursing", "chartdate": "2192-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505386, "text": "43yo female with a history of recurrent stage IIIC adenocarcinoma of\n the ovary , presented yesterday with GI bleed.\n She had received oral topotecan in yesterday in a.m.,\n She had her blood counts checked and her hematocrit returned at 21.1\n from 28.2 on . She was treated with topotecan. She noted\n darker stool over the last 24-36 hours, which she attributed to\n spinach. She went to work after the chemotherapy and had another bowel\n movement that was described as \"sticky.\" It was a small formed stool,\n dark/black in color with red/maroon streaks. She discussed this\n development with her oncologist and was referred to the ED.\n In the ED, vitals were 125/73 95 18 99% 2L. She was given 1 liter\n normal saline and 10 units of regular insulin and admitted to the OMED\n team. Transferred to 11R and was seen by the GI and surgery consult\n teams. Received 1 unit of blood in floor.\n Brought to ICU for close monitoring.\n" }, { "category": "Physician ", "chartdate": "2192-12-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 505488, "text": "TITLE: Resident Progress Note\n Chief Complaint: GI Bleed\n 24 Hour Events:\n Given 3 units blood overnight\n No complaints other than hunger this morning.\n Allergies:\n Penicillins\n Unspecified \n Iodine\n Anaphylaxis;\n Platinum Complexes\n Rash;\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.2\nC (99\n HR: 83 (83 - 107) bpm\n BP: 133/83(95) {99/64(74) - 133/83(95)} mmHg\n RR: 20 (17 - 26) insp/min\n SpO2: 99%\n Total In:\n 637 mL\n 1,505 mL\n PO:\n TF:\n IVF:\n 75 mL\n 1,155 mL\n Blood products:\n 212 mL\n 351 mL\n Total out:\n 0 mL\n 1,425 mL\n Urine:\n 1,425 mL\n NG:\n Stool:\n Drains:\n Balance:\n 637 mL\n 80 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Cardiovascular: RRR w/o mrg\n Respiratory / Chest: CTAB\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: No peripheral edema, warm, well-perfused\n Labs / Radiology\n 451 K/uL\n 9.3 g/dL\n 28.7 %\n 8.2 K/uL\n [image002.jpg]\n Labs pending\n 01:01 AM\n 06:09 AM\n WBC\n 8.2\n Hct\n 22.7\n 28.7\n Plt\n 451\n Other labs: PT / PTT / INR:12.5/22.2/1.1, Differential-Neuts:82.8 %,\n Lymph:13.1 %, Mono:3.5 %, Eos:0.5 %\n Hct trend\n 7am 21.1\n 5pm 20.3\n 1am after 2 units: 22.7\n 6am after 3 units total: 28.7\n Assessment and Plan\n 43 year old female with a history of recurrent stage IIIC\n adenocarcinoma of the ovary who presents with a GI bleed.\n # GI bleed: Hemodynamically stable overnight, was transfused 3 units\n with appropriate Hct bump. Concerning CT finding of pelvic mass likely\n invading the small bowel\n - Maintain 2 large bore PIVs\n - maintain type and screen\n - blood transfusions as necessary to goal Hct of 28\n - Likely EGD this am, and if negative, will need colonoscopy (if that\n unrevealing, needs capsule study)\n - Appreciate GI and surgery recs\n - If instability develops, will plan for tagged red cell/angiography\n - Continue IV PPI for now\n - Maintain NPO status\n - Trend q6h Hct\n # DM: Continue lantus and SSI. need to adjust as NPO. Follow BG\n closely.\n # Recurrent ovarian cancer: C1D1 Topotecan given today.\n - PRN antiemetics\n - Oncologist aware of admission\n # Hypothyroidism: Home levothyroxine\n # High cholesterol: Holding tricor and crestor for now. Can resume once\n bleeding stabilized\n ICU Care\n Nutrition: NPO, replete lytes PRN\n Glycemic Control:\n Lines:\n 18 Gauge - 10:10 PM\n 20 Gauge - 10:10 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer:\n VAP:\n Comments: control with tylenol/percocet\n Communication: Comments:\n Code status: Full code\n Disposition: ICU pending GI workup, then can likely be called out to\n OMED\n" }, { "category": "Nursing", "chartdate": "2192-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505657, "text": "r43yo female with a history of recurrent stage IIIC adenocarcinoma of\n the ovary , presented yesterday with GI bleed.\n She had received oral topotecan in yesterday in a.m.,\n She had her blood counts checked and her hematocrit returned at 21.1\n from 28.2 on . She was treated with topotecan. She noted\n darker stool over the last 24-36 hours, which she attributed to\n spinach. She went to work after the chemotherapy and had another bowel\n movement that was described as \"sticky.\" It was a small formed stool,\n dark/black in color with red/maroon streaks. She discussed this\n development with her oncologist and was referred to the ED.\n In the ED, vitals were 125/73 95 18 99% 2L. She was given 1 liter\n normal saline and 10 units of regular insulin and admitted to the OMED\n team. Transferred to 11R and was seen by the GI and surgery consult\n teams. She received 1 unit of blood on the floor. Brought to ICU for\n close monitoring\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt A/Ox3, very pleasant. One unit of blood was given yesterday for crit\n of 26.7. Post transfusion , was 32.1.\n A.M. crit is 30.1.\n Pt had an endoscopy done yesterday to r/o upper GIB. No active signs\n of bleeding noted. Ambulating to commode independently without any\n difficulty.\n Action:\n Pt currently being prepared with golytely for colonoscopy today via\n her colostomy. She is able to prepare herself only little at a time.\n Response:\n Brown liquid stools with effect from golytely. Stools yet to clear.\n Plan:\n For colonoscopy today. Follow up with hematocrit levels.\n" }, { "category": "Nursing", "chartdate": "2192-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505375, "text": "Ms. is a 43yo female with a history of recurrent stage IIIC\n adenocarcinoma of the ovary who presented today with a GI bleed. She\n arrived to 9 today for C1D1 of oral topotecan. She was recently\n transitioned off gemcitabine when a CT scan demonstrated and interval\n increased size of left pelvic mass, which invaded the pelvic sidewall\n and likely the small bowel. She was feeling well today, except for a\n report of fatigue, most specifically when walking.\n She had her blood counts checked and her hematocrit returned at 21.1\n from 28.2 on . She was treated with topotecan. She noted\n darker stool over the last 24-36 hours, which she attributed to\n spinach. She went to work after the chemotherapy and had another bowel\n movement that was described as \"sticky.\" It was a small formed stool,\n dark/black in color with red/maroon streaks. She discussed this\n development with her oncologist and was referred to the ED.\n In the ED, vitals were 125/73 95 18 99% 2L. She was given 1 liter\n normal saline and 10 units of regular insulin and admitted to the OMED\n team. On the floor, she did well. She was seen by the GI and surgery\n consult teams. She was transfused 1 unit of blood. The surgical team\n felt the patient should be monitored in the ICU overnight and she was\n transferred.\n This evening, she has no specific complaints. She has noted the onset\n of some chemotherapy side effects, which is typical for her. She\n denies headache, orthostasis, vision changes, mouth sores, chest pain,\n palpitations, shortness of breath, abdominal pain, nausea, vomiting,\n further ostomy output, rectal bleeding, joint pain or rash.\n" }, { "category": "Nursing", "chartdate": "2192-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505381, "text": "43yo female with a history of recurrent stage IIIC adenocarcinoma of\n the ovary , presented yesterday with GI bleed.\n She had received oral topotecan in yesterday in a.m.,\n She had her blood counts checked and her hematocrit returned at 21.1\n from 28.2 on . She was treated with topotecan. She noted\n darker stool over the last 24-36 hours, which she attributed to\n spinach. She went to work after the chemotherapy and had another bowel\n movement that was described as \"sticky.\" It was a small formed stool,\n dark/black in color with red/maroon streaks. She discussed this\n development with her oncologist and was referred to the ED.\n In the ED, vitals were 125/73 95 18 99% 2L. She was given 1 liter\n normal saline and 10 units of regular insulin and admitted to the OMED\n team. On the floor, she did well. She was seen by the GI and surgery\n consult teams. She was transfused 1 unit of blood. The surgical team\n felt the patient should be monitored in the ICU overnight and she was\n transferred.\n This evening, she has no specific complaints. She has noted the onset\n of some chemotherapy side effects, which is typical for her. She\n denies headache, orthostasis, vision changes, mouth sores, chest pain,\n palpitations, shortness of breath, abdominal pain, nausea, vomiting,\n further ostomy output, rectal bleeding, joint pain or rash.\n" }, { "category": "Nursing", "chartdate": "2192-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505391, "text": "43yo female with a history of recurrent stage IIIC adenocarcinoma of\n the ovary , presented yesterday with GI bleed.\n She had received oral topotecan in yesterday in a.m.,\n She had her blood counts checked and her hematocrit returned at 21.1\n from 28.2 on . She was treated with topotecan. She noted\n darker stool over the last 24-36 hours, which she attributed to\n spinach. She went to work after the chemotherapy and had another bowel\n movement that was described as \"sticky.\" It was a small formed stool,\n dark/black in color with red/maroon streaks. She discussed this\n development with her oncologist and was referred to the ED.\n In the ED, vitals were 125/73 95 18 99% 2L. She was given 1 liter\n normal saline and 10 units of regular insulin and admitted to the OMED\n team. Transferred to 11R and was seen by the GI and surgery consult\n teams. Received 1 unit of blood in floor.\n Brought to ICU for close monitoring.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt A/O x3 very pleasant. Afebrile, Tmax 99.1 oral. No output from\n colostomy bag since admission to ICU. Pt had received 1unit blood in\n floor. Voiding wnl. Abdomen soft with +BS, passing flatus. Vital signs\n stable.\n Action:\n 1unit PRBC given , Crit checked: 22.7. One more unit blood given. IVF\n at 150cc/hr.\n Pt kept NPO for endoscopy and possible colonoscopy today.\n Response:\n No visible bleed noted, although no improvement in crit noted despite\n multiple transfusions.\n Plan:\n Endoscopy today, if does not reveal source of bleed, will consider\n Colonoscopy. Follow up with serial crits.\n" }, { "category": "Physician ", "chartdate": "2192-12-15 00:00:00.000", "description": "Intensivist Note", "row_id": 505483, "text": "TITLE: Weekend Intensivist 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 Overnight, 3U PRBC, hemodynamically stable. Labs as below.\n Tm99.1 P80-90 BP 100-130s/80s sat\ning on RA.\n I/O 1500/1425 today\n Labs Hct 20->22 after 2U, 28 after additional PRBC.\n Chemistries pending.\n A/P:\n 43 y/o with ovarian cancer on chemotherapy and history of colonic\n perforation resulting in colostomy, presenting with GI bleed. Concern\n for bleeds from metastatic malignancy.\n - Appreciate GI and surgery input - plan for EGD this AM and\n colonoscopy if this is negative\n - Serial Hcts, follow u/o, VS\n - Continue PPI\n - 2 lg bore Ivs\n - If remains stable, consider call out to OMed\n Patient is critically ill\n Total time: 30 min\n" }, { "category": "Physician ", "chartdate": "2192-12-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 505440, "text": "TITLE: Resident Progress Note\n Chief Complaint: GI Bleed\n 24 Hour Events:\n Given 3 units blood\n Allergies:\n Penicillins\n Unspecified \n Iodine\n Anaphylaxis;\n Platinum Complexes\n Rash;\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.2\nC (99\n HR: 83 (83 - 107) bpm\n BP: 133/83(95) {99/64(74) - 133/83(95)} mmHg\n RR: 20 (17 - 26) insp/min\n SpO2: 99%\n Total In:\n 637 mL\n 1,505 mL\n PO:\n TF:\n IVF:\n 75 mL\n 1,155 mL\n Blood products:\n 212 mL\n 351 mL\n Total out:\n 0 mL\n 1,425 mL\n Urine:\n 1,425 mL\n NG:\n Stool:\n Drains:\n Balance:\n 637 mL\n 80 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Cardiovascular: RRR w/o mrg\n Respiratory / Chest: CTAB\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: No peripheral edema, warm, well-perfused\n Labs / Radiology\n 451 K/uL\n 9.3 g/dL\n 28.7 %\n 8.2 K/uL\n [image002.jpg]\n 01:01 AM\n 06:09 AM\n WBC\n 8.2\n Hct\n 22.7\n 28.7\n Plt\n 451\n Other labs: PT / PTT / INR:12.5/22.2/1.1, Differential-Neuts:82.8 %,\n Lymph:13.1 %, Mono:3.5 %, Eos:0.5 %\n Hct trend\n 7am 21.1\n 5pm 20.3\n 1am after 2 units: 22.7\n 6am after 3 units total: 28.7\n Assessment and Plan\n 43 year old female with a history of recurrent stage IIIC\n adenocarcinoma of the ovary who presents with a GI bleed.\n # GI bleed: Hemodynamically stable overnight, was transfused 3 units\n with appropriate Hct bump. Concerning CT finding of pelvic mass likely\n invading the small bowel\n - Maintain 2 large bore PIVs\n - maintain type and screen\n - blood transfusions as necessary to goal Hct of 28\n - Likely EGD this am, and if negative, will need colonoscopy (if that\n unrevealing, needs capsule study)\n - Appreciate GI and surgery recs\n - If instability develops, will plan for tagged red cell/angiography\n - Continue IV PPI for now\n - Maintain NPO status\n - Trend q6h Hct\n # DM: Continue lantus and SSI. need to adjust as NPO. Follow BG\n closely.\n # Recurrent ovarian cancer: C1D1 Topotecan given today.\n - PRN antiemetics\n - Oncologist aware of admission\n # Hypothyroidism: Home levothyroxine\n # High cholesterol: Holding tricor and crestor for now. Can resume once\n bleeding stabilized\n ICU Care\n Nutrition: NPO, replete lytes PRN\n Glycemic Control:\n Lines:\n 18 Gauge - 10:10 PM\n 20 Gauge - 10:10 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer:\n VAP:\n Comments: control with tylenol/percocet\n Communication: Comments:\n Code status: Full code\n Disposition: ICU pending GI workup, then can likely be called out to\n OMED\n" }, { "category": "Physician ", "chartdate": "2192-12-15 00:00:00.000", "description": "Intensivist Note", "row_id": 505460, "text": "TITLE: Weekend Intensivist 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 Overnight, 3U PRBC, hemodynamically stable. Labs as below.\n Tm99.1 P80-90 BP 100-130s/80s sat\ning on RA.\n I/O 1500/1425 today\n Labs Hct 20->22 after 2U, 28 after additional PRBC.\n Chemistries pending.\n A/P:\n 43 y/o with ovarian cancer on chemotherapy and history of colonic\n perforation resulting in colostomy, presenting with GI bleed. Concern\n for bleeds from metastatic malignancy.\n - Appreciate GI and surgery input - plan for EGD this AM and\n colonoscopy if this is negative\n - Serial Hcts, follow u/o, VS\n - Continue PPI\n - 2 lg bore Ivs\n - If remains stable, consider call out to OMed\n Patient is critically ill\n Total time: 30 min\n" }, { "category": "Nursing", "chartdate": "2192-12-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 505754, "text": "Very pleasant 43yo female with a history of recurrent stage IIIC\n adenocarcinoma of the ovary, s/p bowel resection/colostomy for\n sigmoid colon perf. Presented with GI bleed.\n Recent ct scan showed probable mass invading small bowel. She will most\n likely need more debulking surgery this admit. Pt is aware.\n She received a total of 4u PRBCs, the last one being yesterday. EGD\n showed no\n bleeding. She received 4L Go lytely last night for colonoscopy today\n but is not clear. Given 1 bottle of mag citrate this a.m. 1000 Hct\n remains stable. Stools remain brown.\n Plan for colonscopy tomorrow. Per GI team, pt may have cl liqs today\n and resume mag citrate prep this evening until stools yellow green in\n color.\n She is A&O x3. Ambulates independently. Her colostomy bag is currently\n hooked up to urine drainage bag.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n LOWER GI BLEED\n Code status:\n Height:\n Admission weight:\n 74.5 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unspecified \n Iodine\n Anaphylaxis;\n Platinum Complexes\n Rash;\n Aspirin\n Unknown;\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: Hypothyroidism.\n Clear cell ovarian cancer.\n S/P debulking surgery and hysterectomy and bilateral\n salphingoopherectomy, appendectomy, omentectomy , Sigmoid colon\n perforation and colon resection and colonostomy on .\n Surgery / Procedure and date: S/P debulking surgery and hysterectomy\n and bilateral salphingoopherectomy, appendectomy, omentectomy ,\n Sigmoid colon perforation and colon resection and colonostomy on\n .\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:128\n D:78\n Temperature:\n 99.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 103 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 2,760 mL\n 24h total out:\n 3,475 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 03:59 AM\n Potassium:\n 4.3 mEq/L\n 03:59 AM\n Chloride:\n 100 mEq/L\n 03:59 AM\n CO2:\n 27 mEq/L\n 03:59 AM\n BUN:\n 10 mg/dL\n 03:59 AM\n Creatinine:\n 0.7 mg/dL\n 03:59 AM\n Glucose:\n 113 mg/dL\n 03:59 AM\n Hematocrit:\n 29.6 %\n 09:45 AM\n Finger Stick Glucose:\n 129\n 06:00 AM\n Valuables / Signature\n Patient valuables: at bedside\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 EAST\n Transferred to: 1164R\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2192-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505424, "text": "43yo female with a history of recurrent stage IIIC adenocarcinoma of\n the ovary , presented yesterday with GI bleed.\n She had received oral topotecan in yesterday in a.m.,\n She had her blood counts checked and her hematocrit returned at 21.1\n from 28.2 on . She was treated with topotecan. She noted\n darker stool over the last 24-36 hours, which she attributed to\n spinach. She went to work after the chemotherapy and had another bowel\n movement that was described as \"sticky.\" It was a small formed stool,\n dark/black in color with red/maroon streaks. She discussed this\n development with her oncologist and was referred to the ED.\n In the ED, vitals were 125/73 95 18 99% 2L. She was given 1 liter\n normal saline and 10 units of regular insulin and admitted to the OMED\n team. Transferred to 11R and was seen by the GI and surgery consult\n teams. Received 1 unit of blood in floor.\n Brought to ICU for close monitoring.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt A/O x3 very pleasant. Afebrile, Tmax 99.1 oral. No output from\n colostomy bag since admission to ICU. Pt had received 1unit blood in\n floor. Voiding wnl. Abdomen soft with +BS, passing flatus. Vital signs\n stable.\n Action:\n 1unit PRBC given , Crit checked: 22.7. One more unit blood given. IVF\n at 150cc/hr.\n Pt kept NPO for endoscopy and possible colonoscopy today.\n Response:\n No visible bleed noted, although no improvement in crit noted despite\n multiple transfusions.\n Plan:\n Endoscopy today, if does not reveal source of bleed, will consider\n Colonoscopy. Follow up with serial crits.\n" }, { "category": "Nursing", "chartdate": "2192-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505559, "text": "r43yo female with a history of recurrent stage IIIC adenocarcinoma of\n the ovary , presented yesterday with GI bleed.\n She had received oral topotecan in yesterday in a.m.,\n She had her blood counts checked and her hematocrit returned at 21.1\n from 28.2 on . She was treated with topotecan. She noted\n darker stool over the last 24-36 hours, which she attributed to\n spinach. She went to work after the chemotherapy and had another bowel\n movement that was described as \"sticky.\" It was a small formed stool,\n dark/black in color with red/maroon streaks. She discussed this\n development with her oncologist and was referred to the ED.\n In the ED, vitals were 125/73 95 18 99% 2L. She was given 1 liter\n normal saline and 10 units of regular insulin and admitted to the OMED\n team. Transferred to 11R and was seen by the GI and surgery consult\n teams. She received 1 unit of blood on the floor. Brought to ICU for\n close monitoring\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient remains alert and oriented x3 with no active signs of bleeding\n during this shift.\n Action:\n She did have a two point Hct drop to 26.7 and was transfused with one\n unit of PRBC. She will need a repeat Hct draw at the end of\n transfusion, which is currently in progress. She was seen by\n gastroenterology today and had an endoscopy done with no signs of\n bleeding. Her exam was negative. She has been allowed clear fluids this\n evening as she was extremely hungry.\n Response:\n Patient had great concern with hunger prior to and after her procedure.\n She tolerated the procedure without any difficulty. During the\n procedure she did have 6mg versed and 100mcg of fentanyl to achieve\n conscious sedation. She did require 2l of O2 during the procedure. Post\n procedure she has been able to ambulate to the commode with supervision\n and no difficulty on rising and using the commode. Tolerating her\n clears well and there still has been no signs of active bleeding.\n Plan:\n For colonoscopy tomorrow through her stoma, patient is aware and to\n start her golytely tonight.\n" }, { "category": "Physician ", "chartdate": "2192-12-16 00:00:00.000", "description": "Intensivist Note", "row_id": 505747, "text": "TITLE: Intensivist\n Weekend\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 by\n Dr. , including the assessment and plan. I would emphasize\n and add the following points:\n Events notable for EGD negative, Hct 28-> 24, transfused additional\n PRBC 32.1 -> 30.1\n Golytely prep still with formed stool, now getting citrate prep.\n VS T37 P89 BP 118/70 R19 Sat 97%\n I/O 5L/2.4L\n Exam with slight tenderness LLQ, unchanged.\n Labs reviewed.\n Discussed the plan with GI team and surgery. Will give another day for\n better prep and plan for colonoscopy tomorrow. Most likely etiology of\n bleed is tumor invasion of small bowel, which will need resection for\n definitive treatment, and meantime will continue to slowly ooze.\n Here has been hemodynamically stable; requiring 1U PRBC in the last 24\n hours. Unless further signs of instability will plan to call out to\n the floor team\n on tele, maintain 2 PIV access, clot in BB.\n Remainder of plan per ICU team.\n" }, { "category": "Physician ", "chartdate": "2192-12-16 00:00:00.000", "description": "Intensivist Note", "row_id": 505727, "text": "TITLE: Intensivist\n Weekend\n EGD negative\n Hct 28-> 24, transfused additional PRBC 32.1 -> 30.1\n Golytely prep still with formed stool, now getting citrate prep\n VS T 37 P89 BP 118/70 R19 Sat 97%\n I/O 5L/2.4L\n Exam with slight tenderness LLQ, unchanged.\n Plan for colonoscopy today; if negative, capsule study.\n Hemodynamically stable, following Hcts Q8.\n Remainder of plan per ICU team.\n" }, { "category": "Physician ", "chartdate": "2192-12-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 505730, "text": "Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 02:00 PM\n - EGD showed no bleeding; will do bowel prep and scope from ostomy in\n AM. If neg, plan for tagged rbc scan\n - transfused 1 U PRBCs in PM, Hct 26.7 -> 32.1 -> 30.1\n - doing golytely prep for colonoscopy overnight, given Mag Citrate this\n AM because not clear after initial prep.\n Allergies:\n Penicillins\n Unspecified \n Iodine\n Anaphylaxis;\n Platinum Complexes\n Rash;\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 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: 36.3\nC (97.4\n HR: 89 (78 - 105) bpm\n BP: 118/70(82) {97/53(64) - 154/85(116)} mmHg\n RR: 19 (14 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,045 mL\n 2,400 mL\n PO:\n 1,440 mL\n 2,400 mL\n TF:\n IVF:\n 2,905 mL\n Blood products:\n 701 mL\n Total out:\n 4,125 mL\n 1,750 mL\n Urine:\n 4,125 mL\n 1,150 mL\n NG:\n Stool:\n 600 mL\n Drains:\n Balance:\n 920 mL\n 650 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: Well nourished, No acute distress, sitting\n comfortably in bed\n Cardiovascular: RRR, S1, S2, w/o mrg\n Respiratory / Chest: CTAB\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: No peripheral edema, warm, well-perfused\n Labs / Radiology\n 394 K/uL\n 9.9 g/dL\n 113 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 10 mg/dL\n 100 mEq/L\n 136 mEq/L\n 30.1 %\n 8.2 K/uL\n [image002.jpg]\n 01:01 AM\n 06:09 AM\n 12:32 PM\n 08:07 PM\n 03:59 AM\n WBC\n 8.2\n 8.2\n Hct\n 22.7\n 28.7\n 26.7\n 32.1\n 30.1\n Plt\n 451\n 394\n Cr\n 0.7\n 0.7\n Glucose\n 124\n 113\n Other labs: PT / PTT / INR:12.5/22.2/1.1, ALT / AST:, Alk Phos / T\n Bili:112/1.2, Differential-Neuts:82.8 %, Lymph:13.1 %, Mono:3.5 %,\n Eos:0.5 %, Ca++:9.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.6 mg/dL\n No micro pend\n No imaging pend\n Assessment and Plan\n 43 year old female with a history of recurrent stage IIIC\n adenocarcinoma of the ovary who presents with a GI bleed.\n # GI bleed: Hemodynamically stable, was transfused 4 units total with\n Hct stabilized overnight. Concerning CT finding of pelvic mass likely\n invading the small bowel\n - Maintain 2 large bore PIVs\n - maintain type and screen\n - blood transfusions as necessary to goal Hct of 28\n - Plan for colonoscopy this AM (if that unrevealing, needs capsule\n study and/or tagged rbc scan)\n - Appreciate GI and surgery recs\n - Continue IV PPI for now\n - Maintain NPO status\n - Trend q8h Hct -> next draw at noon\n # DM: Continue lantus and SSI. need to adjust as NPO. Follow BG\n closely.\n # Recurrent ovarian cancer: C1D1 Topotecan given .\n - PRN antiemetics\n - Oncologist aware of admission\n # Hypothyroidism: Home levothyroxine\n # High cholesterol: Holding tricor and crestor for now. Can resume once\n bleeding stabilized\n ICU Care\n Nutrition: Clear liquids for now during bowel prep\n Glycemic Control: Lantus and insulin SS\n Lines:\n 18 Gauge - 10:10 PM\n 20 Gauge - 10:10 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: IV PPI \n VAP:\n Comments:\n Communication: Comments: Patient\n Code status: Full, confirmed with patient\n Disposition: ICU for now\n" }, { "category": "Physician ", "chartdate": "2192-12-16 00:00:00.000", "description": "Intensivist Note", "row_id": 505731, "text": "TITLE: Intensivist\n Weekend\n EGD negative\n Hct 28-> 24, transfused additional PRBC 32.1 -> 30.1\n Golytely prep still with formed stool, now getting citrate prep\n VS T 37 P89 BP 118/70 R19 Sat 97%\n I/O 5L/2.4L\n Exam with slight tenderness LLQ, unchanged.\n Plan for colonoscopy today; if negative, capsule study.\n Hemodynamically stable, following Hcts Q8.\n Remainder of plan per ICU team.\n" }, { "category": "Physician ", "chartdate": "2192-12-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 505708, "text": "Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 02:00 PM\n - EGD showed no bleeding; will do bowel prep and scope from ostomy in\n AM. If neg, plan for tagged rbc scan\n - transfused 1 U PRBCs in PM, Hct 26.7 -> 32.1 -> 30.1\n - doing golytely prep for colonoscopy overnight, given Mag Citrate this\n AM because not clear after initial prep.\n Allergies:\n Penicillins\n Unspecified \n Iodine\n Anaphylaxis;\n Platinum Complexes\n Rash;\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 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: 36.3\nC (97.4\n HR: 89 (78 - 105) bpm\n BP: 118/70(82) {97/53(64) - 154/85(116)} mmHg\n RR: 19 (14 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,045 mL\n 2,400 mL\n PO:\n 1,440 mL\n 2,400 mL\n TF:\n IVF:\n 2,905 mL\n Blood products:\n 701 mL\n Total out:\n 4,125 mL\n 1,750 mL\n Urine:\n 4,125 mL\n 1,150 mL\n NG:\n Stool:\n 600 mL\n Drains:\n Balance:\n 920 mL\n 650 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 394 K/uL\n 9.9 g/dL\n 113 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 10 mg/dL\n 100 mEq/L\n 136 mEq/L\n 30.1 %\n 8.2 K/uL\n [image002.jpg]\n 01:01 AM\n 06:09 AM\n 12:32 PM\n 08:07 PM\n 03:59 AM\n WBC\n 8.2\n 8.2\n Hct\n 22.7\n 28.7\n 26.7\n 32.1\n 30.1\n Plt\n 451\n 394\n Cr\n 0.7\n 0.7\n Glucose\n 124\n 113\n Other labs: PT / PTT / INR:12.5/22.2/1.1, ALT / AST:, Alk Phos / T\n Bili:112/1.2, Differential-Neuts:82.8 %, Lymph:13.1 %, Mono:3.5 %,\n Eos:0.5 %, Ca++:9.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.6 mg/dL\n No micro pend\n No imaging pend\n Assessment and Plan\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:10 PM\n 20 Gauge - 10:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2192-12-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 505709, "text": "Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 02:00 PM\n - EGD showed no bleeding; will do bowel prep and scope from ostomy in\n AM. If neg, plan for tagged rbc scan\n - transfused 1 U PRBCs in PM, Hct 26.7 -> 32.1 -> 30.1\n - doing golytely prep for colonoscopy overnight, given Mag Citrate this\n AM because not clear after initial prep.\n Allergies:\n Penicillins\n Unspecified \n Iodine\n Anaphylaxis;\n Platinum Complexes\n Rash;\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 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: 36.3\nC (97.4\n HR: 89 (78 - 105) bpm\n BP: 118/70(82) {97/53(64) - 154/85(116)} mmHg\n RR: 19 (14 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,045 mL\n 2,400 mL\n PO:\n 1,440 mL\n 2,400 mL\n TF:\n IVF:\n 2,905 mL\n Blood products:\n 701 mL\n Total out:\n 4,125 mL\n 1,750 mL\n Urine:\n 4,125 mL\n 1,150 mL\n NG:\n Stool:\n 600 mL\n Drains:\n Balance:\n 920 mL\n 650 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 394 K/uL\n 9.9 g/dL\n 113 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 10 mg/dL\n 100 mEq/L\n 136 mEq/L\n 30.1 %\n 8.2 K/uL\n [image002.jpg]\n 01:01 AM\n 06:09 AM\n 12:32 PM\n 08:07 PM\n 03:59 AM\n WBC\n 8.2\n 8.2\n Hct\n 22.7\n 28.7\n 26.7\n 32.1\n 30.1\n Plt\n 451\n 394\n Cr\n 0.7\n 0.7\n Glucose\n 124\n 113\n Other labs: PT / PTT / INR:12.5/22.2/1.1, ALT / AST:, Alk Phos / T\n Bili:112/1.2, Differential-Neuts:82.8 %, Lymph:13.1 %, Mono:3.5 %,\n Eos:0.5 %, Ca++:9.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.6 mg/dL\n No micro pend\n No imaging pend\n Assessment and Plan\n 43 year old female with a history of recurrent stage IIIC\n adenocarcinoma of the ovary who presents with a GI bleed.\n # GI bleed: Hemodynamically stable overnight, was transfused 4 units\n total with Hct stabilized overnight. Concerning CT finding of pelvic\n mass likely invading the small bowel\n - Maintain 2 large bore PIVs\n - maintain type and screen\n - blood transfusions as necessary to goal Hct of 28\n - Plan for colonoscopy this AM(if that unrevealing, needs capsule study\n and/or tagged rbc scan)\n - Appreciate GI and surgery recs\n - Continue IV PPI for now\n - Maintain NPO status\n - Trend q6h Hct\n # DM: Continue lantus and SSI. need to adjust as NPO. Follow BG\n closely.\n # Recurrent ovarian cancer: C1D1 Topotecan given today.\n - PRN antiemetics\n - Oncologist aware of admission\n # Hypothyroidism: Home levothyroxine\n # High cholesterol: Holding tricor and crestor for now. Can resume once\n bleeding stabilized\n ICU Care\n Nutrition: Clear liquids\n Glycemic Control: Lantus and insulin SS\n Lines:\n 18 Gauge - 10:10 PM\n 20 Gauge - 10:10 PM\n Prophylaxis:\n DVT: Pt ambulatory\n Stress ulcer: IV PPI \n VAP:\n Comments:\n Communication: Comments: Patient\n Code status: Full, confirmed with patient\n Disposition: ICU for now\n" }, { "category": "Nursing", "chartdate": "2192-12-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 505737, "text": "Very pleasant 43yo female with a history of recurrent stage IIIC\n adenocarcinoma of the ovary, s/p bowel resection/colostomy for\n sigmoid colon perf. Presented with GI bleed.\n Recent ct scan showed probable mass invading small bowel. She will most\n likely need more debulking surgery this admit. Pt is aware.\n She received a total of 4u PRBCs, the last one being yesterday. EGD\n showed no bleeding. She received 4L Go lytely last night for\n colonoscopy today but is not clear. Given 1 bottle of mag citrate this\n a.m. 1000 Hct remains stable. Stools remain brown.\n Plan for colonscopy tomorrow. Per GI team, pt may have cl liqs today\n and resume prep this evening until stools yellow green in color.\n She is A&O x3. Ambulates independently. Her colostomy bag is currently\n hooked up to urine drainage bag.\n" }, { "category": "Physician ", "chartdate": "2192-12-15 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 505349, "text": "Chief Complaint: GI Bleed\n HPI:\n Ms. is a 43yo female with a history of recurrent stage IIIC\n adenocarcinoma of the ovary who presented today with a GI bleed. She\n arrived to 9 today for C1D1 of oral topotecan. She was recently\n transitioned off gemcitabine when a CT scan demonstrated and interval\n increased size of left pelvic mass, which invaded the pelvic sidewall\n and likely the small bowel. She was feeling well today, except for a\n report of fatigue, most specifically when walking.\n She had her blood counts checked and her hematocrit returned at 21.1\n from 28.2 on . She was treated with topotecan. She noted\n darker stool over the last 24-36 hours, which she attributed to\n spinach. She went to work after the chemotherapy and had another bowel\n movement that was described as \"sticky.\" It was a small formed stool,\n dark/black in color with red/maroon streaks. She discussed this\n development with her oncologist and was referred to the ED.\n In the ED, vitals were 125/73 95 18 99% 2L. She was given 1 liter\n normal saline and 10 units of regular insulin and admitted to the OMED\n team. On the floor, she did well. She was seen by the GI and surgery\n consult teams. She was transfused 1 unit of blood. The surgical team\n felt the patient should be monitored in the ICU overnight and she was\n transferred.\n This evening, she has no specific complaints. She has noted the onset\n of some chemotherapy side effects, which is typical for her. She\n denies headache, orthostasis, vision changes, mouth sores, chest pain,\n palpitations, shortness of breath, abdominal pain, nausea, vomiting,\n further ostomy output, rectal bleeding, joint pain or rash.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Penicillins\n Unspecified \n Iodine\n Anaphylaxis;\n Platinum Complexes\n Rash;\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n Tricor 145mg daily\n Lantus 80U daily\n Humalog sliding scale\n Levothyroxine 100 mcg daily\n Lorazepam 0.25-0.5mg qhs PRN insomnia\n Prochlorperazine Maleate 10mg po q8 PRN nausea\n Crestor 40mg daily\n Tylenol PRN\n Past medical history:\n Family history:\n Social History:\n Oncologic history (taken from recent oncology notes)\n is 43 yo woman with advanced ovarian ca. She is s/p debulking\n surgery and hysterectomy and bilateral salpingo-oopherectomy. She\n received iv and intraperitoneal chemotherapy as part of her adjuvant\n chemotherapy ending in 7. She was enrolled in study getting\n oral AZD2171 until . She resumed tx with single \n as of ; but had reaction with dose 6/08. Started doxil .\n Had evidence of disease progression so tx changed to Alimta on \n till . Tx changed to Weekly taxol with Avastin on . Due to\n neuropathy from taxol; tx changed to weekly taxotere on . She\n had sigmoid colon perforation and had colon ressection and colonostomy\n on . She has been slow to heal and resumed chemo with gemzar on\n . Tx changed to Topotecan on .\n Past Medical History:\n Diabetes\n Hypothyroidism\n HTN (improved- no meds since )\n Clear cell ovarian Cancer\n s/p TAH-BSO, appendectomy, omentectomy \n s/p sigmoid resection \n Many women on mother's side with cancers including lung, colon,\n gastric, ovarian.\n Occupation: works for TV station\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: Fatigue\n Flowsheet Data as of 11:10 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 89 () bpm\n BP: 106/54\n RR: 18 ()\n SpO2: 98\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 164.1 lbs kg (admission): 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: None\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: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 466\n 6.4\n 0.8\n 12\n 23\n 96\n 4.7\n 133\n 20.3\n 11.1\n [image002.jpg]\n Other labs: PT / PTT / INR:10.8/20.6/0.9, ALT / AST:, Alk Phos / T\n Bili:109/0.3, Differential-Neuts:78.1, Lymph:17.9, Mono:2.8, Eos:0.8,\n Fibrinogen:700, LDH:188, Ca++:9.5, Mg++:2.3, PO4:3.3\n Imaging: 1. Interval increased size of left pelvic mass, which invades\n the pelvic\n sidewall and likely the small bowel.\n 2. Stable left-sided hydroureteronephrosis due to obstruction of the\n ureter\n from this mass.\n Assessment and Plan\n ASSESSMENT AND PLAN: 43yo female with a history of recurrent stage IIIC\n adenocarcinoma of the ovary who presents with a GI bleed.\n # GI bleed: hemodynamically stable. Receiving 2nd unit of prbc now.\n Will recheck HCT following this transfusion. Has 2 peripheral IVs.\n Concerning CT finding of pelvic mass likely invading the small bowel.\n Appreciate surgery and GI recommendations. GI will plan for EGD in am\n in ICU. Following serial hematocrits and will have type/cross for 6\n units ready per surgical recommendations. If instability develops,\n will plan for tagged red cell/angiography. Continue IV PPI for now.\n # DM: continue lantus and SSI. need to adjust as NPO. Follow BG\n closely.\n # Recurrent ovarian cancer: C1D1 Topotecan given today. Prn\n antiemetics.\n # Hypothyroidism: home levothyroxine\n # High cholesterol: holding tricor and crestor for now. Can resume once\n bleeding stabilized\n # FEN: NPO, replete lytes PRN\n # PPx: Pain control with tylenol/percocet, pneumoboots\n # Comm: With patient\n # Code: FULL (confirmed with pt)\n ICU \n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Comments: Lantus\n Lines:\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" }, { "category": "Physician ", "chartdate": "2192-12-15 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 505351, "text": "Chief Complaint: GI Bleed\n HPI:\n Ms. is a 43yo female with a history of recurrent stage IIIC\n adenocarcinoma of the ovary who presented today with a GI bleed. She\n arrived to 9 today for C1D1 of oral topotecan. She was recently\n transitioned off gemcitabine when a CT scan demonstrated and interval\n increased size of left pelvic mass, which invaded the pelvic sidewall\n and likely the small bowel. She was feeling well today, except for a\n report of fatigue, most specifically when walking.\n She had her blood counts checked and her hematocrit returned at 21.1\n from 28.2 on . She was treated with topotecan. She noted\n darker stool over the last 24-36 hours, which she attributed to\n spinach. She went to work after the chemotherapy and had another bowel\n movement that was described as \"sticky.\" It was a small formed stool,\n dark/black in color with red/maroon streaks. She discussed this\n development with her oncologist and was referred to the ED.\n In the ED, vitals were 125/73 95 18 99% 2L. She was given 1 liter\n normal saline and 10 units of regular insulin and admitted to the OMED\n team. On the floor, she did well. She was seen by the GI and surgery\n consult teams. She was transfused 1 unit of blood. The surgical team\n felt the patient should be monitored in the ICU overnight and she was\n transferred.\n This evening, she has no specific complaints. She has noted the onset\n of some chemotherapy side effects, which is typical for her. She\n denies headache, orthostasis, vision changes, mouth sores, chest pain,\n palpitations, shortness of breath, abdominal pain, nausea, vomiting,\n further ostomy output, rectal bleeding, joint pain or rash.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Penicillins\n Unspecified \n Iodine\n Anaphylaxis;\n Platinum Complexes\n Rash;\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n Tricor 145mg daily\n Lantus 80U daily\n Humalog sliding scale\n Levothyroxine 100 mcg daily\n Lorazepam 0.25-0.5mg qhs PRN insomnia\n Prochlorperazine Maleate 10mg po q8 PRN nausea\n Crestor 40mg daily\n Tylenol PRN\n Past medical history:\n Family history:\n Social History:\n Oncologic history (taken from recent oncology notes)\n is 43 yo woman with advanced ovarian ca. She is s/p debulking\n surgery and hysterectomy and bilateral salpingo-oopherectomy. She\n received iv and intraperitoneal chemotherapy as part of her adjuvant\n chemotherapy ending in 7. She was enrolled in study getting\n oral AZD2171 until . She resumed tx with single \n as of ; but had reaction with dose 6/08. Started doxil .\n Had evidence of disease progression so tx changed to Alimta on \n till . Tx changed to Weekly taxol with Avastin on . Due to\n neuropathy from taxol; tx changed to weekly taxotere on . She\n had sigmoid colon perforation and had colon ressection and colonostomy\n on . She has been slow to heal and resumed chemo with gemzar on\n . Tx changed to Topotecan on .\n Past Medical History:\n Diabetes\n Hypothyroidism\n HTN (improved- no meds since )\n Clear cell ovarian Cancer\n s/p TAH-BSO, appendectomy, omentectomy \n s/p sigmoid resection \n Many women on mother's side with cancers including lung, colon,\n gastric, ovarian.\n Occupation: works for TV station\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: Fatigue\n Flowsheet Data as of 11:10 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 89 () bpm\n BP: 106/54\n RR: 18 ()\n SpO2: 98\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 164.1 lbs kg (admission): 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: None\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: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 466\n 6.4\n 0.8\n 12\n 23\n 96\n 4.7\n 133\n 20.3\n 11.1\n [image002.jpg]\n Other labs: PT / PTT / INR:10.8/20.6/0.9, ALT / AST:, Alk Phos / T\n Bili:109/0.3, Differential-Neuts:78.1, Lymph:17.9, Mono:2.8, Eos:0.8,\n Fibrinogen:700, LDH:188, Ca++:9.5, Mg++:2.3, PO4:3.3\n Imaging: 1. Interval increased size of left pelvic mass, which invades\n the pelvic\n sidewall and likely the small bowel.\n 2. Stable left-sided hydroureteronephrosis due to obstruction of the\n ureter\n from this mass.\n Assessment and Plan\n ASSESSMENT AND PLAN: 43yo female with a history of recurrent stage IIIC\n adenocarcinoma of the ovary who presents with a GI bleed.\n # GI bleed: hemodynamically stable. Receiving 2nd unit of prbc now.\n Will recheck HCT following this transfusion. Has 2 peripheral IVs.\n Concerning CT finding of pelvic mass likely invading the small bowel.\n Appreciate surgery and GI recommendations. GI will plan for EGD in am\n in ICU. Following serial hematocrits and will have type/cross for 6\n units ready per surgical recommendations. If instability develops,\n will plan for tagged red cell/angiography. Continue IV PPI for now.\n # DM: continue lantus and SSI. need to adjust as NPO. Follow BG\n closely.\n # Recurrent ovarian cancer: C1D1 Topotecan given today. Prn\n antiemetics.\n # Hypothyroidism: home levothyroxine\n # High cholesterol: holding tricor and crestor for now. Can resume once\n bleeding stabilized\n # FEN: NPO, replete lytes PRN\n # PPx: Pain control with tylenol/percocet, pneumoboots\n # Comm: With patient\n # Code: FULL (confirmed with pt)\n ICU \n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Comments: Lantus\n Lines:\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 ------ Protected Section ------\n Patient seen and examined with Dr.. 43 year-old woman with\n ovarian cancer and history of colonic perforation requiring colostomy\n presents with GI bleeding. HCT 28 to 21. CT reveals a pelvic mass\n that may be invading small bowel.\n Has received 2units PRBC. Hemodynamically stable\n 98.5 106/54 89 98% RA\n PLAN:\n 1. GI endoscopy in AM\n 2. Surgical service aware of patient and new radiographic\n findings\n 3. IV PPI\n 4. Serial HCT\n 5. ------ Protected Section Addendum Entered By: ,\n MD on: 00:38 ------\n 6.\n 7.\n 8. Electronically signed by , MD 00:38\n 9.\n 10.\n" }, { "category": "Physician ", "chartdate": "2192-12-14 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 505344, "text": "Chief Complaint: GI Bleed\n HPI:\n Ms. is a 43yo female with a history of recurrent stage IIIC\n adenocarcinoma of the ovary who presented today with a GI bleed. She\n arrived to 9 today for C1D1 of oral topotecan. She was recently\n transitioned off gemcitabine when a CT scan demonstrated and interval\n increased size of left pelvic mass, which invaded the pelvic sidewall\n and likely the small bowel. She was feeling well today, except for a\n report of fatigue, most specifically when walking.\n She had her blood counts checked and her hematocrit returned at 21.1\n from 28.2 on . She was treated with topotecan. She noted\n darker stool over the last 24-36 hours, which she attributed to\n spinach. She went to work after the chemotherapy and had another bowel\n movement that was described as \"sticky.\" It was a small formed stool,\n dark/black in color with red/maroon streaks. She discussed this\n development with her oncologist and was referred to the ED.\n In the ED, vitals were 125/73 95 18 99% 2L. She was given 1 liter\n normal saline and 10 units of regular insulin and admitted to the OMED\n team. On the floor, she did well. She was seen by the GI and surgery\n consult teams. She was transfused 1 unit of blood. The surgical team\n felt the patient should be monitored in the ICU overnight and she was\n transferred.\n This evening, she has no specific complaints. She has noted the onset\n of some chemotherapy side effects, which is typical for her. She\n denies headache, orthostasis, vision changes, mouth sores, chest pain,\n palpitations, shortness of breath, abdominal pain, nausea, vomiting,\n further ostomy output, rectal bleeding, joint pain or rash.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Penicillins\n Unspecified \n Iodine\n Anaphylaxis;\n Platinum Complexes\n Rash;\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n Tricor 145mg daily\n Lantus 80U daily\n Humalog sliding scale\n Levothyroxine 100 mcg daily\n Lorazepam 0.25-0.5mg qhs PRN insomnia\n Prochlorperazine Maleate 10mg po q8 PRN nausea\n Crestor 40mg daily\n Tylenol PRN\n Past medical history:\n Family history:\n Social History:\n Oncologic history (taken from recent oncology notes)\n is 43 yo woman with advanced ovarian ca. She is s/p debulking\n surgery and hysterectomy and bilateral salpingo-oopherectomy. She\n received iv and intraperitoneal chemotherapy as part of her adjuvant\n chemotherapy ending in 7. She was enrolled in study getting\n oral AZD2171 until . She resumed tx with single \n as of ; but had reaction with dose 6/08. Started doxil .\n Had evidence of disease progression so tx changed to Alimta on \n till . Tx changed to Weekly taxol with Avastin on . Due to\n neuropathy from taxol; tx changed to weekly taxotere on . She\n had sigmoid colon perforation and had colon ressection and colonostomy\n on . She has been slow to heal and resumed chemo with gemzar on\n . Tx changed to Topotecan on .\n Past Medical History:\n Diabetes\n Hypothyroidism\n HTN (improved- no meds since )\n Clear cell ovarian Cancer\n s/p TAH-BSO, appendectomy, omentectomy \n s/p sigmoid resection \n Many women on mother's side with cancers including lung, colon,\n gastric, ovarian.\n Occupation: works for TV station\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: Fatigue\n Flowsheet Data as of 11:10 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 89 () bpm\n BP: 106/54\n RR: 18 ()\n SpO2: 98\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 164.1 lbs kg (admission): 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: None\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: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 466\n 6.4\n 0.8\n 12\n 23\n 96\n 4.7\n 133\n 20.3\n 11.1\n [image002.jpg]\n Other labs: PT / PTT / INR:10.8/20.6/0.9, ALT / AST:, Alk Phos / T\n Bili:109/0.3, Differential-Neuts:78.1, Lymph:17.9, Mono:2.8, Eos:0.8,\n Fibrinogen:700, LDH:188, Ca++:9.5, Mg++:2.3, PO4:3.3\n Imaging: 1. Interval increased size of left pelvic mass, which invades\n the pelvic\n sidewall and likely the small bowel.\n 2. Stable left-sided hydroureteronephrosis due to obstruction of the\n ureter\n from this mass.\n Assessment and Plan\n ASSESSMENT AND PLAN: 43yo female with a history of recurrent stage IIIC\n adenocarcinoma of the ovary who presents with a GI bleed.\n # GI bleed: hemodynamically stable. Receiving 2nd unit of prbc now.\n Will recheck HCT following this transfusion. Has 2 peripheral IVs.\n Concerning CT finding of pelvic mass likely invading the small bowel.\n Appreciate surgery and GI recommendations. GI will plan for EGD in am\n in ICU. Following serial hematocrits and will have type/cross for 6\n units ready per surgical recommendations. If instability develops,\n will plan for tagged red cell/angiography. Continue IV PPI for now.\n # DM: continue lantus and SSI. need to adjust as NPO. Follow BG\n closely.\n # Recurrent ovarian cancer: C1D1 Topotecan given today. Prn\n antiemetics.\n # Hypothyroidism: Continue home levothyroxine.\n # FEN: NPO, replete lytes PRN\n # PPx: Pain control with tylenol/percocet, pneumoboots\n # Comm: With patient\n # Code: FULL (confirmed with pt)\n ICU \n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Comments: Lantus\n Lines:\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" }, { "category": "Physician ", "chartdate": "2192-12-14 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 505345, "text": "Chief Complaint: GI Bleed\n HPI:\n Ms. is a 43yo female with a history of recurrent stage IIIC\n adenocarcinoma of the ovary who presented today with a GI bleed. She\n arrived to 9 today for C1D1 of oral topotecan. She was recently\n transitioned off gemcitabine when a CT scan demonstrated and interval\n increased size of left pelvic mass, which invaded the pelvic sidewall\n and likely the small bowel. She was feeling well today, except for a\n report of fatigue, most specifically when walking.\n She had her blood counts checked and her hematocrit returned at 21.1\n from 28.2 on . She was treated with topotecan. She noted\n darker stool over the last 24-36 hours, which she attributed to\n spinach. She went to work after the chemotherapy and had another bowel\n movement that was described as \"sticky.\" It was a small formed stool,\n dark/black in color with red/maroon streaks. She discussed this\n development with her oncologist and was referred to the ED.\n In the ED, vitals were 125/73 95 18 99% 2L. She was given 1 liter\n normal saline and 10 units of regular insulin and admitted to the OMED\n team. On the floor, she did well. She was seen by the GI and surgery\n consult teams. She was transfused 1 unit of blood. The surgical team\n felt the patient should be monitored in the ICU overnight and she was\n transferred.\n This evening, she has no specific complaints. She has noted the onset\n of some chemotherapy side effects, which is typical for her. She\n denies headache, orthostasis, vision changes, mouth sores, chest pain,\n palpitations, shortness of breath, abdominal pain, nausea, vomiting,\n further ostomy output, rectal bleeding, joint pain or rash.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Penicillins\n Unspecified \n Iodine\n Anaphylaxis;\n Platinum Complexes\n Rash;\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n Tricor 145mg daily\n Lantus 80U daily\n Humalog sliding scale\n Levothyroxine 100 mcg daily\n Lorazepam 0.25-0.5mg qhs PRN insomnia\n Prochlorperazine Maleate 10mg po q8 PRN nausea\n Crestor 40mg daily\n Tylenol PRN\n Past medical history:\n Family history:\n Social History:\n Oncologic history (taken from recent oncology notes)\n is 43 yo woman with advanced ovarian ca. She is s/p debulking\n surgery and hysterectomy and bilateral salpingo-oopherectomy. She\n received iv and intraperitoneal chemotherapy as part of her adjuvant\n chemotherapy ending in 7. She was enrolled in study getting\n oral AZD2171 until . She resumed tx with single \n as of ; but had reaction with dose 6/08. Started doxil .\n Had evidence of disease progression so tx changed to Alimta on \n till . Tx changed to Weekly taxol with Avastin on . Due to\n neuropathy from taxol; tx changed to weekly taxotere on . She\n had sigmoid colon perforation and had colon ressection and colonostomy\n on . She has been slow to heal and resumed chemo with gemzar on\n . Tx changed to Topotecan on .\n Past Medical History:\n Diabetes\n Hypothyroidism\n HTN (improved- no meds since )\n Clear cell ovarian Cancer\n s/p TAH-BSO, appendectomy, omentectomy \n s/p sigmoid resection \n Many women on mother's side with cancers including lung, colon,\n gastric, ovarian.\n Occupation: works for TV station\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: Fatigue\n Flowsheet Data as of 11:10 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 89 () bpm\n BP: 106/54\n RR: 18 ()\n SpO2: 98\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 164.1 lbs kg (admission): 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: None\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: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 466\n 6.4\n 0.8\n 12\n 23\n 96\n 4.7\n 133\n 20.3\n 11.1\n [image002.jpg]\n Other labs: PT / PTT / INR:10.8/20.6/0.9, ALT / AST:, Alk Phos / T\n Bili:109/0.3, Differential-Neuts:78.1, Lymph:17.9, Mono:2.8, Eos:0.8,\n Fibrinogen:700, LDH:188, Ca++:9.5, Mg++:2.3, PO4:3.3\n Imaging: 1. Interval increased size of left pelvic mass, which invades\n the pelvic\n sidewall and likely the small bowel.\n 2. Stable left-sided hydroureteronephrosis due to obstruction of the\n ureter\n from this mass.\n Assessment and Plan\n ASSESSMENT AND PLAN: 43yo female with a history of recurrent stage IIIC\n adenocarcinoma of the ovary who presents with a GI bleed.\n # GI bleed: hemodynamically stable. Receiving 2nd unit of prbc now.\n Will recheck HCT following this transfusion. Has 2 peripheral IVs.\n Concerning CT finding of pelvic mass likely invading the small bowel.\n Appreciate surgery and GI recommendations. GI will plan for EGD in am\n in ICU. Following serial hematocrits and will have type/cross for 6\n units ready per surgical recommendations. If instability develops,\n will plan for tagged red cell/angiography. Continue IV PPI for now.\n # DM: continue lantus and SSI. need to adjust as NPO. Follow BG\n closely.\n # Recurrent ovarian cancer: C1D1 Topotecan given today. Prn\n antiemetics.\n # Hypothyroidism: home levothyroxine\n # High cholesterol: holding tricor and crestor for now. Can resume once\n bleeding stabilized\n # FEN: NPO, replete lytes PRN\n # PPx: Pain control with tylenol/percocet, pneumoboots\n # Comm: With patient\n # Code: FULL (confirmed with pt)\n ICU \n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Comments: Lantus\n Lines:\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" }, { "category": "ECG", "chartdate": "2192-12-14 00:00:00.000", "description": "Report", "row_id": 207485, "text": "Sinus tachycardia. Late R wave progression. Since the previous tracing\nof T wave abnormalities are less prominent. Clinical correlation is\nsuggested.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2170-02-26 00:00:00.000", "description": "Report", "row_id": 1674542, "text": "Respiratory Care:\nPt recieved form IP lab after bronch,pt alert, pt hypercarbic and hypoxemic, placed on NIPPV with IPS 10, PEEP 8. Follow up ABg pending. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2170-02-26 00:00:00.000", "description": "Report", "row_id": 1674543, "text": "Nursing Note: 1700-1900\nSee FHPA for admission information.\n\nNEURO: Alert; difficult to determine orientation as very anxious re: noninvasive mask. Received Morphine 1mg for increased RR/anxiety with good effect. MAE with attempts to pull mask off requiring use of bilat wrist restraints to maintain ventilation. Denies pain.\n\nRESP: Noninvasive as noted. CO2 76. RR 20s. Redrawing ABG after 1.25hrs on mask. (7.33/53/81). LS anteriorly with slight exp wheeze LUL and absent RUL. Bronch confirming RUL occlusion; no stent placed.\n\nC/V: HR 70s, SR. BP initially 130s but decreased to 90s after sedation. MAPS 60s. No appreciable edema. Complete labs drawn in IP lab at 1600.\n\nGI/GU: NPO. Abdomen benign. Foley inserted and patent for clear urine.\n\nID: Tx for pna diagnosed at OSH.\n\nDISPO/PLAN: Full code; noninvasive until corrected; son in and aware of MICU admission.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2170-02-27 00:00:00.000", "description": "Report", "row_id": 1674544, "text": "Pt. has had much of an uneventful shift. pt. did becaome quite anxious early this am. Morphine .5mg i.v. given with desired effects reached. pt. has been afebrile, mae's and has remained very pleasant.\n\nPt. has been nsr in a controlled rate. Refer to carevue for specifics. B/P has also remained wnl's. pulses are weak but palpable.\n\nPt's lungs still remain diminished with exp wheeze noted at times. Pt. had one albuterol neub with desired effects reached. O2 sat remains >95% resp rate controlled. Harse cough noted which remained non productive. Pt. states this is usual.\n\nPt. tolerated a full tray last evening. Abd. remains benign in assessment. no stool. this shift. Foley catheter remains intact while draining ample amt's of amber clear urine.\n\nSkin remains benign in assessment. P.I.V. remain intact, secured, and functioning well.\n\nPlan is for transfer to floor today. Plan to assess pulmonary status closely. Possible code status discussion.\n" }, { "category": "ECG", "chartdate": "2170-02-26 00:00:00.000", "description": "Report", "row_id": 228256, "text": "Baseline artifact. Sinus rhythm. Consider left atrial abnormality.\nLeft ventricular hypertrophy by voltage in lead aVL. Since the previous\ntracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2170-02-25 00:00:00.000", "description": "Report", "row_id": 228257, "text": "Sinus rhythm. Possible left atrial abnormality. Compared to the previous\ntracing of no significant change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2189-02-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1128150, "text": " 5:08 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? WIDENED MEDIASTINUM-PLEASE DO AT 5 PM AND COMPARE TO PREVIOUS FILM DONE PER \n Admitting Diagnosis: THORACIC ANEURYSM\\ASCENDING AND HEMI-ARCH REPLACEMENT W/ FULL MAZE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man s/p Bental\n REASON FOR THIS EXAMINATION:\n repeat\n ______________________________________________________________________________\n WET READ: AJy TUE 6:10 PM\n ETT 4.5 cm above carina. tip of Swan, mediastinal drains, and NG not well\n seen due to underpenetration. While the mediastinum is again widened, it does\n not appear as severe as on prior study. likely small left effusion. low lung\n volumes.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Question widened mediastinum.\n\n Shortly after the study, a preliminary interpretation was provided by A.\n , which stated \"ETT 4.5 cm above carina. Tip of Swan, mediastinal\n drains, and NG not well seen due to underpenetration. While the mediastinum\n is again widened, it does not appear as severe as on the prior study and has\n certainly not progressed. Likely small left effusion. Low lung volumes.\"\n\n CHEST, AP SEMI-UPRIGHT: Comparison is made to and earlier on the\n same day. The film is underpenetrated. The patient is status post recent\n sternotomy. The tip of a right Swan-Ganz catheter can be followed into the\n pulmonary trunk, although the exact site of the tip is unclear, but probably\n there has been no significant change. The patient remains intubated. A\n nasogastric tube can be followed into the stomach. Two mediastinal drains are\n present.\n\n The heart remains enlarged. The mediastinum is widened, although to a less\n striking degree than on the prior radiographs. Mediastinal air is not\n apparent on this study. Part of the apparent change is probably due to\n increased lung volumes on this study, but the mediastinal contours are also\n better defined on this study. There is persistent left basilar opacity\n suggesting atelectasis with minor right basilar atelectasis. There is\n probably a small effusion on the left side.\n\n IMPRESSION: Persistent mediastinal widening, but less striking and with\n contours which are not definitely abnormal. However, continued radiographic\n follow-up is recommended.\n\n\n" }, { "category": "Nursing", "chartdate": "2189-02-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 530590, "text": "Aortic aneurysm, thoracic (TAA)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2189-02-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 530591, "text": "HD7 POD 1- Bental(29 Freestyle Ao root heart valve)Maze w/LAA lig\n Ejection Fraction: 40-45\n Hemoglobin A1c: 5.9\n Pre-Op Weight: 319 lbs 144.7 kgs\n Baseline Creatinine: 0.6\n Aortic aneurysm, thoracic (TAA)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2189-02-18 00:00:00.000", "description": "ICU Note - CVI", "row_id": 530592, "text": "CVICU\n HPI:\n HD7 POD 1-Bental(29Freestyle Ao root heart valve)Maze w/LAA lig\n Ejection Fraction:40-45\n Hemoglobin A1c:5.9\n Pre-Op Weight:319 lbs 144.7 kgs\n Baseline Creatinine:0.6\n TLD:R IJ cordis:Day2\n Foley:Day2\n PMHx:\n PMH: Hypertension, Hyperlipidemia, Morbid obesity, Diabetes Mellitus ,\n Probable Metabolic syndrome, Atrial Fibrillation s/p failed\n cardioversion (on Coumadin), Obstructive sleep apnea -CPAP ,\n Hypothyroidism, Depression\n PSH: s/p Lap Cholecystectomy, s/p Tonsillectomy, s/p Bilateral carpal\n tunnel surgery, s/p left foot surgery\n : Atenolol 100A/50P, Enalapril 10', Prozac 20', Metformin 500\",\n Nasonex, Simvastatin 40', Coumadin- held since , Ambien CR 10/hs\n synthroid 75'\n Current medications:\n Acetaminophen 5. Amiodarone 6. Aspirin EC 7. Calcium Gluconate 8.\n Captopril . Docusate Sodium 11. Fluoxetine 12. Fluticasone Propionate\n NASAL 13. Furosemide 14. Insulin 15. Levothyroxine Sodium 16. Magnesium\n Sulfate 17. Metoclopramide 19. Metoprolol Tartrate 20. Milk of Magnesia\n 21. Morphine Sulfate 22. Nitroglycerin 23. Oxycodone-Acetaminophen 24.\n Phenylephrine 25. Potassium Chloride 26. Ranitidine 27. Simvastatin\n Vancomycin\n 24 Hour Events:\n EKG - At 03:00 PM\n NASAL SWAB - At 03:00 PM\n OR RECEIVED - At 03:20 PM\n bentall\n ARTERIAL LINE - START 03:28 PM\n CORDIS/INTRODUCER - START 03:39 PM\n CCO PAC - START 03:39 PM\n Events:\n OR-\n dental xtraction\n OR cancelled 2'lack Dental clearance.*Dental to see.\n Post operative day:\n HD7 POD 1-Bental(29Freestyle Ao root heart valve)Maze w/LAA lig\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Infusions:\n Insulin - Regular - 5 units/hour\n Nitroglycerin - 4 mcg/Kg/min\n Other ICU medications:\n Insulin - Regular - 04:19 PM\n Metoprolol - 06:00 AM\n Morphine Sulfate - 06:20 AM\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n HR: 79 (59 - 98) bpm\n BP: 123/62(78) {85/48(61) - 150/91(111)} mmHg\n RR: 24 (15 - 24) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n CVP: 5 (5 - 26) mmHg\n PAP: (25 mmHg) / (14 mmHg)\n CO/CI (Fick): (13.5 L/min) / (5.2 L/min/m2)\n CO/CI (CCO): (10.2 L/min) / (3.6 L/min/m2)\n SvO2: 77%\n Mixed Venous O2% sat: 72 - 84\n Total In:\n 7,165 mL\n 886 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,315 mL\n 886 mL\n Blood products:\n 1,850 mL\n Total out:\n 1,250 mL\n 575 mL\n Urine:\n 665 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,915 mL\n 311 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Set): 600 (550 - 600) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 0 cmH2O\n Plateau: 24 cmH2O\n SPO2: 94%\n ABG: 7.36/47/95./25/0\n Ve: 9.4 L/min\n PaO2 / FiO2: 240\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Irregular), w/freq PVC's\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, No(t) Bowel sounds present,\n Obese\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 Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 123 K/uL\n 10.6 g/dL\n 109\n 0.7 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 12 mg/dL\n 107 mEq/L\n 138 mEq/L\n 31.5 %\n 7.5 K/uL\n [image002.jpg]\n 02:00 AM\n 02:16 AM\n 02:39 AM\n 03:00 AM\n 04:00 AM\n 05:00 AM\n 06:00 AM\n 06:01 AM\n 06:52 AM\n 07:00 AM\n WBC\n 7.5\n Hct\n 31.5\n Plt\n 123\n Creatinine\n 0.7\n TCO2\n 26\n 27\n 28\n Glucose\n 115\n 141\n 131\n 136\n 124\n 105\n 100\n 111\n 109\n 109\n Other labs: PT / PTT / INR:13.2/29.1/1.1, Fibrinogen:292 mg/dL, Lactic\n Acid:1.1 mmol/L, Mg:2.1 mg/dL\n Assessment and Plan\n .H/O ATRIAL FIBRILLATION (AFIB), .H/O DIABETES MELLITUS (DM), TYPE I,\n .H/O OBESITY (INCLUDING OVERWEIGHT, MORBID OBESITY), .H/O OBSTRUCTIVE\n SLEEP APNEA (OSA), .H/O VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR),\n AORTIC ANEURYSM, THORACIC (TAA)\n Assessment and Plan: 43yoM s/p Bental (29Freestyle Ao root heart\n valve)Maze w/LAA ligation() . Extubated and hemodynamically stable.\n Neurologic: Pain controlled, Pain controlled with Morphine, will\n transition to percocet. Will add Toradol if needed\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor,\n Will add amiodarone-s/p Maze, ?coumadin currently in SR\n will add ACE for afterload reduction\n Pulmonary: IS, Extubate today, extubated on rounds this AM, encourage\n C&DB/IS\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet, Advance diet as tolerated\n Renal: Foley, Adequate UO, will start gentle diuresis today, goal net\n negative 1 liter/day\n Monitor BUN/Cr\n Hematology: stable post-op anemia\n continue to monitor Hct\n will check coags and potentially start coumadin given hx Afib/Maze\n Endocrine: Insulin drip, will transition to lantus and sliding scale\n today\n Infectious Disease: No active issues\n Afebrile, normal wbc\n complete peri-op antibx\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Consults: CT surgery, P.T.\n ICU Care\n Nutrition: Regular heart healthy diet/ADAT\n Glycemic Control: Insulin infusion\n Lines: Arterial Line - 03:28 PM\n 16 Gauge - 03:29 PM\n Cordis/Introducer - 03:39 PM\n CCO PAC - 03:39 PM\n Prophylaxis: DVT: (Systemic anticoagulation: Coumadin (R),\n OOB-ambulate today)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Comments: potential to transfer to floor later today if weans off\n vasoactive infusions\n Code status: Full code\n Disposition: Transfer to floor\n ------ Protected Section ------\n Agree with note by .\n ------ Protected Section Addendum Entered By: , MD\n on: 16:01 ------\n" }, { "category": "Nursing", "chartdate": "2189-02-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530507, "text": "Aortic aneurysm, thoracic (TAA)\n Assessment:\n s/p bental and MAZE \n Sr with frequent pac, Epicardial wires on 40 ademand back up, sense and\n pace appropriately.\n CT with serosang drainage.\n SBP goal <110, CO/CI within normal range\n Finger sticks requiring regular insulin drip protocol\n Pain at incision site and back\n Intubated and ventilated, to remain overnight\n Action:\n Ntg and metoprolol to keep SBP in parameters\n Morphine for pain\n Propofol for sedation while intubated\n Insulin gtt titrated per protocol\n Albumin x 1 dose iv\n Weaned from CMV to CPAP \n Response:\n Tolerating CPAP on propofol at 10, slightly anxious.\n UOP adequate, CT output slowing\n BP difficult to maintain low parameter\n Pain controlled for short periods of time.\n Plan:\n Continue to wean ventilator settings and propofol, goal to extubate\n Wean insulin gtt\n Assess and treat for pain as indicated.\n Emotional support for patient and family.\n Patient has own CPAP machine from home located in central lockers at\n this time, does not tolerate hospital machine.\n ------ Protected Section ------\n Extubated to face tent at 0713.\n ------ Protected Section Addendum Entered By: , RN\n on: 07:14 ------\n" }, { "category": "Physician ", "chartdate": "2189-02-18 00:00:00.000", "description": "ICU Note - CVI", "row_id": 530520, "text": "CVICU\n HPI:\n HD7 POD 1-Bental(29Freestyle Ao root heart valve)Maze w/LAA lig\n Ejection Fraction:40-45\n Hemoglobin A1c:5.9\n Pre-Op Weight:319 lbs 144.7 kgs\n Baseline Creatinine:0.6\n TLD:R IJ cordis:Day2\n Foley:Day2\n PMHx:\n PMH: Hypertension, Hyperlipidemia, Morbid obesity, Diabetes Mellitus ,\n Probable Metabolic syndrome, Atrial Fibrillation s/p failed\n cardioversion (on Coumadin), Obstructive sleep apnea -CPAP ,\n Hypothyroidism, Depression\n PSH: s/p Lap Cholecystectomy, s/p Tonsillectomy, s/p Bilateral carpal\n tunnel surgery, s/p left foot surgery\n : Atenolol 100A/50P, Enalapril 10', Prozac 20', Metformin 500\",\n Nasonex, Simvastatin 40', Coumadin- held since , Ambien CR 10/hs\n synthroid 75'\n Current medications:\n Acetaminophen 5. Amiodarone 6. Aspirin EC 7. Calcium Gluconate 8.\n Captopril . Docusate Sodium 11. Fluoxetine 12. Fluticasone Propionate\n NASAL 13. Furosemide 14. Insulin 15. Levothyroxine Sodium 16. Magnesium\n Sulfate 17. Metoclopramide 19. Metoprolol Tartrate 20. Milk of Magnesia\n 21. Morphine Sulfate 22. Nitroglycerin 23. Oxycodone-Acetaminophen 24.\n Phenylephrine 25. Potassium Chloride 26. Ranitidine 27. Simvastatin\n Vancomycin\n 24 Hour Events:\n EKG - At 03:00 PM\n NASAL SWAB - At 03:00 PM\n OR RECEIVED - At 03:20 PM\n bentall\n ARTERIAL LINE - START 03:28 PM\n CORDIS/INTRODUCER - START 03:39 PM\n CCO PAC - START 03:39 PM\n Events:\n OR-\n dental xtraction\n OR cancelled 2'lack Dental clearance.*Dental to see.\n Post operative day:\n HD7 POD 1-Bental(29Freestyle Ao root heart valve)Maze w/LAA lig\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Infusions:\n Insulin - Regular - 5 units/hour\n Nitroglycerin - 4 mcg/Kg/min\n Other ICU medications:\n Insulin - Regular - 04:19 PM\n Metoprolol - 06:00 AM\n Morphine Sulfate - 06:20 AM\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n HR: 79 (59 - 98) bpm\n BP: 123/62(78) {85/48(61) - 150/91(111)} mmHg\n RR: 24 (15 - 24) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n CVP: 5 (5 - 26) mmHg\n PAP: (25 mmHg) / (14 mmHg)\n CO/CI (Fick): (13.5 L/min) / (5.2 L/min/m2)\n CO/CI (CCO): (10.2 L/min) / (3.6 L/min/m2)\n SvO2: 77%\n Mixed Venous O2% sat: 72 - 84\n Total In:\n 7,165 mL\n 886 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,315 mL\n 886 mL\n Blood products:\n 1,850 mL\n Total out:\n 1,250 mL\n 575 mL\n Urine:\n 665 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,915 mL\n 311 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Set): 600 (550 - 600) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 0 cmH2O\n Plateau: 24 cmH2O\n SPO2: 94%\n ABG: 7.36/47/95./25/0\n Ve: 9.4 L/min\n PaO2 / FiO2: 240\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Irregular), w/freq PVC's\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, No(t) Bowel sounds present,\n Obese\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 Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 123 K/uL\n 10.6 g/dL\n 109\n 0.7 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 12 mg/dL\n 107 mEq/L\n 138 mEq/L\n 31.5 %\n 7.5 K/uL\n [image002.jpg]\n 02:00 AM\n 02:16 AM\n 02:39 AM\n 03:00 AM\n 04:00 AM\n 05:00 AM\n 06:00 AM\n 06:01 AM\n 06:52 AM\n 07:00 AM\n WBC\n 7.5\n Hct\n 31.5\n Plt\n 123\n Creatinine\n 0.7\n TCO2\n 26\n 27\n 28\n Glucose\n 115\n 141\n 131\n 136\n 124\n 105\n 100\n 111\n 109\n 109\n Other labs: PT / PTT / INR:13.2/29.1/1.1, Fibrinogen:292 mg/dL, Lactic\n Acid:1.1 mmol/L, Mg:2.1 mg/dL\n Assessment and Plan\n .H/O ATRIAL FIBRILLATION (AFIB), .H/O DIABETES MELLITUS (DM), TYPE I,\n .H/O OBESITY (INCLUDING OVERWEIGHT, MORBID OBESITY), .H/O OBSTRUCTIVE\n SLEEP APNEA (OSA), .H/O VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR),\n AORTIC ANEURYSM, THORACIC (TAA)\n Assessment and Plan: 43yoM s/p Bental (29Freestyle Ao root heart\n valve)Maze w/LAA ligation() . Extubated and hemodynamically stable.\n Neurologic: Pain controlled, Pain controlled with Morphine, will\n transition to percocet. Will add Toradol if needed\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor,\n Will add amiodarone-s/p Maze, ?coumadin currently in SR\n will add ACE for afterload reduction\n Pulmonary: IS, Extubate today, extubated on rounds this AM, encourage\n C&DB/IS\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet, Advance diet as tolerated\n Renal: Foley, Adequate UO, will start gentle diuresis today, goal net\n negative 1 liter/day\n Monitor BUN/Cr\n Hematology: stable post-op anemia\n continue to monitor Hct\n will check coags and potentially start coumadin given hx Afib/Maze\n Endocrine: Insulin drip, will transition to lantus and sliding scale\n today\n Infectious Disease: No active issues\n Afebrile, normal wbc\n complete peri-op antibx\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Consults: CT surgery, P.T.\n ICU Care\n Nutrition: Regular heart healthy diet/ADAT\n Glycemic Control: Insulin infusion\n Lines: Arterial Line - 03:28 PM\n 16 Gauge - 03:29 PM\n Cordis/Introducer - 03:39 PM\n CCO PAC - 03:39 PM\n Prophylaxis: DVT: (Systemic anticoagulation: Coumadin (R),\n OOB-ambulate today)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Comments: potential to transfer to floor later today if weans off\n vasoactive infusions\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2189-02-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 530620, "text": "HD7 POD 1- Bental(29 Freestyle Ao root heart valve)Maze w/LAA lig\n Ejection Fraction: 40-45\n Hemoglobin A1c: 5.9\n Pre-Op Weight: 319 lbs 144.7 kgs\n Baseline Creatinine: 0.6\n Aortic aneurysm, thoracic (TAA)\n Assessment:\n Alert and oriented X3,. Moves all extremities with equal strength.\n 80-60\ns SR with PACs. Palpable pedal pulses. Feet warn with good CSM.\n CCO swan with CI>3 and PAD 16-20. CVP- On NTG 4 to keep SBP <120\n Epicardial wires to pacer set at A demand 40.\n Extubated at 7am to 70% OFT neb. Sats 90-95% initially. Lungs very\n diminished in bases.\n Meds and R pleural CT to suction without airleak and small serosang\n drainage.\n Abdomen obese, soft, NT and ND. Hypoactive bowel sounds.\n Foley to gd. UO initially slightly blood tinged. Wt 155.7 up >10kg\n from preop.\n Sternum and CT with DSD-small old drainage.\n Glucose 134 at 8am. Pt received 50 units glargine and regular insulin\n 10units to convert off insulin gtt.\n C/o incisional chest pain with coughing and moving.\n Action:\n Oral meds started and tolerated well.\n Lopressor 25 mg po and amiodarone 400 mg po given @ 9am\n Captopril 6.25 then ^ to 12.5 mg tid given-last dose 1600pm,\n Swan dc\n Percocet 2 given for pain then repeated 1 at 1530pm.\n Toradol 30mg given X1 at 1030am then additional 15mg given 1710pm.\n Lasix 10mg IV given @ 850am then additional 20mg given at 1130am with\n fair diuresis.\n Weaned off NTG gtt.\n K and Ca repleted.\n O2 weaned to 4L nc O2 with sats > 96%\n OOB to chair with 2 assists-moves very well.\n CT\ns dc\nd with post CXR done at 1600pm\n Coumadin started 5mg given 1600.\n Instructed in use of IS- Now using to 2500cc.\n Covered with CTS sliding scale regular insulin for glucoses 140-165\n with 4 and 6 units regular insulin.\n Response:\n Pain well controlled with adequate oxygenation\n Moving well. Tolerating OOB to chair.\n Tolerating lopressor, captopril and lasix\n Plan:\n Continue cardiac rehab-wean O2 as tolerates, Continue to \n Transfer to 6 for continued care, PT consult.\n" }, { "category": "Nursing", "chartdate": "2189-02-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530485, "text": "Aortic aneurysm, thoracic (TAA)\n Assessment:\n s/p bental and MAZE \n Sr with frequent pac, Epicardial wires on 40 ademand back up, sense and\n pace appropriately.\n CT with serosang drainage.\n SBP goal <110, CO/CI within normal range\n Finger sticks requiring regular insulin drip protocol\n Pain at incision site and back\n Intubated and ventilated, to remain overnight\n Action:\n Ntg and metoprolol to keep SBP in parameters\n Morphine for pain\n Propofol for sedation while intubated\n Insulin gtt titrated per protocol\n Albumin x 1 dose iv\n Weaned from CMV to CPAP \n Response:\n Tolerating CPAP on propofol at 10, slightly anxious.\n UOP adequate, CT output slowing\n BP difficult to maintain low parameter\n Pain controlled for short periods of time.\n Plan:\n Continue to wean ventilator settings and propofol, goal to extubate\n Wean insulin gtt\n Assess and treat for pain as indicated.\n Emotional support for patient and family.\n Patient has own CPAP machine from home located in central lockers at\n this time, does not tolerate hospital machine.\n" }, { "category": "Physician ", "chartdate": "2189-02-18 00:00:00.000", "description": "Intensivist Note", "row_id": 530618, "text": "CVICU\n HPI:\n HD7 POD 1-Bental(29Freestyle Ao root heart valve)Maze w/LAA lig\n Ejection Fraction:40-45\n Hemoglobin A1c:5.9\n Pre-Op Weight:319 lbs 144.7 kgs\n Baseline Creatinine:0.6\n TLD:R IJ cordis:Day2\n Foley:Day2\n PMHx:\n PMH: Hypertension, Hyperlipidemia, Morbid obesity, Diabetes Mellitus ,\n Probable Metabolic syndrome, Atrial Fibrillation s/p failed\n cardioversion (on Coumadin), Obstructive sleep apnea -CPAP ,\n Hypothyroidism, Depression\n PSH: s/p Lap Cholecystectomy, s/p Tonsillectomy, s/p Bilateral carpal\n tunnel surgery, s/p left foot surgery\n : Atenolol 100A/50P, Enalapril 10', Prozac 20', Metformin 500\",\n Nasonex, Simvastatin 40', Coumadin- held since , Ambien CR 10/hs\n synthroid 75'\n Current medications:\n Acetaminophen 5. Amiodarone 6. Aspirin EC 7. Calcium Gluconate 8.\n Captopril . Docusate Sodium 11. Fluoxetine 12. Fluticasone Propionate\n NASAL 13. Furosemide 14. Insulin 15. Levothyroxine Sodium 16. Magnesium\n Sulfate 17. Metoclopramide 19. Metoprolol Tartrate 20. Milk of Magnesia\n 21. Morphine Sulfate 22. Nitroglycerin 23. Oxycodone-Acetaminophen 24.\n Phenylephrine 25. Potassium Chloride 26. Ranitidine 27. Simvastatin\n Vancomycin\n 24 Hour Events:\n EKG - At 03:00 PM\n NASAL SWAB - At 03:00 PM\n OR RECEIVED - At 03:20 PM\n bentall\n ARTERIAL LINE - START 03:28 PM\n CORDIS/INTRODUCER - START 03:39 PM\n CCO PAC - START 03:39 PM\n Events:\n OR-\n dental xtraction\n OR cancelled 2'lack Dental clearance.*Dental to see.\n Post operative day:\n HD7 POD 1-Bental(29Freestyle Ao root heart valve)Maze w/LAA lig\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Infusions:\n Insulin - Regular - 5 units/hour\n Nitroglycerin - 4 mcg/Kg/min\n Other ICU medications:\n Insulin - Regular - 04:19 PM\n Metoprolol - 06:00 AM\n Morphine Sulfate - 06:20 AM\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n HR: 79 (59 - 98) bpm\n BP: 123/62(78) {85/48(61) - 150/91(111)} mmHg\n RR: 24 (15 - 24) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n CVP: 5 (5 - 26) mmHg\n PAP: (25 mmHg) / (14 mmHg)\n CO/CI (Fick): (13.5 L/min) / (5.2 L/min/m2)\n CO/CI (CCO): (10.2 L/min) / (3.6 L/min/m2)\n SvO2: 77%\n Mixed Venous O2% sat: 72 - 84\n Total In:\n 7,165 mL\n 886 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,315 mL\n 886 mL\n Blood products:\n 1,850 mL\n Total out:\n 1,250 mL\n 575 mL\n Urine:\n 665 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,915 mL\n 311 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Set): 600 (550 - 600) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 0 cmH2O\n Plateau: 24 cmH2O\n SPO2: 94%\n ABG: 7.36/47/95./25/0\n Ve: 9.4 L/min\n PaO2 / FiO2: 240\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Irregular), w/freq PVC's\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, No(t) Bowel sounds present,\n Obese\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 Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 123 K/uL\n 10.6 g/dL\n 109\n 0.7 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 12 mg/dL\n 107 mEq/L\n 138 mEq/L\n 31.5 %\n 7.5 K/uL\n [image002.jpg]\n 02:00 AM\n 02:16 AM\n 02:39 AM\n 03:00 AM\n 04:00 AM\n 05:00 AM\n 06:00 AM\n 06:01 AM\n 06:52 AM\n 07:00 AM\n WBC\n 7.5\n Hct\n 31.5\n Plt\n 123\n Creatinine\n 0.7\n TCO2\n 26\n 27\n 28\n Glucose\n 115\n 141\n 131\n 136\n 124\n 105\n 100\n 111\n 109\n 109\n Other labs: PT / PTT / INR:13.2/29.1/1.1, Fibrinogen:292 mg/dL, Lactic\n Acid:1.1 mmol/L, Mg:2.1 mg/dL\n Assessment and Plan\n .H/O ATRIAL FIBRILLATION (AFIB), .H/O DIABETES MELLITUS (DM), TYPE I,\n .H/O OBESITY (INCLUDING OVERWEIGHT, MORBID OBESITY), .H/O OBSTRUCTIVE\n SLEEP APNEA (OSA), .H/O VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR),\n AORTIC ANEURYSM, THORACIC (TAA)\n Assessment and Plan: 43yoM s/p Bental (29Freestyle Ao root heart\n valve)Maze w/LAA ligation() . Extubated and hemodynamically stable.\n Neurologic: Pain controlled, Pain controlled with Morphine, will\n transition to percocet. Will add Toradol if needed\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor,\n Will add amiodarone-s/p Maze, ?coumadin currently in SR\n will add ACE for afterload reduction\n Pulmonary: IS, Extubate today, extubated on rounds this AM, encourage\n C&DB/IS\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet, Advance diet as tolerated\n Renal: Foley, Adequate UO, will start gentle diuresis today, goal net\n negative 1 liter/day\n Monitor BUN/Cr\n Hematology: stable post-op anemia\n continue to monitor Hct\n will check coags and potentially start coumadin given hx Afib/Maze\n Endocrine: Insulin drip, will transition to lantus and sliding scale\n today\n Infectious Disease: No active issues\n Afebrile, normal wbc\n complete peri-op antibx\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Consults: CT surgery, P.T.\n Billing Dx: Respiratory Failure; Post-op Hypertension.\n ICU Care\n Nutrition: Regular heart healthy diet/ADAT\n Glycemic Control: Insulin infusion\n Lines: Arterial Line - 03:28 PM\n 16 Gauge - 03:29 PM\n Cordis/Introducer - 03:39 PM\n CCO PAC - 03:39 PM\n Prophylaxis: DVT: (Systemic anticoagulation: Coumadin (R),\n OOB-ambulate today)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Comments: potential to transfer to floor later today if weans off\n vasoactive infusions\n Code status: Full code\n Disposition: ICU\n Time Spent : 31 min\n" }, { "category": "Nursing", "chartdate": "2189-02-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 530611, "text": "HD7 POD 1- Bental(29 Freestyle Ao root heart valve)Maze w/LAA lig\n Ejection Fraction: 40-45\n Hemoglobin A1c: 5.9\n Pre-Op Weight: 319 lbs 144.7 kgs\n Baseline Creatinine: 0.6\n Aortic aneurysm, thoracic (TAA)\n Assessment:\n Alert and oriented X3,. Moves all extremities with equal strength.\n 80-60\ns SR with PACs. Palpable pedal pulses. Feet warn with good CSM.\n CCO swan with CI>3 and PAD 16-20. CVP- On NTG 4 to keep SBP <120\n Epicardial wires to pacer set at A demand 40.\n Extubated at 7am to 70% OFT neb. Sats 90-95% initially. Lungs very\n diminished in bases.\n Meds and R pleural CT to suction without airleak and small serosang\n drainage.\n Abdomen obese, soft, NT and ND. Hypoactive bowel sounds.\n Foley to gd. UO initially slightly blood tinged. Wt 155.7 up >10kg\n from preop.\n Sternum and CT with DSD-small old drainage.\n Glucose 134 at 8am. Pt received 50 units glargine and regular insulin\n 10units to convert off insulin gtt.\n C/o incisional chest pain with coughing and moving.\n Action:\n Oral meds started and tolerated well.\n Lopressor 25 mg po and amiodarone 400 mg po given @ 9am\n Captopril 6.25 then ^ to 12.5 mg tid given-last dose 1600pm,\n Swan dc\n Percocet 2 given for pain then repeated 1 at 1530pm.\n Toradol 30mg given X1 at 1030am then additional 15mg given 1710pm.\n Lasix 10mg IV given @ 850am then additional 20mg given at 1130am with\n fair diuresis.\n OOB to chair with 2 assists-moves very well.\n CT\ns dc\nd with post CXR done at 1600pm\n Coumadin started 5mg given 1600.\n Instructed in use of IS- Now using to 2500cc.\n Covered with CTS sliding scale regular insulin for glucoses\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2189-02-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 530447, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 0\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Weaning sedation and extubation in the am.\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n" }, { "category": "Nursing", "chartdate": "2189-02-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530361, "text": ".H/O diabetes Mellitus (DM), Type I\n Assessment:\n BS elevated.\n Action:\n Insulin drip\n 4 units reg insulin IV\n Response:\n BS 91, drip currently off.\n Plan:\n Recheck BS\n Restart drip as needed.\n .H/O valve replacement, freestyle aortic root bioprosthetic (AVR)/MAZE\n with LAA Ligation.\n Assessment:\n Pt is a 43yo man admitted with ascending aortic aneurysm. BPT 185\n, XC\n 139\n. BP labile, co/ci adequate by Fick. CT draining small amount of\n s/s drainage. Arrived to unit on 80mg Propofol, and neo .5. ABG\n acidotic.\n Action:\n Neo titrated on and off.\n Ntg on briefly.\n Warmed and reversed.\n Fluid given.\n Peep increased and TV increased.\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2189-02-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 530581, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\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 Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments: patient was extubated to 50% cool aerosol. Patient had a\n good cuff leak, strong cough and gag. Tolerating well with spo2 of 92%.\n" }, { "category": "Nursing", "chartdate": "2189-02-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 530632, "text": "HD7 POD 1- Bental(29 Freestyle Ao root heart valve)Maze w/LAA lig\n Ejection Fraction: 40-45\n Hemoglobin A1c: 5.9\n Pre-Op Weight: 319 lbs 144.7 kgs\n Baseline Creatinine: 0.6\n Aortic aneurysm, thoracic (TAA)\n Assessment:\n Alert and oriented X3,. Moves all extremities with equal strength.\n 80-60\ns SR with PACs. Palpable pedal pulses. Feet warn with good CSM.\n CCO swan with CI>3 and PAD 16-20. CVP- On NTG 4 to keep SBP <120\n Epicardial wires to pacer set at A demand 40.\n Extubated at 7am to 70% OFT neb. Sats 90-95% initially. Lungs very\n diminished in bases.\n Meds and R pleural CT to suction without airleak and small serosang\n drainage.\n Abdomen obese, soft, NT and ND. Hypoactive bowel sounds.\n Foley to gd. UO initially slightly blood tinged. Wt 155.7 up >10kg\n from preop.\n Sternum and CT with DSD-small old drainage.\n Glucose 134 at 8am. Pt received 50 units glargine and regular insulin\n 10units to convert off insulin gtt.\n C/o incisional chest pain with coughing and moving.\n Action:\n Oral meds started and tolerated well.\n Lopressor 25 mg po and amiodarone 400 mg po given @ 9am\n Captopril 6.25 then ^ to 12.5 mg tid given-last dose 1600pm,\n Swan dc\n Percocet 2 given for pain then repeated 1 at 1530pm.\n Toradol 30mg given X1 at 1030am then additional 15mg given 1730pm.\n Lasix 10mg IV given @ 850am then additional 20mg given at 1130am with\n fair diuresis.\n Weaned off NTG gtt.\n K and Ca repleted.\n O2 weaned to 4L nc O2 with sats > 96%\n OOB to chair with 2 assists-moves very well.\n CT\ns dc\nd with post CXR done at 1600pm\n Coumadin started 5mg given 1600.\n Instructed in use of IS- Now using to 2500cc.\n Covered with CTS sliding scale regular insulin for glucoses 140-165\n with 4 and 6 units regular insulin.\n Response:\n Pain well controlled with adequate oxygenation\n Moving well. Tolerating OOB to chair.\n Tolerating lopressor, captopril and lasix\n Plan:\n Continue cardiac rehab-wean O2 as tolerates, Continue to \n Transfer to 6 for continued care, PT consult.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n THORACIC ANEURYSM ASCENDING AND HEMI-ARCH REPLACEMENT W/ FU\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 145 kg\n Daily weight:\n 155.7 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: Arrhythmias, CAD, Hypertension\n Additional history: Hyperlipidemia, Morbid obesity, Metabolic Syndrome,\n Atrial Fibrilation, failed cardioversion-takes coumadin, Obstructive\n sleep apnea-CPAP, Hypothyroidism, Depression, S/P lap Chole-, S/P\n Tonsillectomy, S/P Bil Carpal tunnel syndrome, S/P L foot surgery.\n Dental extraction-2 teeth .\n Surgery / Procedure and date: -Bental procedure with 29mm\n freestyle aortic root heart valve, full maze with LAA ligation. bpt\n 185\", xc 139\". Defib with 10 joules coming off pump. SR under paced\n rthymn. Arrived on Neo, Insulin and Propofol.\n pre-EF 40%, post-op EF 50-60%, no AR.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:47\n Temperature:\n 97.5\n Arterial BP:\n S:143\n D:66\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 69 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 2,440 mL\n 24h total out:\n 2,235 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 40 bpm\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Temporary pacemaker wires ground:\n 0\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 02:16 AM\n Potassium:\n 3.9 mEq/L\n 12:09 PM\n Chloride:\n 107 mEq/L\n 02:16 AM\n CO2:\n 25 mEq/L\n 02:16 AM\n BUN:\n 12 mg/dL\n 02:16 AM\n Creatinine:\n 0.7 mg/dL\n 02:16 AM\n Glucose:\n 140 mg/dL\n 12:09 PM\n Hematocrit:\n 31.5 %\n 02:16 AM\n Finger Stick Glucose:\n 165\n 05:00 PM\n Valuables / Signature\n Patient valuables: Transferred with patient\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 793\n Transferred to: 6\n Date & time of Transfer: 1830pm.\n" }, { "category": "Nursing", "chartdate": "2189-02-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 530628, "text": "HD7 POD 1- Bental(29 Freestyle Ao root heart valve)Maze w/LAA lig\n Ejection Fraction: 40-45\n Hemoglobin A1c: 5.9\n Pre-Op Weight: 319 lbs 144.7 kgs\n Baseline Creatinine: 0.6\n Aortic aneurysm, thoracic (TAA)\n Assessment:\n Alert and oriented X3,. Moves all extremities with equal strength.\n 80-60\ns SR with PACs. Palpable pedal pulses. Feet warn with good CSM.\n CCO swan with CI>3 and PAD 16-20. CVP- On NTG 4 to keep SBP <120\n Epicardial wires to pacer set at A demand 40.\n Extubated at 7am to 70% OFT neb. Sats 90-95% initially. Lungs very\n diminished in bases.\n Meds and R pleural CT to suction without airleak and small serosang\n drainage.\n Abdomen obese, soft, NT and ND. Hypoactive bowel sounds.\n Foley to gd. UO initially slightly blood tinged. Wt 155.7 up >10kg\n from preop.\n Sternum and CT with DSD-small old drainage.\n Glucose 134 at 8am. Pt received 50 units glargine and regular insulin\n 10units to convert off insulin gtt.\n C/o incisional chest pain with coughing and moving.\n Action:\n Oral meds started and tolerated well.\n Lopressor 25 mg po and amiodarone 400 mg po given @ 9am\n Captopril 6.25 then ^ to 12.5 mg tid given-last dose 1600pm,\n Swan dc\n Percocet 2 given for pain then repeated 1 at 1530pm.\n Toradol 30mg given X1 at 1030am then additional 15mg given 1730pm.\n Lasix 10mg IV given @ 850am then additional 20mg given at 1130am with\n fair diuresis.\n Weaned off NTG gtt.\n K and Ca repleted.\n O2 weaned to 4L nc O2 with sats > 96%\n OOB to chair with 2 assists-moves very well.\n CT\ns dc\nd with post CXR done at 1600pm\n Coumadin started 5mg given 1600.\n Instructed in use of IS- Now using to 2500cc.\n Covered with CTS sliding scale regular insulin for glucoses 140-165\n with 4 and 6 units regular insulin.\n Response:\n Pain well controlled with adequate oxygenation\n Moving well. Tolerating OOB to chair.\n Tolerating lopressor, captopril and lasix\n Plan:\n Continue cardiac rehab-wean O2 as tolerates, Continue to \n Transfer to 6 for continued care, PT consult.\n" }, { "category": "Echo", "chartdate": "2189-02-17 00:00:00.000", "description": "Report", "row_id": 90650, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Congenital heart disease. Left ventricular function. Preoperative assessment.\nStatus: Inpatient\nDate/Time: at 12:54\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal regional LV systolic function.\nMildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nhypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nhypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Moderately dilated aortic sinus. Moderately dilated ascending aorta.\nNormal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Bicuspid aortic valve. No AS. Mild to moderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nConclusions:\nPREBYPASS\nNo atrial septal defect is seen by 2D or color Doppler. There is mild\nsymmetric left ventricular hypertrophy. Regional left ventricular wall motion\nis normal. Overall left ventricular systolic function is mildly depressed\n(LVEF= 40 %). The right ventricular cavity is mildly dilated with mild global\nfree wall hypokinesis. The aortic root is moderately dilated at the sinus\nlevel. The ascending aorta is moderately dilated. There are simple atheroma in\nthe descending thoracic aorta. The aortic valve is bicuspid. There is no\naortic valve stenosis. Mild to moderate (+) aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen.\n\nPOSTBYPASS\nBiventricular systolic function now appears normal. There is a well\nfunctioning xenograft, bioprosthesis in the aortic position. No AI is\nvisualized. Aortic contours of the descending aorta are intact. There is a\nxenograft position at the aortic root and proximal ascending aorta.\n\n\n" }, { "category": "ECG", "chartdate": "2189-02-17 00:00:00.000", "description": "Report", "row_id": 231492, "text": "Sinus rhythm with atrial premature beats. ST-T wave abnormalities. Since the\nprevious tracing of sinus rhythm is now present.\n\n" }, { "category": "ECG", "chartdate": "2189-02-12 00:00:00.000", "description": "Report", "row_id": 231493, "text": "Atrial fibrillation. T wave abnormalities. No previous tracing available for\ncomparison.\n\n" }, { "category": "Radiology", "chartdate": "2189-02-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1128272, "text": " 3:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: THORACIC ANEURYSM\\ASCENDING AND HEMI-ARCH REPLACEMENT W/ FULL MAZE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man s/p Bentall and CT removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n WET READ: JXKc WED 4:38 PM\n Left retrocardiac atelectasis. No PTX.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post Bentall and chest tube removal. Rule out pneumothorax.\n\n COMPARISON: at 5:25 p.m.\n\n CHEST, SINGLE AP VIEW: Median sternotomy wires are unchanged. There has been\n interval removal of an endotracheal tube, NG tube, chest tubes, as well as a\n Swan-Ganz catheter, with a right internal jugular catheter sheath remaining in\n place. Cardiomegaly remains stable. Left retrocardiac opacity likely\n reflects atelectasis. The lungs are otherwise clear. No pleural effusion or\n pneumothorax is identified.\n\n IMPRESSION:\n 1. Left retrocardiac opacities, likely reflective of atelectasis.\n 2. No evidence of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2189-02-17 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1128130, "text": " 2:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pleural effusion, pulmonary edema, tamponade, pneumthorax. P\n Admitting Diagnosis: THORACIC ANEURYSM\\ASCENDING AND HEMI-ARCH REPLACEMENT W/ FULL MAZE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with BENTAL/MAZE\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, tamponade, pneumthorax. Page \n with issues. Pt in OR 1 and will be in CSRU in 90 mins.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 43-year-old male post Bentall and MAZE procedure.\n\n COMPARISON: .\n\n CHEST, AP: There is marked mediastinal widening, concerning for new hematoma.\n Linear lucencies along the right cardiomediastinal border likely represent\n residual pneumomediastinum, although medial pneumothorax cannot be excluded.\n Lung volumes are low, with new left lower lobe atelectasis. Median sternotomy\n wires, mediastinal clips, and two mediastinal drains are present. An\n endotracheal tube is seen 3.5 cm from the carina. A Swan-Ganz catheter\n terminates in the main pulmonary artery, just beyond the right ventricular\n outflow tract. There are no large pleural effusions or pneumothorax.\n\n IMPRESSION: Mediastinal widening concerning for hematoma. Recommend repeat\n radiograph in two hours. This was paged to , NP, on at 3\n p.m.\n\n" }, { "category": "Radiology", "chartdate": "2189-02-12 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1127457, "text": " 4:30 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: r/o acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with preop ascending aorta/hemiarch replacement, maze\n REASON FOR THIS EXAMINATION:\n r/o acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 43-year-old male for MAZE procedure.\n\n There are no prior examinations for comparison.\n\n CHEST, PA AND LATERAL: The cardiomediastinal silhouette is mildly enlarged.\n The hilar contours are normal. The lungs are clear. There are no pleural\n effusions.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2189-02-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1128576, "text": " 10:08 AM\n CHEST (PA & LAT) Clip # \n Reason: interval chnage\n Admitting Diagnosis: THORACIC ANEURYSM\\ASCENDING AND HEMI-ARCH REPLACEMENT W/ FULL MAZE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with bentall\n REASON FOR THIS EXAMINATION:\n interval chnage\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after Bentall procedure.\n\n PA and lateral upright chest radiographs were reviewed in comparison to , .\n\n Cardiomediastinal silhouette is stable including cardiomegaly. Lungs are\n essentially clear. There is no evidence of failure. The lateral view\n demonstrates small amount of pleural effusion most likely bilateral.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2196-02-19 00:00:00.000", "description": "Report", "row_id": 1374531, "text": "Pt. received from OR @ s/p VP shunt removal and placement of R. vent drain. VSS. Alert, moving all extremities except RUE. Eyes open spont, PERRLA. Not following commands, tracking. Grimaces w/repositioning. Tylenol given x1 for comfort and ? RUE stiffness/pain. ICP 7-13. Vent drain draining clear CSF.\nCurrently on IMV 500/12, 60%. Pt. does not have aline. #6.5 ETT in stoma - plan for trach placement in am by SICU team. Lung sounds coarse, dim to bases.\nAfebrile. SR-ST, no ectopy. SBP 140s-150s. Pboots on. Vanco P/T done.\n+BS, abdomen soft. TFs restarted @ goal via PEG, tolerating w/minimal residuals. -stool. Skin intact. Foley patent adequate amount amber urine. Given SSRI/NPH dose for glucose levels >200. Am labs pending.\nA/P: Monitor neuro status, vent drain, pulm. hygeine, skin care. Trach placement in am. Cont. current plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-19 00:00:00.000", "description": "Report", "row_id": 1374532, "text": "ETT in stoma replaced by a #7 trach Portex patient tolerats procedure well. Weaned from SIMV to PS 5/5. Fi02 down to 40% based on ABG. Plan to go to trach collar tonight MD order.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-19 00:00:00.000", "description": "Report", "row_id": 1374533, "text": "FOCUS: STATUS UPDATE\nDATA:\nPT ALERT BUT NOT FOLLOWING COMMANDS. MOVING ALL EXTREMITIES EXCEPT R ARM. PERL. VENTRICULAR DRAIN IN PLACE AT 10CM ABOVE TRAGUS DRAINING CLEAR DRAINAGE. ICP 5-8.\n\nETT REMOVED AND #7 PORTEX TRACH PLACED. SLIGHT BLOODY SECRETIONS POST INSERTION BUT WELL TOLERATED PER PT. CHANGED TO CPAP 5/5 W/GOOD ABG'S. NOW ON TRACH COLLAR W/SAT 100%. MINIMAL SECRETIONS.\n\nCONT ON TF AT GOAL. ABD SOFT, NONTENDER W/POS BS.\n\nBLOOD CULTURES DONE VIA PICC AND PERIPHERALLY. U/CX SENT. POSITIVE CSF CX TODAY.\n\nPLAN:\nCONTINUE CURRENT PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-20 00:00:00.000", "description": "Report", "row_id": 1374534, "text": "Resp Care Note, Pt placed on t-collar 50%. Tol well. Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-20 00:00:00.000", "description": "Report", "row_id": 1374535, "text": "CONDITION UPDATE\nNEURO STATUS UNCHANGED. SEE FLOWSHEETS. TOLERATING TRACH MASK ENTIRE SHIFT. SAT 100%. MIN SUCTIONING FOR THICK TAN SPUTUM. LUNGS CTA BILAT. TOLERATING TFEED - NO RESIDUAL NOTED. ABD SOFTLY DISTENDED - POSITIVE BOWEL SOUNDS. U/O QS VIA FOLEY. LG AMT CLEAR DRAINAGE VIA VENT DRAIN. ICP W/IN NL LIMITS. CONT CLOSE NEURO ASSESSMENT. MONITOR FOR S/S OF INFECTION. PULMONARY TOILET. FAMILY TEACHING AND SUPPORT. CONT CURRENT ICU CARE AND ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-20 00:00:00.000", "description": "Report", "row_id": 1374536, "text": "Resp Care Note, ABG drawn from L radial artery. test done bleeding controlled. t-collar 50%\n" }, { "category": "Nursing/other", "chartdate": "2196-02-20 00:00:00.000", "description": "Report", "row_id": 1374537, "text": "PATIENT REMAINS ON 40% COOL MIST.SUCTIONED PRN FOR THICK WHITE SPUTUM DOES NOT RESPOND TO COMMAND,LOOKS CONFORTABLE WILL CONTINUE TO FOLLOW.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-17 00:00:00.000", "description": "Report", "row_id": 1374526, "text": "CONDITION UPDATE\nD: AFEBRILE. OTHER VSS. NEURO STATUS UNCHANGED. SHUNT DRAINING 15CC/HR CLEAR FLUID. LEVEL ADJUSTED ACCORDINGLY TO MAINTAIN SET OUTPUT. PICC LINE SITE CLEAN AND DRY- DRAWS WELL.\nA: NEURO STATUS MONITORED, SX PRN\nR: UNCHANGED NEURO STATUS, CONTINUE TO MONITOR CLOSELY\n" }, { "category": "Nursing/other", "chartdate": "2196-02-17 00:00:00.000", "description": "Report", "row_id": 1374527, "text": "SICU Nursing Progress Note\nNeuro: Pt alert occ makes a sound when spoken too, but nothing comprehensible. Pt Tracks, smiles and nods but likely not purpousful. Pt moves L side purpousful on bed, R side decreased movement on Bed, barely moves RUE. Pupils pearl. Pt has VP shunt that is now external and is leveled to drain 15cc/hr. CSF clear.\n\nCardiac: Pt in SR HR 65-78 no ectopy BP 136-151/66-86. Pt on multiple anti-hypertensives. Pts Mg repleated.\n\nResp: Pt has trach, on .35 TM. Pts O2 sat 100%. BS clear, decreased in bases bilaterally. Pt not requiring any suctioning. Pt would benefit from Chest PT with frequent turns.\n\nGI: Pt has G-tube. On promote w/ fiber at goal of 60cc/hr, -BM, +BS. Abd soft distended.\n\nGU: Pt has f/c with good u/o. Yellow in color.\n\nAccess: Pt has R dbl lumen PICC.\n\nID: Pt has hx of VRE in stool, yeast in urine and MRSE in CSF. Pt had CSF cx sent, WBC grew >50 con't to be MRSE. Pts vanco increased to 1.5g, peak and trough due on 3rd dose. Pt afebrile. MRSA screen pending. Team awaiting decision from Neurosurg regarding VP shunt, it will likely need to be removed.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-17 00:00:00.000", "description": "Report", "row_id": 1374528, "text": "SICU Nursing Progress Note\nEndo: Pt requiring coverage via RISS, in addition to fixed NPH dose.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-18 00:00:00.000", "description": "Report", "row_id": 1374529, "text": "Nursing note: See flowsheet for details.\n Neuro unchanged. Opens eyes spont, ? tracking. PERRLA. Moves LUE spont on bed, moves bilat. LEs. No movement of RUE noted. Grimaces w/movement, esp. of RUE. Drain leveled to 15cc/hr drainage. Draining clear CSF. Insertion site to R chest intact.\nLow grade temp 100. SR in 90s, no ectopy. SBP 120s. Palpable pulses.\nLung sounds coarse , sats 97-100% on 35% trach mask. +cough. +BS, abdomen soft. -stool. Tolerating TFs at goal of 65cc/hr via PEG. Foley patent adequate amount amber urine. Given SSRI as well as fixed dose NPH, glucose levels in 200s. Skin intact; turned, repositioned frequently.\nA/P: Stable neurologically. Cont. to follow WBCs, drain to be leveled for 15cc/hr CSF output, aggressive pulm. hygeine.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-18 00:00:00.000", "description": "Report", "row_id": 1374530, "text": "FOCUS: STATUS UPDATE\nDATA:\nPT ALERT AND APPEARED TO TRACK SPEAKER AT TIMES. WHISPERED HELLO WHEN GREETED. SQUEEZING HAND TO COMMAND BUT NOT RELEASING TO COMMAND. GRABBING SIDERAIL TO HOLD ON TO WHEN TURNED. PERL AT 4MM. DRAIN ADJUSTED TO DRAIN 15ML/HR AS ORDERED. CLEAR CSF. CSF CX SENT PER DR. THIS AM. POSITIVE PRELIMINARY RESULTS.\n\nLUNGS CLEAR BILAT. ON TRACH COLLAR AT 35%. NO SECRETIONS. SATS 100%.\n\nABD SOFT, NON-TENDER W/POSITIVE BS. TOL TF IN AM UNTIL D/C'D IN PREP. FOR OR THIS PM.\n\nIVF STARTED WHILE NPO.\n\nURINE OUTPUT ADEQUATE.\n\nPLAN:\nTO OR FOR SHUNT REMOVAL.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-14 00:00:00.000", "description": "Report", "row_id": 1374518, "text": "focus hemodynmics\ndata: vss. opens eyes when name being called. no movement in r arm. moves left arm off the bed. moves legs on the bed. vp shunt drain intact and titrated to obtain 10cc of drainage q1hr. suctioned for white sputum via trach. u.o yellow and abd soft with hypoactive bowel sounds. tol tube fdgs.\naction: suctioned prn. iv vanco, dilantin and ceftazadime given. labs obtained via ho drawing this am.\nresponse: monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-14 00:00:00.000", "description": "Report", "row_id": 1374519, "text": "NEURO: OPENING EYES SPONT AND TO VOICE, PERL. NOT FOLLOWING COMMNANDS, NO MVMT NOTICED FROM RUE, ABLE TO LIFT/HOLD RUE & LLE, MOVING RLE ON BED. VP SHUNT EXTERNALIZED, DRAINAGE TITRATED TO 10CC/HR, CLEAR FLUID. HEAD CT DONE-UNCHANGED PER DR. .\n\nCV: HR 70-92, NSR, NO ECTOPY, SBP 131-164.\n\nRESP: LUNG SOUNDS ARE COARSE, RR 15-30, O2 SAT 100% ON 35% HIGH HUMIDITY O2.\n\nGI: ABD SOFT NT/ND, +BS, TOLERATING TF VIA PEG AT GOAL AT 40CC/HR.\n\nGU: GOOD U/O VIA FOLEY, CLEAR YELLOW URINE.\n\nID: TMAX 99.7\n\nPLAN: MONITOR VS, RESP STATUS, NEURO STATUS. CONT W/ ABX UNTIL INFXN RESOLVED THEN VP SHUNT TO BE CHANGED PER .\n" }, { "category": "Nursing/other", "chartdate": "2196-02-15 00:00:00.000", "description": "Report", "row_id": 1374520, "text": "Respiratory CAre\nPt remain on t- 35% PT has Pavona sleep trach tube, SXsmal to mod thick white secretion, BS diminshed RR in the lower 20's.Pt is going for a pig tube today.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-15 00:00:00.000", "description": "Report", "row_id": 1374521, "text": "focus hemodynmics\ndata: vss as per flow sheet. opens eyes moves left arm and no movement in r arm. moves legs on the bed. perla #3 bilaterally. sleep apnea trach patent and suctioned for mod amt of white sputum. o2sats 96-100%. vp shunt intact and drain leveled to reach 10cc q1hr.\naction: suction prn. vp shunt to obtain 10ccq1hr. on iv dilantin and vanco. and cefatazadime. unable to draw labs and to have picc line today. tol tube fdgs. '\nresp: monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-15 00:00:00.000", "description": "Report", "row_id": 1374522, "text": "STATUS\nD: AFEBRILE..NEURO: P=RL MOVES BOTH LEGS & LF ARM..NO MOVEMENT OF RT ARM..OPENS EYES TO STIMULI..DOESN'T FOLLOW COMMANDS\nA: VP DRAIN DRAINING 10CC/H OF CLEAR PER HO..REMAINS ON TF'S @ GOAL..ELEVATED BS'S TX'D WITH SLIDING SCALE\nR: UNCHANGED\nP: TO IR FOR PIC PLACEMENT\n" }, { "category": "Nursing/other", "chartdate": "2196-02-16 00:00:00.000", "description": "Report", "row_id": 1374523, "text": "condition update\nD: NEURO: ESSENTIALLY UNCHANGED. MOVES LE ON BED, ABLE TO LIFT AND HOLD LEFT ARM BUT NOT TO COMMAND. NO MOVEMENT OF RIGHT ARM SEEN. OPENS EYES SPONT, PUPILS 3MM WITH EQUAL REACTION. VP SHUNT DRAINING 15 CC/HR CLEAR FLUID (LEVEL ADJUSTED TO OBTAIN 15CC/HR).\nCV: SEE CAREVUE FOR SPECIFICS. NO ISSUES.\nRESP: TRACH COLLAR AT 0.35%, SATS 98-100%. BS CLEAR\nGI/GU: ABD SOFT WITH + BS, SOFT BROWN BM X 1, TOL TF AT GOAL VIA PEG. ADEQUATE UO- SEE CAREVUE FOR SPECIFICS\nENDO: COVERED WITH SLIDING SCALE- SEE .\nIV ACCESS: REMAINS AN ISSUE. UNABLE TO DRAW AM LABS. ? PICC TODAY\nA: NEURO STATUS MONITORED, VENT DRAIN ADJUSTED ACCORDINGLY TO OBTAIN 15CC DRAINAGE Q1HR\nR: UNCHANGED\n" }, { "category": "Nursing/other", "chartdate": "2196-02-16 00:00:00.000", "description": "Report", "row_id": 1374524, "text": "STATUS\nD: NEURO UNCHANGED..VP DRAIN DRAINING CLEAR FLUID..\nA: SUCTIONED SM AMT WHITE..TO IR FOR PIC PLACEMENT RT ANTICUB..TOL PROCEDURE WELL..TOL TF'S AT GOAL..NO STOOL..GOOD HUO..CULT VP DRAIN SENT\nR: ESSENTIALLY UNCHANGED\nP: AWAITING VP DRAIN CULTURE REPORTS\n" }, { "category": "Nursing/other", "chartdate": "2196-02-16 00:00:00.000", "description": "Report", "row_id": 1374525, "text": "RESP\nPT REMAINS ON 50% TRACH MASK. DECREASED BREATH SOUNDS. SX FOR SMALL AMT. WILL CONTINUE TO MONITOR\n" }, { "category": "Nursing/other", "chartdate": "2196-02-12 00:00:00.000", "description": "Report", "row_id": 1374513, "text": "Neuro: Pt alert all day, very rarely will close eyes. Pupils 3mm sluggish. RUE no movement. RLE occasionally will move on bed. LUE very purposeful movement. LLE moves on bed spontaneously. Continues with L gaze. No tracking noted. Appears to have no pain. Vent drain draining 10cc/hr leveled at shoulder.\nCV: afebrile, HR 80's NSR with no ectopy. SBP 130's all day controlled well with lopressor, captopril and hydralazine. No need for PRN anti-hypertensives.\nRESP: lungs clear to dim at bases. O2 remains trach mask at 35% FIO2\nGI: tolerating tube feed. at goal, No stool today.\nGU: foley draining adequate amounts of clear yellow urine.\nEndocrine: blood sugars 200-300's covered with RISS.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-13 00:00:00.000", "description": "Report", "row_id": 1374514, "text": "CONDITION UPDATE:\nD/A: T MAX 98.4\n\nNEURO: UNCHANGED. VP SHUNT EXTERNALIZED AND CONNECTED TO VENTRICULOSTOMY DRAINAGE SYSTEM, LEVELED AT SHOULDER, DRAINING CLEAR FLUID.\n\nCV: HR 80'S NSR, NBP ~ 153/76, + PPP BILAT, RIGHT HAND + EDEMA (FLACID ARM AS WELL).\n\nRESP: LS COARSE-CLEAR WITH X1 SUCTIONING THROUGH SLEEP APNEA TUBE / TRACH. O2 SATS CONSISTENTLY 100%.\n\nGI: TUBE FEEDS ON HOLD WHILE DILANTIN LOAD IN PROGRESS.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nSX: FAMILY VISITED\n\nR: AFEBRILE, NEURO STATUS UNCHANGED, VSS, DRAIN PERFORMING WELL WITH GOAL OF 10CC/HR OF CSF.\n\nP: CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGEMENT.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-13 00:00:00.000", "description": "Report", "row_id": 1374515, "text": "Respiratory Care\nPt remain on Sx tthick yelow Sputum.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-13 00:00:00.000", "description": "Report", "row_id": 1374516, "text": "focus update\nT max 99.1 axillary, VSS NSR, except at 0800 prior to lopressor dose py briefly 112 ST, LSC- o2sat 100% via trach mask at 35% fio2- humidified, TF restarted at 1000, BS hypo active pt cont colace and senna tabs- no BM, skin intact, UO clear yellow 25-80cc/hr, NS with 20 KCL at 50cc/hr cont.\n\nneuro: pt opens eyes spont, to voice pt opens eyes and turns head to voice, pt does not follow commands, moves BLE to pain and does not move RUE, moves LUE spontaneously and purposefully- LUE restrained to avoid accidental dislodging of external VP shunt, VP shunt drain raised or lowered to obtain goal CSF output of 10cc/hr- CSF is clear, pupils brisk bilat. dilantin IV started infused slowly secondary to periperal administration and per ICU fellow as pt is on lopressor- both lopressor and IV dilantin may decrease SBP- per fellow.\n\npt evaluated for piccline IV RN today - no access and will have piccline placed in IR on monday.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-14 00:00:00.000", "description": "Report", "row_id": 1374517, "text": "Respiratory Care:\nUnable to ascertain exact description patients artificial airway. It appears to be brand appliance, miniature, cuffless trach tube (described by Rehab hospital as an \"Obstructive airway trach\", but all trach tubes eliminate airway obstruction). B/S course>>able to pass up to a size 12 French suction catheter, although we are using size 10French with good effect. Pt. tolerating 35% cool aerosol to trach mask, with SPO2 100%, RR high teens to low 20's this shift. Some dried secretions noted around Pt.'s stoma (cleaned now). Should the need arise, it may be doubtful that even a Shiley brand size 4 cuffles trach tube could be fitted into Pt.'s stoma (O.D. of 4 cuffless ~ 9.5mm). Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-21 00:00:00.000", "description": "Report", "row_id": 1374541, "text": "micu npn 1000-1900\nplease see carevue for all objective data\n\n\nneuro- pt essentially remains unchanged. vent drain remains at 10 cm above tragus. icp 4-8 over the day. no movement noted to r arm, other extremeties moving on bed. not following commands. grimacing to painful stimuli. no sz activity noted. dilantin level 3.2, extra dose given today, to recheck in am.\n\ncv- as per carevue. mult cv meds, captopril, hydralizine.. all given. sbp 130-150's. hr 80's w/ occasional pvc nopted. k 4.4 this am. mg 1.9.\nresp- trache mask weaned to 35%, sats 100%, l/s course/dim. suctioned via trache x2 for scant white.\n\ngi/gu- tube feeds, replete w/fiber continue to peg w/o issue. 2 sm amts of smearing stool. u/o remains excellent.\n\nid- neuro conts to draw daily cx of csf. appears clear. wbc 6.1. low grade fevers through day to 99.7 po. vanco drawn before dose, will draw peak as well.\nheme- hct 26.4 this am, no transfusion per , t+c sent.\n\nsocial- 2 daughters in today, updated on pt's status, very supportive to patient\n\nplan per surgery is for new vp shunt ??maybe next week. pt will not have to remain afebrile because will not be off abx. date/time to be decided on by neurosurgery team..\n" }, { "category": "Nursing/other", "chartdate": "2196-02-11 00:00:00.000", "description": "Report", "row_id": 1374509, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nPT IS A 64 Y/O WELL KNOWN TO AFTER HOSP STAY. ON PT HAD A SAH, AND LMCA ANEURYSM REQUIRING COILING. SHE WAS TRACHED/PEGGED ON . SHE HAD A VP SHUNT PLACED ON AND WAS D/C'D TO AN EXTENDED CARE FACILITY ON . SHE PRESENTED TO THE EW ON WITH TEMP 105. SHE WAS FOUND TO HAVE UTI AND ? INFECTED SHUNT. PE AS FOLLOWS:\n\nNEURO-PT AWAKE, OPENS EYES SPONT, ? OCC TRACKS. MOVES LEFT ARM PURPOSEFULLY. MOVES LEFT LEG ON BED. SL WITHDRAWS ON RIGHT TO PAIN. DOES NOT FOLLOW COMMANDS. NEUROSURG IN TO EXTERNALIZE VP SHUNT. DRAIN LEVELED AT \"SHOULDERS\", OPEN WITH CLEAR DRG. NO SX ACTIVITY. REMAINS ON DILANTIN.\n\nCV-TMAX 100.7. HR/BP STABLE. SKIN W+D. +PP. PBOOTS ON. ON PO ANTIHYPERTENSIVES AND SC HEPARIN.\n\nRESP-PT WITH ON TRACH COLLAR, 35% FIO2. O2 SAT 100%. LS CLEAR, DECREASED AT BASES. NARD NOTED.\n\nGI-ABD SOFTLY DISTENDED. +BS. TF STARTED VIA G-TUBE. WILL ADVANCE AS TOL.\n\nGU-VOIDING VIA FOLEY AMTS CL YELLOW URINE.\n\nENDO-SSRI ABD GLYBURIDE.\n\nPLAN-CON'T WITH CURRENT PLAN. FOLLW TEMP. ABX. VENT DRAIN. SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-22 00:00:00.000", "description": "Report", "row_id": 1374542, "text": "MICU-B NPN 1900-0700\nPLEASE SEE FHP FOR ADMIT HX. AND ICU/UPDATE FOR HOSP. COURSE.\n\nNEURO - PT. OPENING EYES SPONT. INCONSISTENTLY FOLLWS COMMANDS; WILL GRASP HAND, BUT WILL NOT RELEASE. (R)SIDED HEMIPLEGIA TO RUE; MOVES RLE, LUE, &LLL IN BED. PERRLA 4MM/4MM WITH BRISK RESPONSE. VENT. DRAIN REMAINS IN PLACE; PATENT @ 10CM TO TRAGUS. ICP 5-8 OVER/NOC WITH CLEAR DRAINAGE 2-35CC/HR. NO SEIZURE ACTIVITY NOTED. REMAINS ON DILANTIN. EXTRA DOSED YEST FOR LOW DILANTIN LEVEL.\n\nRESP - REMAINS ON TRACH. MASK .35%/10L. O2SATS 99-100%. RR TEENS>20'S. LS COURSE T/O. SX. FOR MOD. AMTS. THICK, YELLOW, BLD. TINGED SECRETIONS.\n\nC/V - HR 90'S-100'S, NSR>ST WITH NO ECTOPY NOTED. NBP ONE-TEENS>150'S/50'S-80'S. PT. ON PO HYDRAL, LOPRESSOR, & CAPTOPRIL. + GENERALIZED ANASARCA. PERIPHERAL PULSES PALPABLE.\n\nID - TMAX 100.5 OVER/NOC. REMAINS ON VANCO. PT. W/VRE/MRSA.\n\nHEME - HCT YEST. AM 26.4. NO TRANSFUSION. T&S SENT. AWAITING AM RESULTS.\n\nGI/GU - PEG TUBE IN PLACE; PATENT AND DELIVERING GOAL TF (PROMOTE W/FIBER) @ 60/HR. ABD. SOFT, NTND, WITH +BS. SM. SMEAR STOOL OVER/NOC. INDWELLING FOLEY IN PLACE; PATENT WITH GOOD AMTS. CLEAR, YELLOW URINE OUT OVER/NOC.\n\nACCESS - (R)PICC IN PLACE; PATENT, DOES NOT DRAW.\n\nSOCIAL - NO CONTACT FROM FAMILY OVER/NOC.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2196-02-11 00:00:00.000", "description": "Report", "row_id": 1374510, "text": "RESP CARE NOTE\n\n\nPT CURRENTLY ON 35% AEROSOL WITH SPO2 100%. HAS MINI TRACH USED FOR SUCTIONING AND IN PT WITH OSA. AIRWAY IS PATENT, SUCTIONED FOR SMALL AMTS OF YELLOW SPUTUM.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-12 00:00:00.000", "description": "Report", "row_id": 1374511, "text": "RESP CARE: Pt remains on 35% trach collar with 02 sats 99%. Pt has sleep apnea tube in place.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-12 00:00:00.000", "description": "Report", "row_id": 1374512, "text": "CONDITION UPDATE:\nD/A: T MAX 100.3\n\nNEURO: PLEASE SEE CAREVIEW FOR Q 2 HOUR NEURO CHECKS. UNCHANGED. VP SHUNT EXTERNALIZED, CONNECTED TO VENTRICULOSTOMY DRAINAGE SYSTEM TO LEVEL @ PT'S SHOULDERS WITH GOAL OF 10 CC'S/HR OF DRAINAGE. CLEAR FLUID DRAINING.\n\nCV: HR 80'S NSR. NBP ~ 143/60. FLUID BALANCE MN-0600 + 486 CC'S.\n\nRESP: LS CLEAR, DECREASED BASES. \"TRACH\" CARE DONE ON SLEEP APNEA TUBE PER RESPIRATORY. PT O2 SATS ~ 100%.\n\nGI: TUBE FEEDS ADVANCING, NO RESIDUALS.\n\nGU: FOLEY-BSD ? LEAKAGE AROUND FOLEY?\n\nR: NEUROLOGICALLY UNCHAGED WITH VP SHUNT NOW EXTERNALIZED. VSS.\n\nP: CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGEMENT. PT AND FAMILY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-21 00:00:00.000", "description": "Report", "row_id": 1374538, "text": "focus hemodynmics\ndata: neuro: vent drain 10cm above the tragus. drainage clear. icp 6-12. no movement in r arm. l arm moves on the bed. legs moves on the bed. perla #3 and reacts sluggishly. opens eyes to voice. grasps left hand but when asked to let go, pt does not follow command. at times when talking to pt, pt will nod if asked if she has pain. tylenol via tube given. on iv dilantin.\n\n\n\nresp: trach patent and trach collar tol well. suctioned for lg amt of white sputum. o2sats 99-100%. on 40%o2.\n\ncardiac: remains in nsr. no ectopy seen. on lopressor, captopril and hydralazine via tube. no drop in bp or hr. hr 80's and bp >110syst.\n\ngu: foley patent and draining yellow urine.\n\nsocial: family in to visit this afternoon.\n\nendocrine: blood sugars being drawn q6hrs. 2200 bls. 199. receives 20units of nph insulin at bedtime and sliding scale insulin.\n\n\naction: neuro signs q1hr. tol tube fdgs . on iv vanco. vent drain at 10a the tragus and drainage clear. blood sugars monitored q6hrs.\n\nresponse: monitor closely.\n\n\n\n\n\nGi: abd soft and active bowel sounds. no stool . tol tube fdgs ok.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-21 00:00:00.000", "description": "Report", "row_id": 1374539, "text": "focus: hemodynmics\ndata: transferred to micu a. pt tol transfer fine.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-21 00:00:00.000", "description": "Report", "row_id": 1374540, "text": "MICU-B ADMIT NOTE 0200-0700\nPLEASE SEE FHP AND ICU UPDATE FOR ADMIT HX. AND HOSP. COURSE. PT. ADMIT TO MICU-B FROM SICU @ 0200. ALL ALARMS AND EQUIP. SECURED FOR PT. SAFETY.\n\nNEURO - PT. AROUSING TO VOICE; OPENING EYES SPONT. NODDING HEAD OCCAS. TO QUESTIONS. WITHDRAWS TO PAIN. WILL GRASP HAND, BUT DOES NOT LET GO. NO MOVEMENT OF RUE, MOVES. RLL ON BED, LIFT/HOLD LLE & LUE. PUPILS 4MM/4MM WITH BRISK RESPONSE. VENT. DRAIN IN PLACE @ 10CM TO TRAGUS; PATENT PER CT YEST. DRAINING 7-10CC/HR CLEAR DRAINAGE. ICP 7-9. NO SEIZURE ACTIVITY.\n\nC/V - HR 80'S-90'S, NSR WITH NO ECTOPY NOTED. NBP 100'S-130'S/50'S-90'S. PT. PERIPHERAL PULSES PALPABLE. + GENERALIZED ANASARCA.\n\nID - TMAX 100.1. ON VANCO. FOR ABX. COVERAGE. PT. WITH VRE + MRSA.\n\nRESP - PT. ON TRACH MASK COOL NEB. 10L/.40 WITH RR TEEENS>20'S. O2SATS. 100%. AND SX. FOR MOD>COPIOUS AMTS. THICK, WHITE SECRETIONS. LS COURSE T/O. NO COUGH NOTED.\n\nGI/GU - PEG TUBE IN PLACE; PATENT AND DELIVERING TF (PROMOTE W/FIBER). ABD, SOFT, NTND WITH +BS. NO STOOL THIS SHIFT. INDWELLING FOLEY IN PLACE; PATENT WITH GOOD AMTS. CLEAR, YELLOW, URINE OUT OVER/NOC.\n\n\nENDO - PT. ON QID RISS - TX. @ 0400 FOR BS 161 WITH 6U PER SLIDING SCALE. ALSO ON STANDING DOSE COVERAGE NPH IN AM AND @ BEDTIME.\n\nACCESS - (R)PICC LINE IN PLACE; PATENT,, SITE WNL. CONT. KVO THROUGH EACH PORT. POOR DRAW.\n\nSOCIAL - NO CONTACT FROM FAMILY OVER/NOC. PT. HOWEVER WITH VERY SUPPORTIVE FAMILY. WILL NEED TO CALL FAMILY TO UPDATE THEM ON PT. TRANSFER TO MICU-B.\n\nDISPO - CONT. SUPPORTIVE CARE. MONITOR NEURO STATUS CLOSELY. ?SCREEN FOR REHAB. PT. DNR/DNI.\n" }, { "category": "ECG", "chartdate": "2196-02-26 00:00:00.000", "description": "Report", "row_id": 288393, "text": "Sinus rhythm\nSeptal ST-T changes are nonspecific\nPoor R wave progression in leads V1-V3\nNondiagnostic lateral T wave flattening\nSince previous tracing, T wave changes in lead V2 more pronounced\n\n" }, { "category": "Nursing/other", "chartdate": "2196-02-24 00:00:00.000", "description": "Report", "row_id": 1374547, "text": "MICU NPN 11AM-7PM:\nNeuro: Pt remains awake but does not follow commands. Moves left side well and right side is flaccid. PEARL. ICP 4-11 (Please call team if greater than 20) and drain is draining clear fluid 5-10cc/hr. Vent drain is leveled at 10cm above the tragus. Pt turned and positioned.\n\nCV: VSS. HR 70-90's. BP 120-160.\n\nResp: Remains on 35% TM. Lungs coarse. No suction required. RR 20\n\nGI: Tolerates tube feeds at goal rate via PEG. No stool. +BS.\n\nGU: UO excellent via foley.\n\nEndo: Pt getting NPH and regular as ordered. QID sliding scale requiring coverage.\n\nID: WBC 6.5. Pt with low grade fevers still 99 PO. Still getting vanco Q18hrs. Plan is for peak and trough levels around noon-time dose tomorrow.\n\nSocial: Daughter came by to visit and wants her to go back to a different rehab if possible when she is ready. I have asked her to speak to case management about this.\n\nPlan: Plan is for potential placement of VP shunt at the end of the week.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-25 00:00:00.000", "description": "Report", "row_id": 1374548, "text": "NURSING PROGRESS NOTE:\nPT ALERT AND WILL FOLLOW SIMPLE COMMAND ON OCCASION. PEARL, MOVES LEFT SIDE WELL. RIGHT SIDE IS FLACID. PT HAS ICP DRAIN MEASURING . DRAINING SMALL AMT'S OF CLEAR FLUID. PT SLEPT FOR SHORT TIME TONIGHT, OTHERWISE AWAKE MOST OF THE TIME.\nCV: PT IN NSR WITH HR 70'S TO 90'S. PT RECEIVING LOPRESSOR/HYDRALAZINE/CAPTOPRIL, TOLERATING WELL. BP STABLE ON THESE DRUGS, SEE FLOWSHEET FOR DATA. CONT WITH LOW GRADE TEMP, WILL BE RECEIVING VANCO AT NOON.\nRESP: PT ON 35/% TM, SX OCC FOR SM AMT OF WHITE SPUTUM. LUNG SOUNDS BASICLY CLEAR. O2SAT'S 99-100%. TRACH SITE WELL HEALED AND NO DRAINAGE. TRACH CARE GIVEN.\nGI: PT RECEIVING TUBE FEEDS AT GOAL RATE VIA PEG.BOWEL SOUNDS PRESENT BUT NO STOOL AT THIS TIME. PT RECEIVING BOWEL REGIMEN.\nGU: FOLEY CATH PATENT DRAINING LRG AMT OF YELLOW URINE.\nENDO: PT ON SSRI AND FIXED DOSE OF NPH AND GLYBURIDE.\nSOCIAL: HAVE NOT HEARD FROM FAMILY OVERNIGHT.\n\n" }, { "category": "Nursing/other", "chartdate": "2196-02-25 00:00:00.000", "description": "Report", "row_id": 1374549, "text": "nursing note: 7a-7p\nneuro-pt awake and alert most of day. at times pt nodding appropriately to simple questions. able to squeeze with left hand on command at times as well. left arm flaccid. moves lower extremities in bed. perla. vent drain at 10cm above tragus with clear drainage. icp 7-10.\n\nresp- ls clear slightly diminished at bases. on trach collar at 35% with sats >95%.\n\ncv- hr 70-100 sr no ectopy noted. bp stable, elevated at times to sbp 160 just prior to scheduled lopressor and hydralizine doses. afebrile\n\ngi- abd soft obese + bs no stool. tf via peg promote with fiber at now 70cc/h. no residuals. free water boluses started for na 151 tf's to be held at midnight in prep for or tomorrow.\n\ngu- foley patent for adequate u/o. ivf to start at midnight\n\nsocial- no family contact today.\n\ndispo- remains in micu on nsicu service. dnr. awaiting new vp shunt placement planned for tommorrow.\n\n" }, { "category": "Nursing/other", "chartdate": "2196-02-23 00:00:00.000", "description": "Report", "row_id": 1374545, "text": "MICUB 0700-1900 RN note\n\nNeuro: Awake alert appears to have intermittent periods of understanding and responding with nods and facial expressions, opens eyes spont pupils 4MM equal react brisk. Moves Left arm puposeful, R arm flaccid and edematous, grimaces with movement. Moves LE random. Vent drain intact positioned 10>tragus, open to drain. CSF drainage 8-16cc/hr clear CSF specimen obtained for C&S, ICP 6-9 with sharp wave form. Drain dsg intact with old serous stain. No siezure activity, free dilantin level 9.2.. Cont with Dilantin IV per routine.\nActivity OOB chair with Lift for 5 hrs. tol well.\n\nCV: HR 78-105 NSR-ST rare PVC, SBP 164-140 cont with Captopril/Lopressor and Hydralizine per routine. IV Access R PICC intact NS 10cc/hr.\n\nResp: RR 18-24 reg #8 portex trach intact O2 via TM 35% cool Mist. productive cough suctioned via trach for sm-mod amt thick tan secretions. O2 sat 87-100%. Lungs Coarse BS.\n\nID: Afebrile, T-Max 99.2, Con t on Vanco q18hrs. Oral Thrush Tx with Nystatin, daily CSF cult neg/pending\n\nGI: Abd soft distended +BS no BM. GT intact with Promote with Fiber FS TF @ 60cc/hr.\n\nGU: Foley u/o 50-180cc/hr.\nPlan: VP Shunt placement by end of week.\nSocial: Daughter called and updated aon pt status. Plan to visit thei evening. Code status DNR.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-24 00:00:00.000", "description": "Report", "row_id": 1374546, "text": "MICU-B NPN 1900-0700\nPLEASE SEE FHP AND ICU/UPDATE FOR PMHX. AND HOSP. COURSE. PT. 64 Y/O FEMALE S/P SAH RESULTANT FROM ANEURYSM. TRACHED /PEGGED AND TO REHAB . RE-ADMIT FOR FEVERS INFECTION TO VP SHUNT. PERSISTENT VEG. STATE. S/P SHUNT REMOVAL FOR INFECTION. VENT. DRAIN IN PLACE; AWAITING VP SHUNT PLACEMENT BY END OF WEEK.\n\nNEURO - PT. OPENING EYES SPONT. FOLLOWING SIMPLE COMMANDS VERY INCONSISTENTLY. OCCAS. NODDING HEAD APPROPRIATELY TO QUESTIONS. NO EVIDENCE PAIN. NO MOVEMENT RUE. MOVES ALL OTHER EXTREM. ON BED; LIFT/HOLD LUE. VENT. DRAIN IN PLACE TO 10CM @ TRAGUS W/ CLEAR, DRAINAGE OUT. ICP 4-9. HOB MAINTAINED @ 30 DEGREES. PERRLA 4MM/4MM W/BRISK RESPONSE.\n\nC/V - HEMODYNMICALLY STABLE. HR 70'S-100'S, NSR W/NO ECTOPY. NBP 120'S-160'S/60'S-90'S. PT. ON CAPTOPRIL, HYDRALAZINE & LOPRESSOR. PERIPHERAL PULSES STRONG PALPABLE. + EDEMA TO EXTREM.\n\nRESP - PT. W/PORTEX TRACH #. ON TRACH MASK .35/COOL NEB. RR TEENS>20'S. O2SATS 100%. SX. THIS SHIFT. FOR SM. AMT. YELLOW, THICK SECRETIONS. PT. W/STRONG PROD. COUGH AT TIMES. LS COURSE T/O.\n\nID- LOW-GRADE TEMP. OVER/NOC. TMAX 99.4. ON Q18/HR VANCO. CSF SPECS. DAILY. LAST +CX. ON .\n\nGI/GU - PEG TUBE IN PLACE; PATENT AND DELIVERING GOAL TF (PROMOTE W/FIBER) @ 60/HR. ABD. SOFT, NTND W/+BS. +FLATUS. NO STOOL ON BOWEL REGIME. INDWELLING FOLEY IN PLACE; PATENT W/GOOD AMTS. CLEAR, YELLOW, URINE OUT OVER/NOC.\n\nSKIN - GROSSLY INTACT.\n\nEDNO - ON QID RISS AND SCHEDULED AM/PM DOSES NPH. TX. OVER/NOC PER SLIDING SCALE FOR FS 209.\n\nACCESS - (R)PICC; BOTH PORTS PATENT. DOES NOT DRAW. SITE WNL.\n\nSOCIAL - NO CONTACT FROM FAMILY OVER/NOC. PT. W/VERY SUPPORTIVE FAMILY WHO HAS BEEN CONTINUALLY UPDATED BY TEAM/NURSING STAFF.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-27 00:00:00.000", "description": "Report", "row_id": 1374552, "text": "MICUB 1900-0700 RN Note\n\n@ Returned from OR s/p L Frontal VP Shunt\n\nNeuro: Arrived sedated Propofol 75mcg/kg/min wean to off @2100. Initailly minimal response to painful stimulation. Pupils 4mm equal react sluggish. Anesthesia reversed sedation upon arrival and patient became more wakeful. Opening eyes spontaneously Pupils equal react brisk. tracking visual field. RE remains flaccid, LE moves randomly and puposeful. Moves LE on bed. Surgical site VP shunt dsg D&I. grimaces with apparent pain with movement of head. No siezure activity. Dilantin Per routine cont.\n\nCV: HR 55-80 SR-SB no ectopy. SBP 136-198 episode of hypertension SBP 198 recieved Hydalizine 10mg IV with responding BP to SBP<160. Goal SBP <160. Resumed Lopressor/Captopril/Hydralizine per routine via GT. Access> #16 agio placed R foot in OR NS 10cc/hr. R PICC Line intact D5 0.45% NS 20KCL @ 75cc/hr.\n0400 Labs pending\n\nResp: Intubated with #8 portex trache, returned on vent a/c %-5peep. 02sat 100%. increased spont resp 18-22 Sp TV 200-360 wean to CPAP PS 10/5, 02 sat 98-100% , Lungs coarse BS -clear. Suctioned via trach for sm-mod white thick and orrally mod amt clear.\nPlan to wean to CPAP PS 5/5 and TM 40%.\n\nGI: Abd fim distended +BS no BM. GT intact restarted TF promote with Fiber 30cc goal 70cc/hr.\n\nGU: Foley Clear yellow urine U/o 40-100cc.hr.\n\nSocial: Daughter called and updated on pt status. Patient remaind full code atatus.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-27 00:00:00.000", "description": "Report", "row_id": 1374553, "text": "Respiratory Care\nPt remained ventilated overnight on a/c, wean back to pressure support without problems. = 45. Spontaneous breathng trial was started at 0600. Plan is to change back to trache collar later today.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-27 00:00:00.000", "description": "Report", "row_id": 1374554, "text": "MICU NURSING PROGRESS NOTE. 0700-1900\n SEE TRANSFER NOTE FOR NURSING PROGRESS NOTE, SEE CAREVIEW FOR OBJECTIVE DATA.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-28 00:00:00.000", "description": "Report", "row_id": 1374555, "text": "MICUB 1900-0700 RN Note\nCall out to floor\nNeuro: Awake, opens eyes spontaneously follows with eyes. Pupils 3mm equal react brisk. RUE flaccid, LUE weak hand grasp move puposefully. Moves LE on bed RLE minimal movement. Appears to understand simple questions via facial s and nods. No siezure activity. Dilantin Admin per routine. VP shunt surgical site Dsg intact posteria head staples intact.\n\nCV: HR 70-90 NSR no ectopy. SBP 130-170 goal SBP <160. recieved Hydralizine, Lopressor/captopril per routine. R brachieal PICC line intact IV D5 0.45%NS with 20KCL @ 75cc/hr stopped @ 0200. R foot Peripheral Site intact NS 10cc/hr.\n\nResp: RR 16-22 reg. #* Protex trach inplace 02 35% TM. Sat 100%. Lungs coarse BS. Suctioned Via trache for smamts thich yellow. Orally for sm amt clear.\n\nID: Afebrile T-Max 99.2 ax. Vanco q18hrs cont next dose @ 1200.\nEndo: FSBS 179 insulin per protocol\nGU: Foley U/o 50-120cc/hr.\n\nGI: Abd firm distended +BS no BM. GT inplace Recieving Promote with Fiber FS @ 50cc/hr Goal 70cc/hr.\n Social. No family contact, Full code status\n" }, { "category": "Nursing/other", "chartdate": "2196-02-22 00:00:00.000", "description": "Report", "row_id": 1374543, "text": "MICUB 0700-1900 RN Note\n\nNeuro: Opens eyes spontaneously, follows with eyes. Pupils 4-5mm equal react brisk. No purposeful movements Left hand grasp weak and nonpuposeful Move L arm and legs randomly on bed. R Arm flaccid. Ventral drain inplace Dsg D&I with old serous stain. HOB maintained 30 degrees. ICP 6-12 positioned 10cm >tragus. ICP open to dr 5-18cc/hr clear CSF fluid. CSF specimen obtained by HO sent to Lab. CSF WBC-25.\nNo siezure activity. Cont on Dilantin IV TID. Plan: Shunt placement pending ID approval\n\nCV: HR 90-110 NSR-ST no ectopy. SBP 130-180 recieved Hydralizine/Lopressor/Captopril per routine order. Access R brachial PICC line intact Site WNL.\n\nResp: RR 16-22 reg. Portex trach inplace, TM 35% cool Neb. Suctioned via trach for mod to sm amts thick yellow bl secretions. adn orally for sm amts . Lungs coarse BS throughout.\n\nID: Afebrile T-max 98.3, Cont on Vanco Q18hrs.\n\nGI: Abd soft nontender Peg FT in place recieving TF promote with Fiber 60cc/hr.\n\nGU: Foley clear yellow urine 5-180cc/hr.\n\nSocial: No family contact. status DNR\n" }, { "category": "Nursing/other", "chartdate": "2196-02-23 00:00:00.000", "description": "Report", "row_id": 1374544, "text": "MICU-B NPN 1900-0700\nNO EVENTS OVER/NOC. PT. AWAITING VP SHUNT PLACEMENT. PER . TEAM LAST EVE. WILL TAKE PLACE IN ABOUT A WEEK. PT. TO REMAIN IN ICU UNTIL VP SHUNT PLACEMENT W/VENT. DRAIN FOR HYDROCEPHALUS.\n\nNEURO - PT. OPENING EYES SPONT. NO MOVEMENT RUE. MOVING ALL OTHER EXTREM. IN BED. DOES LOCALIZE PAIN. NOT FOLLOWING COMMANDS. PERRLA 4MM/4MM WITH BRISK RESPONSE. VENT. DRAIN REMAINS IN PLACE AS ABOVE FOR HYDROCEPHALUS @ 10CM TO TRAGUS. 2--20CC/HR CLEAR, DRAINAGE OVER/NOC. ICP 5-9. NO SEIZURE ACTIVITY. ON DILANTIN.\n\nRESP - PT. ON TRACH MASK COOL NEB. .35. RR TEENS>20'S O2SATS 99-100%. LS COARSE>CLEAR W/SX. W/BILAT. DIMIN. BASES. SX. OVER/NOC FOR THICK, YELLOW PLUG.\n\nC/V - HR 90'S-ONE-TEENS, NSR>ST WITH NO ECTOPY NOTED. NBP 130'S-160'S/60'S-70'S. ON CAPTOPRIL, LOPRESSOR, & HYDRALAZINE. PERIPHERAL PULSES PALPABLE. + GENERALIZED ANASARCA NOTED.\n\nID - TMAX 99.8. REMAINS ON Q18/HR VANC.\n\nGI/GU - PEG TUBE IN PLACE; PATENT AND DELIVERING GOAL TF(PROMOTE W/FIBER) @ 60CC/HR. ABD. SOFT, NTND W+BS. NO STOOL OVER/NOC. INDWELLING FOLEY IN PLACE; PATENT WITH GOOD AMTS. CLEAR, YELLOW, URINE OUT OVER/NOC.\n\nACCESS -(R)PICC LINE IN PLACE; PATENT, DOES NOT DRAW, SITE WNL.\n\nSOCIAL - NO CONTACT FROM FAMILY OVER/NOC.\n\nDISPO - PT. AWAITING VP SHUNT PLACEMENT. TO REMAIN IN MICU UNTIL THEN. CONT. SUPPORTIVE CARE. CONT. TO. MONITOR NEURO STATUS. PT. DNR/DNI.\n\n" }, { "category": "Nursing/other", "chartdate": "2196-02-26 00:00:00.000", "description": "Report", "row_id": 1374550, "text": "NURSING PROGRESS NOTE:\nPT REMAINS TRACH/ON 35% TM, PT IS ALERT WHEN AWAKE AND WILL NOD YES/NO APPROPRIATELY TO QUESTIONS. PT MOVING LEFT SIDE WELL. RIGHT ARM NO MOVEMENT AND WILL MOVE RIGHT LEG SLIGHTLY ON BED.\nPT'S TRACH SX FOR SM AMT'S OF THICK WHITE SPUTUM WHICH PLUGGED OFF X 1 DURING THE NIGHT. TRACH IRRIGATED WITH SALINE/BAGGED AND SX AND CLEARED THE PLUG. LUNG SOUNDS CLEAR WITH SOME WHEEZING NOTED WHEN NEEDING TO BE SX'D. O2 SAT'S HIGH 90'S TO 100%.\nTUBE FEEDING AT GOAL RATE UNTIL MIDNIGHT AND THEN TURNED OFF FOR PREOP. IV OF NS WITH 20KCL AT 75/HR STARTED. PT'S NPH AT 2200 WAS HALVED (10UNITS). EKG AND LABS SENT FOR COAGS/BLOOD BANK.\nANESTHESIA CONSENT HAS BEEN SIGNED AND WITNESSED BY THIS NURSE.\nPT HAS FOLEY CATH AND DRAINING LRG AMT'S OF CLEAR YELLOW URINE.\nPT ON BOWEL REGIMEN MED'S BUT HAS NOT STOOLED AT THIS TIME BUT IS PASSING FLATUS.\nPT'S SKIN IN TACT.\nPT'S ICP DRAIN DRAINING MOD AMT'S OF CLEAR FLUID. SEE FLOWSHEET FOR DATA.\nPT TO OR TODAY FOR REVISION OF OLD SHUNT.\nPT IS FULL CODE.\nFAMILY INTO VISIT EARLIER IN THE SHIFT.\nCV: HEART RATE IN THE 70'S TO 90'S. NO ECTOPY NOTED. PT ON HYDRALAZINE/CAPTOPRIL/LOPRESSOR BP TOLERATES THESE MEDS VERY WELL.\nPT'S TEMP 99.2 PO.\n" }, { "category": "Nursing/other", "chartdate": "2196-02-26 00:00:00.000", "description": "Report", "row_id": 1374551, "text": "pmicu nursing progress 7a-7p\nreview of systems\nCV-vs have been stable, receivng cardiac meds as ordered.\nRESP-35% cool neb, lungs sound clear, sx for thick sputum.sats have been >95%.\nID-afebrile. vanco q 18 hrs.\nGI-abd soft and large with positive bowel sounds. no stool today.tube feeds on hold due to procedure.\nNEURO-opens eyes spontaneously, waves L arm. no sedatives given. ICP draining crystal clear fluid, then clamped as per neuro team.\nENDO- regular insulin as per sliding scale.\nF/E- ivf changed to D5 1/2 NS at 75/hr. has been voiding sufficient quantities via foley. mild peripheral edema noted.\nIV ACCESS- has a double lumen PICC in R antecube\nSOCIAL-daughters in to visit, gave phone consent for procedure.\na-uneventful day leading up to OR for VP shunt revision\nP-left a short while ago to OR for shunt revision, continue with good pulm toilet.\n\n" }, { "category": "Nursing/other", "chartdate": "2196-02-28 00:00:00.000", "description": "Report", "row_id": 1374556, "text": "MICU NURSING PROGRESS NOTE. 0700-1900\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: Awaiting floor bed, called out as of . No significant changes throughout shift.\n\n Neuro: Opens eyes to verbal stimulus, easily arousable, occn follows commands like hand squeeze or open mouth. Occn appears to refuse commands. Tracks with eyes, pupils 3mm and brisk. Moving rt lower extrem on bed, rt ue lifts and holds. Temperature max. 98.0 axillary.\n\n Respiratory: Lung sounds are coarse in upper fields, diminished in lower fields bilat. RR 12-20 and non labored. O2 saturation 97-100% on 40% Trach mask. No sz activity noted. Suctioned several times for thick white secretions.\n\n CV: Sinus rhythm with no ectopy noted, rate in 70's and 80's. Nbp 110's to 150's systolic. Ivf kvo rt foot, wnl. Picc line rt ac wnl. Good bp control on present antihypertensive regimen.\n\n GI/GU: Abdomen obese, soft with + bs. Tf promote w/fiber at 60cc/hr, goal of 70cc/hr. 1lg formed guiac - lt brown bm. Foley catheter patent and draining good amts clear yellow urine.\n\n Endocrine: Riss and fixed dose in use, fs 150at noon, covered with 4 units regular insulin.\n\n Plan: Transfer to floor when bed available.\n" } ]

[ { "category": "ECG", "chartdate": "2174-07-11 00:00:00.000", "description": "Report", "row_id": 262272, "text": "Sinus rhythm\nLow QRS voltages in limb leads\nRight bundle branch block\nSince previous tracing of , sinus tachycardia absent\n\n" }, { "category": "ECG", "chartdate": "2174-07-10 00:00:00.000", "description": "Report", "row_id": 258750, "text": "Sinus tachycardia. Right bundle-branch block. Left anterior fascicular block.\nCompared to the previous tracing of there is continued diffuse low\nvoltage representing a change compared to the previous tracing of .\nClinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2174-07-10 00:00:00.000", "description": "Report", "row_id": 258751, "text": "Sinus tachycardia. Diffuse low voltage. Right bundle-branch block. Compared to\nthe previous tracing of there is generalized decrease in voltage which\nmay represent pericardial effusion. Followup and clinical correlation are\nsuggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2174-07-07 00:00:00.000", "description": "Report", "row_id": 258752, "text": "Poor quality tracing. Borderline sinus tachycardia with frequent atrial\npremature beats. Complete right bundle-branch block. Marked right axis\ndeviation. Probable underlying anterolateral myocardial infarction which may\naccount for the right axis deviation, althougth left posterior fascicular block\nor right ventricular overload cannot be excluded. Low limb lead voltage.\nCompared to the previous tracing of no diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2174-07-06 00:00:00.000", "description": "Report", "row_id": 258753, "text": "Sinus rhythm\nFrequent atrial premature complexes\nBorderline first degree AV delay\nIndeterminate frontal QRS axis\nRight bundle branch block\nLow QRS voltages in limb leads - is nonspecific\nSince previous tracing of , sinus tachycardia absent, atrial ectopy\nseen, QRS voltages and T wave changes less prominent\n\n\n" }, { "category": "ECG", "chartdate": "2174-07-04 00:00:00.000", "description": "Report", "row_id": 258754, "text": "Sinus tachycardia, rate 104. Right bundle-branch block/left posterior\nhemiblock. Peaked T waves in the precordium - exclude hyperkalemia. Compared to\nthe previous tracing of the axis is more rightward. Mid-precordial\nT waves are newly peaked and QRS voltage is much larger in the precordial\nleads, raising the question of biventricular hypertrophy.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2201-03-22 00:00:00.000", "description": "Intensivist Note", "row_id": 452861, "text": "SICU\n HPI:\n This is a 73 year old patient who is on Coumadin for an\n embolic stroke in and fell at 0500 this morning when he was\n getting out of bed. This fall was unwitnessed, but his wife\n heard him fall and went immediately to the bedroom to his side.\n He was brought to ED and then was transferred here\n for further evaluation. Upon arrival to the ED his INR was 5.6 he\n was reversed with Vitamin K, profiline, and FFP.\n Chief complaint:\n SDH s/p fall\n PMHx:\n embolic stroke \n Current medications:\n . 1000 mL NS\n Continuous at 75 ml/hr\n Change to peripheral lock when taking POs Order date: @ 12.\n Gentamicin 80 mg IV Q8H Duration: 3 Doses Order date: @ \n 2. Acetaminophen 325-650 mg PO Q6H:PRN\n do not excedd 4 grams in 24 hours Order date: @ 13.\n HYDROmorphone (Dilaudid) 0.125 mg IV Q3H:PRN\n hold lethargy or RR < 12 Order date: @ \n 3. Bisacodyl 10 mg PO/PR DAILY Order date: @ 14. Heparin\n Flush (10 units/ml) 3 mL IV PRN Order date: @ 2242\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 2218 15. HydrALAzine 10 mg IV Q6H:PRN\n for sbp > 140 Order date: @ \n 5. Dexamethasone 4 mg iv q6 Duration: 24 Hours Order date: @ \n 16. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 2206\n 6. Dexamethasone 3 mg iv q6 Duration: 24 Hours Start: After 4 mg\n tapered dose. Order date: @ 17. LeVETiracetam 1000 mg IV\n BID Order date: @ 0443\n 7. Dexamethasone 2 mg iv q6 Duration: 24 Hours Start: After 3 mg\n tapered dose. Order date: @ 18. Ondansetron 4 mg IV Q8H:PRN\n call neurosurg for nausea or vomiting post-op but may give- pager\n Order date: @ \n 8. Dexamethasone 1 mg iv q6 Duration: 24 Hours Start: After 2 mg\n tapered dose. Order date: @ 19. Pneumococcal Vac Polyvalent\n 0.5 ml IM ASDIR Order date: @ 1807\n 9. Dexamethasone 0 mg iv q6 Duration: 24 Hours Start: After 1 mg\n tapered dose. Order date: @ 20. Propofol 20-100 mcg/kg/min\n IV DRIP TITRATE TO comfort Order date: @ 0034\n 10. Docusate Sodium 100 mg PO BID Order date: @ 21. Senna 1\n TAB PO BID Order date: @ \n 11. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 2206 22. Vancomycin 1000 mg IV Q 12H Duration: 3 Days Order date:\n @ \n 24 Hour Events:\n MULTI LUMEN - START 10:40 PM\n ARTERIAL LINE - START 10:41 PM\n ARTERIAL LINE - START 10:42 PM\n ARTERIAL LINE - STOP 10:44 PM\n OR RECEIVED - At 10:52 PM\n ARTERIAL LINE - START 11:00 PM\n ARTERIAL LINE - STOP 11:50 PM\n INVASIVE VENTILATION - START 12:00 AM\n Post operative day:\n POD#1 - R crani for evacuation SDH\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:13 PM\n Gentamicin - 12:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37.3\nC (99.1\n HR: 77 (67 - 77) bpm\n BP: 107/20(45) {93/19(44) - 159/78(114)} mmHg\n RR: 18 (15 - 25) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69 kg (admission): 70 kg\n Total In:\n 4,830 mL\n 791 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,353 mL\n 791 mL\n Blood products:\n 2,477 mL\n Total out:\n 720 mL\n 945 mL\n Urine:\n 220 mL\n 945 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,110 mL\n -154 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n PS : 5 cmH2O\n RR (Set): 15\n PEEP: 5 cmH2O\n FiO2: 100%\n RSBI: 29\n RSBI Deferred: FiO2 > 60%\n PIP: 13 cmH2O\n Plateau: 12 cmH2O\n SPO2: 100%\n ABG: 7.46/32/440/20/0\n Ve: 10.7 L/min\n PaO2 / FiO2: 440\n Physical Examination\n HEENT: Left pupil dilated\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\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: Sedated\n Labs / Radiology\n 278 K/uL\n 10.6 g/dL\n 75 mg/dL\n 0.9 mg/dL\n 20 mEq/L\n 4.4 mEq/L\n 18 mg/dL\n 113 mEq/L\n 142 mEq/L\n 31.1 %\n 12.8 K/uL\n [image002.jpg]\n 07:55 PM\n 10:41 PM\n 12:51 AM\n 02:19 AM\n 04:15 AM\n 05:55 AM\n WBC\n 10.7\n 12.8\n Hct\n 22\n 27.9\n 30.4\n 31.1\n Plt\n 272\n 278\n Creatinine\n 0.8\n 0.9\n TCO2\n 23\n 21\n 23\n Glucose\n 177\n 165\n 75\n Other labs: PT / PTT / INR:14.0/25.9/1.2, Lactic Acid:1.1 mmol/L,\n Ca:8.3 mg/dL, Mg:2.1 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n .H/O FALL(S), .H/O HYPERTENSION, BENIGN, .H/O CVA (STROKE, CEREBRAL\n INFARCTION), OTHER , SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 1 hr, stable, sedated on propofol\n Cardiovascular: stable, hydralazine for BP>140\n Pulmonary: Cont ETT, (Ventilator mode: CMV), wean as tolerated\n Gastrointestinal / Abdomen: stable\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, stable\n Endocrine: stable\n Infectious Disease:\n Lines / Tubes / Drains: Foley, ETT, RIJ, Right radial A-line\n Wounds:\n Imaging: CXR today\n Fluids: NS, 75 cc/hr\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:30 PM\n 20 Gauge - 10:38 PM\n Multi Lumen - 10:40 PM\n Arterial Line - 11:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status:\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2201-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 452850, "text": "73 year old patient who is on Coumadin for an embolic stroke in \n and fell when he was\n getting out of bed. This fall was unwitnessed, but his wife heard him\n fall and went immediately to the bedroom to his side. He was brought\n to ED and then was transferred here\n for further evaluation. Upon arrival to the ED his INR was 5.6, hct 16\n he was reversed with Vitamin K, profiline, and FFP. Pt received 4\n units pRBCs, 2 units platelets. R crani done for evacuation of large\n hematoma under Dr.. Pt arrived to SICU around 2300.\n Subdural hemorrhage (SDH)\n Assessment:\n Pt arriving to SICU from OR and CT done. Paralyzed from OR, sedated on\n propfol. Started on low dose Fentanyl for comfort and propofol gtts.\n Pupils assessed as unequal as noted in ED, R>L ~. Per Dr., no\n full neuro assessment off propofol until ~03-0400 when paralytics will\n have worn off. At 0400, sedation shut off, Fentanyl running at\n 25mcg/hr. Pt moving all extremities excepting LUE d/t old embolic\n stroke, baseline contracture. Pupils ~ R-L respectively. Both\n reactive. Pt still not opening eyes, but withdrawing on RUE, RLE, LLE\n to pain. Facial grimacing to pain. Cough/gag (+).\n Action:\n Sedation weaned to off. BP parameters SBP>140 maintained. Neuro q 1\n after 0400. Antibiotics as ordered. Steroids/keppra as ordered. Lytes\n repleted. Hct/coags q4hr. Pt put on CPAP after sedation turned off.\n Response:\n Pt responsive to stimuli. Appears comfortable on Fentanyl gtt.\n Plan:\n Cont to wean to extubate. Neuro q1hr. Abx/antiseizure med/steroids as\n ordered. Hct/coags q4 hr until stabilized.\n" }, { "category": "Respiratory ", "chartdate": "2201-03-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 452833, "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:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt received from OR S/P SDH evacuation intub with OETT and\n placed on mech vent as per Metavision. Lung sounds ess clear. ABGs\n stable; no vent changes required overnoc. Cont mech vent support;\n ?extub today.\n" }, { "category": "Respiratory ", "chartdate": "2201-03-22 00:00:00.000", "description": "Generic Note", "row_id": 452996, "text": "TITLE:\n Resp Care: Pt received intubated via 7.5 ETT secured 23cm at lip. BS\n coarse bilat. Sx\nd for copious amt of thick tan sputum. Weaned and\n extubated MD. Placed on 1.0 cool neb. No stridor noted. Plan: to\n leave on 1.0 until 2300, per neuro team. Goals being achieved, will\n cont. to monitor.\n 17:03\n" }, { "category": "Rehab Services", "chartdate": "2201-03-23 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 453156, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 432 /\n Reason of referral: Eval and tx\n History of Present Illness / Subjective Complaint: 73 year old patient\n on Coumadin s/p fall at home , presented to OSH with a large right\n SDH. Pt was transferred to for further management. In ED his INR\n was 5.6, it was reversed and pt was taken emergently to OR for\n evacuation of the subdural hematoma via craniotomy.\n Past Medical / Surgical History: embolic CVA \n Medications: HydrALAzine , Dilaudid, Metoprolol\n Radiology: Head CT : large acute on chronic right subdural\n hematoma. No significant shift of midline. There is compression of the\n temporal of the right lateral ventricle. 2. Severe\n encephalomalacia of the right frontal lobe compatible with prior\n infarction. 3. Hemorrhagic contusion in the left frontal lobe with\n small adjacent area of acute subdural hematoma. 4. Unchanged chronic\n left frontal subdural hematoma Head CT post-op: The tension\n pneumocephalus noted above has resulted in substantially increased mass\n effect, compression of the right lateral ventricle, and midline shift.\n Status post right craniotomy and SDH evacuation with new small leftward\n shift of 4 mm\n Labs:\n 29.7\n 10.0\n 281\n 18.1\n [image002.jpg]\n Other labs:\n INR. 1.2\n Activity Orders: OOB c A\n Social / Occupational History: Per chart pt has supportive family\n Living Environment: Unable to obtain information from pt due to\n decreased arousal\n Prior Functional Status / Activity Level: Unable to obtain information\n from patient due to decreased arousal\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt lethargic, eyes\n closed thru out 80% of evaluation. Dysarthric, inconsistently answering\n yes/no questions.\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 103\n 120/73\n 95% RA\n Rest\n /\n Sit\n 116\n 135/63\n Activity\n /\n Stand\n /\n Recovery\n 100\n 128/73\n 95% RA\n Total distance walked:\n Minutes:\n Pulmonary Status: Even and coordinated breathing pattern, diminished LS\n t/o\n Integumentary / Vascular: large R craniotomy incision open to air, R\n orbital edema, R IJ, foley\n Sensory Integrity: Withdraws to pain x 4\n Pain / Limiting Symptoms: Pt grimacing with L arm movement and bed\n mobility\n Posture: increased thoracic kyphosis\n Range of Motion\n Muscle Performance\n L shldr appears to be anteriority dislocated\n L UE in extension, IR, and wrist flexion contracture\n Pt able to move R UE and LE against gravity\n No active movement of L UE or LE noted t/o treatment however pt was\n attempting to perform AAROM of L LE at EOB\n Motor Function: Pt was able to follow approx 25% of simple 1 step\n commands with R UE and LE. L LE increased extensor tone 3+\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 T\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n N/A\n\n\n\n\n\n\n Sit to Stand:\n N/A\n\n\n\n\n\n\n Ambulation:\n N/A\n\n\n\n\n\n\n Stairs:\n N/A\n\n\n\n\n\n\n Balance: Pt required Max A x 2 to achieve sitting at EOB, once upright\n pt required Max A to maintain midline due to strong pushing to L. Pt\n tolerated for approximately 8-10 mins.\n Education / Communication: Pt status discussed with RN, pt educated on\n role of PT.\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Motor Function, Impaired\n 5.\n Muscle Performance, Impaired\n 6.\n Range of Motion, Impaired\n Clinical impression / Prognosis: 73 yo m s/p fall with resultant large\n R SDH now s/p craniotomy and evacuation presents with above impairments\n c/w nonprogressive CNS dysfunction. Pt is currently requiring Max A\n with all mobility, he was able to follow some commands, and showed\n active and purposeful movement of R UE and LE. Pt will require skilled\n PT/OT in rehab setting upon discharge in order to optimize functional\n mobility and safety.\n Goals\n Time frame: 1 wk\n 1.\n follow > 50% of 1 step commands\n 2.\n maintain eyes open t/o treatment\n 3.\n Mod A for bed mobility\n 4.\n Mod A to sit at EOB > 10 mins\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n f/u bed mobility, EOB balance activities, strength training, cognitive\n stimulation. Cont pt education and discharge planning\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n No mental status\n" }, { "category": "Nursing", "chartdate": "2201-03-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 453162, "text": "Subdural hemorrhage (SDH)\n Assessment:\n Pt lethargic. Opens eyes at times to voice and pain. Perrl. Right\n eye/face very swollen. Left side with min movement on bed at baseline\n from cva in\n99. moves right side to command at times. Lifts/holds on\n right. Oriente to person. Saying only a few words and inconsistently.\n Incision ota, wnl. No sz acitivty. Pt too lthergic to swallow pills.\n Sbp <140.\n Action:\n Neuro checks., keepra.\n Response:\n Unchanged.\n Plan:\n Con\nt neuro checks. Keepra. Monitor bp. ? doboff.\n" }, { "category": "Nursing", "chartdate": "2201-03-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 453163, "text": "73 year old patient who is on Coumadin for an embolic stroke in \n and fell when he was\n getting out of bed on .This fall was unwitnessed, but his\n wife heard him fall and went immediately to the bedroom to his side.\n He was brought to ED and then was transferred here\n for further evaluation. Upon arrival to the ED his INR was 5.6, hct 16\n he was reversed with Vitamin K, profiline, and FFP. Pt received 4\n units pRBCs, 2 units platelets. R crani done on for evacuation of\n large hematoma. He has since been extubated and is now stable for tx to\n floor.\n Subdural hemorrhage (SDH)\n Assessment:\n Pt lethargic. Opens eyes at times to voice and pain. Perrl. Right\n eye/face very swollen. Left side with min movement on bed at baseline\n from cva in\n99. moves right side to command at times. Lifts/holds on\n right. Oriente to person. Saying only a few words and inconsistently.\n Incision ota, wnl. No sz activity. Pt too lethergic to swallow pills.\n Sbp <140.\n Action:\n Neuro checks. keepra.\n Response:\n Unchanged.\n Plan:\n Con\nt neuro checks. Keepra. Monitor bp. ? doboff.\n Physical therapy following pt. PT dangled on side of bed, see Physical\n therapy note.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n SUBDURAL HEMATOMA\n Code status:\n Full code\n Height:\n Admission weight:\n 70 kg\n Daily weight:\n 65.7 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: CVA, Hypertension\n Additional history: embolic stoke in \n Surgery / Procedure and date: CT/CT SPINE- \n R SDH evacuation, crani- \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:63\n Temperature:\n 99.1\n Arterial BP:\n S:201\n D:186\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 104 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 1,471 mL\n 24h total out:\n 1,390 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 02:15 AM\n Potassium:\n 3.6 mEq/L\n 02:15 AM\n Chloride:\n 106 mEq/L\n 02:15 AM\n CO2:\n 19 mEq/L\n 02:15 AM\n BUN:\n 14 mg/dL\n 02:15 AM\n Creatinine:\n 0.8 mg/dL\n 02:15 AM\n Glucose:\n 132 mg/dL\n 02:15 AM\n Hematocrit:\n 29.7 %\n 02:15 AM\n Finger Stick Glucose:\n 221\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:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2201-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 453046, "text": "Subdural hemorrhage (SDH)\n Assessment:\n n Ox1\n n As baseline, pt does not move LUE d/t old embolic stroke (\n n Moving other extremities occasionally to command, able to lift\n and hold RU/RLE, moves LLE on bed\n n Patient will open eyes to speech/stimuli\n n Pupils 3-4mm, R slightly larger and irregular in comparison to\n L\n n Reported headache a few times during shift, otherwise stating\n to pain\n Action:\n n Dilaudid IVP 0.25mg for h/a\n n Neuro checks Q1\n n\n Response:\n With assistance patient able to clear secretions, maintain patent\n airway.\n Inr 1.2 at time of report (parameters is to keep inr <1.4)\n Pain controlled with iv Dilaudid patient comfortable at time of report.\n Hct remains >29. WBC 15.8 team aware.\n Patient tolerated phosphate, calcium and potassium supplement.\n Plan:\n Patient to remains npo, may need speech and swallow evaluation\n Will recheck pt at 20pm Inr to be kept <1.4\n Continue with frequent chest pt and pulmonary toileting.\n Continue to monitor Neuro checks Q1.\n Administer analgesia to keep patient comfortable and monitor\n effectiveness\n If patient continues to improve patient may transfer out of unit.\n .H/O hypertension, benign\n Assessment:\n Patient SBP 115-155\n Action:\n Patient SBP to be kept <140\n Iv hydralazine 10mgs given prn\n Iv lopressor 5-10mgs given prn to maintain SBP within parameters\n Response:\n SBP with parameters\n Plan:\n To continue to monitor and treat accordingly to maintain SBP <140\n Tomorrow parameters will be increase to maintain SBP <150\n" }, { "category": "Nursing", "chartdate": "2201-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 453057, "text": "Subdural hemorrhage (SDH)\n Assessment:\n Ox1As baseline, pt does not move LUE d/t old embolic stroke (\n Moving other extremities occasionally to command, able to lift and\n hold RU/RLE, moves LLE on bed\n Patient will open eyes to speech/stimuli\n Pupils 3-4mm, R slightly larger and irregular in comparison to L\n Reported headache a few times during shift, otherwise stating\n to pain\n Action:\n Dilaudid IVP 0.25mg for h/a\n Neuro checks Q1\n Coags drawn q6 d/t elevated INR on admission to \n Response:\n Pt getting good relief from dilaudid IVP\n Plan:\n Continue to monitor Neuro checks Q1\n Dilaudid PRN for h/a\n Inr to be kept <1.4\n CT today\n .H/O hypertension, benign\n Assessment:\n Art line difficult to draw from, inaccurate waveform in\n beginning of shift\n Dr. SICU resident in to attempt to re-wire/re-site\n art line\n Per Dr. (present during attempt to re-site), discontinue\n the art line and use NBP for SBP goal <140\n BP ranging from 90s-140s\n Action:\n PRN lopressor 10mg IVP x1\n Response:\n SBP with parameters with use of dilaudid during times of\n pain/headache and PRN lopressor\n Plan:\n SBP <140 to be lessened to <150 today\n" }, { "category": "Physician ", "chartdate": "2201-03-23 00:00:00.000", "description": "Intensivist Note", "row_id": 453135, "text": "SICU\n HPI:\n Date HD 3 POD 2\n .\n Abx: vancomycin\n .\n AC: boots\n .\n CC: .\n HPI:This is a 73 year old patient who is on Coumadin for an\n embolic stroke in and fell at 0500 this morning when he was\n getting out of bed. This fall was unwitnessed, but his wife\n heard him fall and went immediately to the bedroom to his side.\n He was brought to ED and then was transferred here\n for further evaluation. Upon arrival to the ED his INR was 5.6 he\n was reversed with Vitamin K, profiline, and FFP.\n .\n PMH:\n .embolic stroke \n PSH:\n .\n Meds:Diovan, tramadol, Coumadin,\n Cyplex, Tylenol\n .\n :coumadin, diovan, tramadol, ceplex, tylenol\n .\n ALLERGIES: NKDA\n .\n 24 HOUR EVENTS:\n : emergent evacuation of the subdural hematoma. in OR--required\n pressors, off on admission to SICU, remained intubated.\n : Extubated without complication. Tachypneic but oxygenating well.\n Lost arterial line.\n .\n MICRO:\n .\n Imaging/Diagnostics:\n CT head: Status post right craniotomy and SDH evacuation with new\n small leftward shift of 4 mm. More apparent hypodensity around dilated\n posterior right lateral ventricle. Similar left frontal ICH. More\n apparent left frontal subdural hematoma.\n CT torso: negative\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 10:58 AM\n ARTERIAL LINE - STOP 08:24 PM\n Post operative day:\n POD#2 - R crani for evacuation SDH\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Gentamicin - 04:00 PM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 04:00 PM\n Famotidine (Pepcid) - 07:45 PM\n Metoprolol - 10:50 PM\n Hydromorphone (Dilaudid) - 01:57 AM\n Other medications:\n Flowsheet Data as of 06:06 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: 37.3\nC (99.2\n HR: 92 (73 - 111) bpm\n BP: 105/79(84) {90/41(44) - 143/79(87)} mmHg\n RR: 23 (15 - 32) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.7 kg (admission): 70 kg\n CVP: 3 (0 - 11) mmHg\n Total In:\n 3,386 mL\n 655 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,386 mL\n 655 mL\n Blood products:\n Total out:\n 2,715 mL\n 600 mL\n Urine:\n 2,715 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 671 mL\n 56 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 800 (800 - 800) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 12 cmH2O\n SPO2: 96%\n ABG: 7.48/25/180/19/-2\n Ve: 16 L/min\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: NAD\n HEENT: PERRL; right facial / orbital edema.\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : mild)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 1), No(t) Moves all\n extremities, (LUE: Weakness), LUE contracture at wrist\n Labs / Radiology\n 281 K/uL\n 10.0 g/dL\n 132 mg/dL\n 0.8 mg/dL\n 19 mEq/L\n 3.6 mEq/L\n 14 mg/dL\n 106 mEq/L\n 135 mEq/L\n 29.7 %\n 18.1 K/uL\n [image002.jpg]\n 10:41 PM\n 12:51 AM\n 02:19 AM\n 04:15 AM\n 05:49 AM\n 05:55 AM\n 10:02 AM\n 02:27 PM\n 05:38 PM\n 02:15 AM\n WBC\n 10.7\n 12.8\n 15.0\n 15.8\n 18.1\n Hct\n 27.9\n 30.4\n 31.1\n 30.9\n 31.3\n 29.6\n 29.7\n Plt\n 272\n 278\n 304\n 292\n 281\n Creatinine\n 0.8\n 0.9\n 0.9\n 0.8\n TCO2\n 21\n 23\n 19\n Glucose\n 165\n 75\n 225\n 67\n 132\n Other labs: PT / PTT / INR:14.2/25.8/1.2, Lactic Acid:1.8 mmol/L,\n Ca:8.2 mg/dL, Mg:1.8 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n .H/O FALL(S), .H/O HYPERTENSION, BENIGN, .H/O CVA (STROKE, CEREBRAL\n INFARCTION), OTHER , SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: Assessment and Plan: 73y man with R SDH s/p\n craniotomy and evacuation.\n .\n Neurologic: Neuro checks Q: 1 hr, dexamethasone taper for cerebral\n edema.\n Cardiovascular: hydralazine and lopressor for BP>140\n Pulmonary: Cont ETT, (Ventilator mode: CMV), wean as tolerated\n Gastrointestinal / Abdomen: stable\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: vitamin K for coumadin reversal x3 days, follow coags\n Endocrine: ISS, dexamethasone taper\n Infectious Disease: vancomycin post op\n Lines / Tubes / Drains: Foley, RIJ CVL\n Wounds: R craniotomy - CDI\n Imaging: none\n Fluids: NS, 75 cc/hr\n Consults: Neurosurgery\n Dispo: Floor\n Billing Diagnosis: Respiratory failure; SDH\n ICU Care\n Lines:\n 18 Gauge - 10:30 PM\n Multi Lumen - 10:40 PM\n Total time spent: 33\n" }, { "category": "Rehab Services", "chartdate": "2201-03-23 00:00:00.000", "description": "Deferred Bedside Swallow Evaluation", "row_id": 453137, "text": "TITLE:\nATTEMPTED BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 73 y/o male on Coumadin s/p\nembolic CVA in admitted on s/p fall while getting\nOOB. Pt was taken to OSH where CT scan showed large right sided\nSDH s/p craniotomy for subdural hematoma evacuation on . Pt\nwas weaned and extubated . We were consulted to evaluate the\npt for oral and pharyngeal dysphagia.\nDEFERRED EVALUATION:\nRN reported pt was minimally responsive, but does wake and answer\nsome basic questions appropriate. I discussed with MD and it was\nagreed upon to postpone the evaluation and place a Dobbhoff for\nalternate means of nutrition until pt wakes up further.\nRECOMMENDATIONS:\n1. Suggest pt remain strictly NPO, including meds and ice chips.\n2. Q4 oral care.\n3. Dobbhoff for alternate means of nutrition, hydration and\nmedication. Please consult nutrition for tube feed recs.\n4. We will f/u later in the week to evaluate once more awake and\nalert.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nTotal time: 20 minutes\n [BUTTON Input] (not implemented)_____\n 10:27\n" }, { "category": "Nursing", "chartdate": "2201-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 453223, "text": "Subdural hemorrhage (SDH)\n Assessment:\n pt lethargic. Oriented to person. Opens eyes to voice and pain at\n times. Min movement of left side, per baseline. Left hand contact.\n Moves right side spont, lifts/holds. Occ follows commands. Perrl. Right\n eye very swollen. Incision wnl.. no sz. Too lethargic to take po\ns. sbp\n <140.\n Action:\n neuro checks. Keepra. Had head ct.\n Response:\n unchanged\n Plan:\n neuro checks. ? doboff. To floor when bed avail.\n" }, { "category": "Nursing", "chartdate": "2201-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 453225, "text": "Subdural hemorrhage (SDH)\n Assessment:\n pt lethargic. Oriented to person. Opens eyes to voice and pain at\n times. Min movement of left side, per baseline. Left hand contact.\n Moves right side spont, lifts/holds. Occ follows commands. Perrl. Right\n eye very swollen. Incision wnl.. no sz. Too lethargic to take po\ns. sbp\n <140.\n Action:\n neuro checks. Keepra. Had head ct.\n Response:\n unchanged\n Plan:\n neuro checks. ? doboff. To floor when bed avail.\n Physical therapy in to eval. Pt dangled on side of bed, tol well.\n" }, { "category": "Nursing", "chartdate": "2201-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 452843, "text": "HPI: This is a 73 year old patient who is on Coumadin for an\n embolic stroke in and fell at 0500 this morning when he was\n getting out of bed. This fall was unwitnessed, but his wife\n heard him fall and went immediately to the bedroom to his side.\n He was brought to ED and then was transferred here\n for further evaluation. Upon arrival to the ED his INR was 5.6 he\n was reversed with Vitamin K, profiline, and FFP.\n" }, { "category": "Nursing", "chartdate": "2201-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 453025, "text": "73 year old patient who is on Coumadin for an embolic stroke in \n and fell when he was\n getting out of bed. This fall was unwitnessed, but his wife heard him\n fall and went immediately to the bedroom to his side. He was brought\n to ED and then was transferred here\n for further evaluation. Upon arrival to the ED his INR was 5.6, hct 16\n he was reversed with Vitamin K, profiline, and FFP. Pt received 4\n units\n pRBCs, 2 unit\ns platelets. R crani done for evacuation of large\n hematoma under Dr.. Pt arrived to SICU around 2300.\n Subdural hemorrhage (SDH)\n Assessment:\n Patient intubated on cpap at being of shift. Sedation had been wean\n off, patient extubated at @ 11am.\n Placed on 100% fio2 for 24hrs (to finish at 23pm )\n Lungs clear, moderate amount of secretions noted, patient has strong\n cough, however needs assistance with clearing of secretions with oral\n suctioning.\n Patient will open eyes to speech, perrla.\n Speech is garbled, orientated x1, but will follow commands.\n Right ue/le patient able to given strong hand grasp, wiggle toes. Moves\n spontaneously.\n Left ue /le contracted from previous cva patient is able to given a\n weak toe wiggle to command.\n Complains of headache.\n Patient had high inr prior to surgery, labs monitored Q4 throughout\n day.\n Patient to lethargic to safely have po intake.\n Action:\n Chest pt and pulmonary toileting preformed to clear secretions.\n Nebs ordered and administered.\n Abg obtained to monitor resp status. Dr results\n Patient continues on 100% fio2 until 23pm\n Cbc and pt monitored Q4, Vit k given as ordered (patient to have 3\n daily doses)\n Phosphate, calcium and potassium replaced as ordered.\n Iv Dilaudid given for discomfort.\n Patient remains npo, with frequent oral hygiene.\n Monitor neuro checks Q1 hrly\n Response:\n With assistance patient able to clear secretions, maintain patent\n airway.\n Inr 1.2 at time of report (parameters is to keep inr <1.4)\n Pain controlled with iv Dilaudid patient comfortable at time of report.\n Hct remains >29. WBC 15.8 team aware.\n Patient tolerated phosphate, calcium and potassium supplement.\n Plan:\n Patient to remains npo, may need speech and swallow evaluation\n Will recheck pt at 20pm Inr to be kept <1.4\n Continue with frequent chest pt and pulmonary toileting.\n Continue to monitor Neuro checks Q1.\n Administer analgesia to keep patient comfortable and monitor\n effectiveness\n If patient continues to improve patient may transfer out of unit.\n .H/O hypertension, benign\n Assessment:\n Patient SBP 115-155\n Action:\n Patient SBP to be kept <140\n Iv hydralazine 10mgs given prn\n Iv lopressor 5-10mgs given prn to maintain SBP within parameters\n Response:\n SBP with parameters\n Plan:\n To continue to monitor and treat accordingly to maintain SBP <140\n Tomorrow parameters will be increase to maintain SBP <150\n" }, { "category": "Physician ", "chartdate": "2201-03-23 00:00:00.000", "description": "Intensivist Note", "row_id": 453087, "text": "SICU\n HPI:\n Date HD 3 POD 2\n .\n Abx: vancomycin\n .\n AC: boots\n .\n CC: .\n HPI:This is a 73 year old patient who is on Coumadin for an\n embolic stroke in and fell at 0500 this morning when he was\n getting out of bed. This fall was unwitnessed, but his wife\n heard him fall and went immediately to the bedroom to his side.\n He was brought to ED and then was transferred here\n for further evaluation. Upon arrival to the ED his INR was 5.6 he\n was reversed with Vitamin K, profiline, and FFP.\n .\n PMH:\n .embolic stroke \n PSH:\n .\n Meds:Diovan, tramadol, Coumadin,\n Cyplex, Tylenol\n .\n :coumadin, diovan, tramadol, ceplex, tylenol\n .\n ALLERGIES: NKDA\n .\n 24 HOUR EVENTS:\n : emergent evacuation of the subdural hematoma. in OR--required\n pressors, off on admission to SICU, remained intubated.\n : Extubated without complication. Tachypneic but oxygenating well.\n Lost arterial line.\n .\n MICRO:\n .\n Imaging/Diagnostics:\n CT head: Status post right craniotomy and SDH evacuation with new\n small leftward shift of 4 mm. More apparent hypodensity around dilated\n posterior right lateral ventricle. Similar left frontal ICH. More\n apparent left frontal subdural hematoma.\n CT torso: negative\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 10:58 AM\n ARTERIAL LINE - STOP 08:24 PM\n Post operative day:\n POD#2 - R crani for evacuation SDH\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Gentamicin - 04:00 PM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 04:00 PM\n Famotidine (Pepcid) - 07:45 PM\n Metoprolol - 10:50 PM\n Hydromorphone (Dilaudid) - 01:57 AM\n Other medications:\n Flowsheet Data as of 06:06 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: 37.3\nC (99.2\n HR: 92 (73 - 111) bpm\n BP: 105/79(84) {90/41(44) - 143/79(87)} mmHg\n RR: 23 (15 - 32) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.7 kg (admission): 70 kg\n CVP: 3 (0 - 11) mmHg\n Total In:\n 3,386 mL\n 655 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,386 mL\n 655 mL\n Blood products:\n Total out:\n 2,715 mL\n 600 mL\n Urine:\n 2,715 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 671 mL\n 56 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 800 (800 - 800) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 12 cmH2O\n SPO2: 96%\n ABG: 7.48/25/180/19/-2\n Ve: 16 L/min\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : mild)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 1), No(t) Moves all\n extremities, (LUE: Weakness), LUE contracture at wrist\n Labs / Radiology\n 281 K/uL\n 10.0 g/dL\n 132 mg/dL\n 0.8 mg/dL\n 19 mEq/L\n 3.6 mEq/L\n 14 mg/dL\n 106 mEq/L\n 135 mEq/L\n 29.7 %\n 18.1 K/uL\n [image002.jpg]\n 10:41 PM\n 12:51 AM\n 02:19 AM\n 04:15 AM\n 05:49 AM\n 05:55 AM\n 10:02 AM\n 02:27 PM\n 05:38 PM\n 02:15 AM\n WBC\n 10.7\n 12.8\n 15.0\n 15.8\n 18.1\n Hct\n 27.9\n 30.4\n 31.1\n 30.9\n 31.3\n 29.6\n 29.7\n Plt\n 272\n 278\n 304\n 292\n 281\n Creatinine\n 0.8\n 0.9\n 0.9\n 0.8\n TCO2\n 21\n 23\n 19\n Glucose\n 165\n 75\n 225\n 67\n 132\n Other labs: PT / PTT / INR:14.2/25.8/1.2, Lactic Acid:1.8 mmol/L,\n Ca:8.2 mg/dL, Mg:1.8 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n .H/O FALL(S), .H/O HYPERTENSION, BENIGN, .H/O CVA (STROKE, CEREBRAL\n INFARCTION), OTHER , SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: Assessment and Plan: 73y man with R SDH s/p\n craniotomy and evacuation.\n .\n Neurologic: Neuro checks Q: 1 hr, dexamethasone taper for cerebral\n edema.\n Cardiovascular: hydralazine and lopressor for BP>140\n Pulmonary: Cont ETT, (Ventilator mode: CMV), wean as tolerated\n Gastrointestinal / Abdomen: stable\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: vitamin K for coumadin reversal x3 days, follow coags\n Endocrine: ISS, dexamethasone taper\n Infectious Disease: vancomycin post op\n Lines / Tubes / Drains: Foley, RIJ CVL\n Wounds: R craniotomy - CDI\n Imaging: none\n Fluids: NS, 75 cc/hr\n Consults: Neurosurgery\n Dispo:\n Billing Diagnosis:\n ICU Care\n Lines:\n 18 Gauge - 10:30 PM\n Multi Lumen - 10:40 PM\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2201-03-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 453187, "text": "73 year old patient who is on Coumadin for an embolic stroke in \n and fell when he was\n getting out of bed on .This fall was unwitnessed, but his\n wife heard him fall and went immediately to the bedroom to his side.\n He was brought to ED and then was transferred here\n for further evaluation. Upon arrival to the ED his INR was 5.6, hct 16\n he was reversed with Vitamin K, profiline, and FFP. Pt received 4\n units pRBCs, 2 units platelets. R crani done on for evacuation of\n large hematoma. He has since been extubated and is now stable for tx to\n floor.\n Subdural hemorrhage (SDH)\n Assessment:\n Pt lethargic. Opens eyes at times to voice and pain. Perrl. Right\n eye/face very swollen. Left side with min movement on bed at baseline\n from cva in\n99. has contracted left hand at baseline. moves right side\n to command at times. Lifts/holds on right. Oriented to person. Saying\n only a few words and inconsistently. Incision ota, wnl. No sz activity.\n Pt too lethargic to swallow pills. Sbp <140.\n Action:\n Neuro checks. keepra.\n Response:\n Unchanged.\n Plan:\n Con\nt neuro checks. Keepra. Monitor bp. ? doboff.\n Physical therapy following pt. PT dangled on side of bed, see Physical\n therapy note.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n SUBDURAL HEMATOMA\n Code status:\n Full code\n Height:\n Admission weight:\n 70 kg\n Daily weight:\n 65.7 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: CVA, Hypertension\n Additional history: embolic stoke in \n Surgery / Procedure and date: CT/CT SPINE- \n R SDH evacuation, crani- \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:63\n Temperature:\n 99.1\n Arterial BP:\n S:201\n D:186\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 104 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 1,471 mL\n 24h total out:\n 1,390 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 02:15 AM\n Potassium:\n 3.6 mEq/L\n 02:15 AM\n Chloride:\n 106 mEq/L\n 02:15 AM\n CO2:\n 19 mEq/L\n 02:15 AM\n BUN:\n 14 mg/dL\n 02:15 AM\n Creatinine:\n 0.8 mg/dL\n 02:15 AM\n Glucose:\n 132 mg/dL\n 02:15 AM\n Hematocrit:\n 29.7 %\n 02:15 AM\n Finger Stick Glucose:\n 221\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:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2201-03-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 453265, "text": "73 year old patient who is on Coumadin for an embolic stroke in \n and fell when he was\n getting out of bed on .This fall was unwitnessed, but his\n wife heard him fall and went immediately to the bedroom to his side.\n He was brought to ED and then was transferred here\n for further evaluation. Upon arrival to the ED his INR was 5.6, hct 16\n he was reversed with Vitamin K, profiline, and FFP. Pt received 4\n units pRBCs, 2 units platelets. R crani done on for evacuation of\n large hematoma. He has since been extubated and is now stable for tx to\n floor.\n Subdural hemorrhage (SDH)\n Assessment:\n Pt lethargic. Opens eyes at times to voice and pain. Perrl. Right\n eye/face very swollen. Left side with min movement on bed at baseline\n from cva in\n99. has contracted left hand at baseline. moves right side\n to command at times. Lifts/holds on right. Oriented to person. Saying\n only a few words and inconsistently. Incision ota, wnl. No sz activity.\n Pt too lethargic to swallow pills. Sbp <140.\n Action:\n Neuro checks. keepra.\n Response:\n Unchanged.\n Plan:\n Con\nt neuro checks. Keepra. Monitor bp. ? doboff.\n Physical therapy following pt. PT dangled on side of bed, see Physical\n therapy note.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n SUBDURAL HEMATOMA\n Code status:\n Full code\n Height:\n Admission weight:\n 70 kg\n Daily weight:\n 65.7 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: CVA, Hypertension\n Additional history: embolic stoke in \n Surgery / Procedure and date: CT/CT SPINE- \n R SDH evacuation, crani- \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:63\n Temperature:\n 99.1\n Arterial BP:\n S:201\n D:186\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 104 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 1,471 mL\n 24h total out:\n 1,390 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 02:15 AM\n Potassium:\n 3.6 mEq/L\n 02:15 AM\n Chloride:\n 106 mEq/L\n 02:15 AM\n CO2:\n 19 mEq/L\n 02:15 AM\n BUN:\n 14 mg/dL\n 02:15 AM\n Creatinine:\n 0.8 mg/dL\n 02:15 AM\n Glucose:\n 132 mg/dL\n 02:15 AM\n Hematocrit:\n 29.7 %\n 02:15 AM\n Finger Stick Glucose:\n 221\n 10:00 AM\n Valuables / Signature\n Patient valuables: dentures with pt\n 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: 11\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2201-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 452897, "text": "73 year old patient who is on Coumadin for an embolic stroke in \n and fell when he was\n getting out of bed. This fall was unwitnessed, but his wife heard him\n fall and went immediately to the bedroom to his side. He was brought\n to ED and then was transferred here\n for further evaluation. Upon arrival to the ED his INR was 5.6, hct 16\n he was reversed with Vitamin K, profiline, and FFP. Pt received 4\n units pRBCs, 2 units platelets. R crani done for evacuation of large\n hematoma under Dr.. Pt arrived to SICU around 2300.\n Subdural hemorrhage (SDH)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2201-03-22 00:00:00.000", "description": "Intensivist Note", "row_id": 452901, "text": "SICU\n HPI:\n This is a 73 year old patient who is on Coumadin for an\n embolic stroke in and fell at 0500 this morning when he was\n getting out of bed. This fall was unwitnessed, but his wife\n heard him fall and went immediately to the bedroom to his side.\n He was brought to ED and then was transferred here\n for further evaluation. Upon arrival to the ED his INR was 5.6 he\n was reversed with Vitamin K, profiline, and FFP.\n Chief complaint:\n SDH s/p fall\n PMHx:\n embolic stroke \n Current medications:\n . 1000 mL NS\n Continuous at 75 ml/hr\n Change to peripheral lock when taking POs Order date: @ 12.\n Gentamicin 80 mg IV Q8H Duration: 3 Doses Order date: @ \n 2. Acetaminophen 325-650 mg PO Q6H:PRN\n do not excedd 4 grams in 24 hours Order date: @ 13.\n HYDROmorphone (Dilaudid) 0.125 mg IV Q3H:PRN\n hold lethargy or RR < 12 Order date: @ \n 3. Bisacodyl 10 mg PO/PR DAILY Order date: @ 14. Heparin\n Flush (10 units/ml) 3 mL IV PRN Order date: @ 2242\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 2218 15. HydrALAzine 10 mg IV Q6H:PRN\n for sbp > 140 Order date: @ \n 5. Dexamethasone 4 mg iv q6 Duration: 24 Hours Order date: @ \n 16. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 2206\n 6. Dexamethasone 3 mg iv q6 Duration: 24 Hours Start: After 4 mg\n tapered dose. Order date: @ 17. LeVETiracetam 1000 mg IV\n BID Order date: @ 0443\n 7. Dexamethasone 2 mg iv q6 Duration: 24 Hours Start: After 3 mg\n tapered dose. Order date: @ 18. Ondansetron 4 mg IV Q8H:PRN\n call neurosurg for nausea or vomiting post-op but may give- pager\n Order date: @ \n 8. Dexamethasone 1 mg iv q6 Duration: 24 Hours Start: After 2 mg\n tapered dose. Order date: @ 19. Pneumococcal Vac Polyvalent\n 0.5 ml IM ASDIR Order date: @ 1807\n 9. Dexamethasone 0 mg iv q6 Duration: 24 Hours Start: After 1 mg\n tapered dose. Order date: @ 20. Propofol 20-100 mcg/kg/min\n IV DRIP TITRATE TO comfort Order date: @ 0034\n 10. Docusate Sodium 100 mg PO BID Order date: @ 21. Senna 1\n TAB PO BID Order date: @ \n 11. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 2206 22. Vancomycin 1000 mg IV Q 12H Duration: 3 Days Order date:\n @ \n 24 Hour Events:\n MULTI LUMEN - START 10:40 PM\n ARTERIAL LINE - START 10:41 PM\n ARTERIAL LINE - START 10:42 PM\n ARTERIAL LINE - STOP 10:44 PM\n OR RECEIVED - At 10:52 PM\n ARTERIAL LINE - START 11:00 PM\n ARTERIAL LINE - STOP 11:50 PM\n INVASIVE VENTILATION - START 12:00 AM\n Post operative day:\n POD#1 - R crani for evacuation SDH\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:13 PM\n Gentamicin - 12:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37.3\nC (99.1\n HR: 77 (67 - 77) bpm\n BP: 107/20(45) {93/19(44) - 159/78(114)} mmHg\n RR: 18 (15 - 25) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69 kg (admission): 70 kg\n Total In:\n 4,830 mL\n 791 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,353 mL\n 791 mL\n Blood products:\n 2,477 mL\n Total out:\n 720 mL\n 945 mL\n Urine:\n 220 mL\n 945 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,110 mL\n -154 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n PS : 5 cmH2O\n RR (Set): 15\n PEEP: 5 cmH2O\n FiO2: 100%\n RSBI: 29\n RSBI Deferred: FiO2 > 60%\n PIP: 13 cmH2O\n Plateau: 12 cmH2O\n SPO2: 100%\n ABG: 7.46/32/440/20/0\n Ve: 10.7 L/min\n PaO2 / FiO2: 440\n Physical Examination\n HEENT: Left pupil dilated\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, benign.\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: Sedated; Left sided hemiparesis; F.C.\n Labs / Radiology\n 278 K/uL\n 10.6 g/dL\n 75 mg/dL\n 0.9 mg/dL\n 20 mEq/L\n 4.4 mEq/L\n 18 mg/dL\n 113 mEq/L\n 142 mEq/L\n 31.1 %\n 12.8 K/uL\n [image002.jpg]\n 07:55 PM\n 10:41 PM\n 12:51 AM\n 02:19 AM\n 04:15 AM\n 05:55 AM\n WBC\n 10.7\n 12.8\n Hct\n 22\n 27.9\n 30.4\n 31.1\n Plt\n 272\n 278\n Creatinine\n 0.8\n 0.9\n TCO2\n 23\n 21\n 23\n Glucose\n 177\n 165\n 75\n Other labs: PT / PTT / INR:14.0/25.9/1.2, Lactic Acid:1.1 mmol/L,\n Ca:8.3 mg/dL, Mg:2.1 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n .H/O FALL(S), .H/O HYPERTENSION, BENIGN, .H/O CVA (STROKE, CEREBRAL\n INFARCTION), OTHER , SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 1 hr, stable, sedated on propofol\n Cardiovascular: stable, hydralazine for BP>140; Start Lopressor IV PRN\n and transition to PO; need labetalol gtt for SBP <140.\n Pulmonary: Cont ETT, (Ventilator mode: CMV), wean as tolerated\n extubate after Head CT this AM.\n Gastrointestinal / Abdomen: Place NGT\n Nutrition: NPO\n Renal: Foley, Adequate UO\n cont to follow UOP.\n Hematology: Coumadin coagulopathy\n follow coags Q6hours and give FFP\n for INR < 1.4; Will cont Vitamin K x 3 days.\n Endocrine: RISS\n Infectious Disease: periop Vancomycin/Gent per primary team.\n Lines / Tubes / Drains: Foley, ETT, RIJ, Right radial A-line\n Wounds: dry dressing\n Imaging: CXR today\n Fluids: NS, 75 cc/hr\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:30 PM\n 20 Gauge - 10:38 PM\n Multi Lumen - 10:40 PM\n Arterial Line - 11:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2Blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full\n Disposition: SICU\n Total time spent: 32\n Patient is critically ill\n" }, { "category": "Radiology", "chartdate": "2201-03-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1072734, "text": " 9:42 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: post-op changes\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p evacuation right SDH\n REASON FOR THIS EXAMINATION:\n post-op changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GWp SUN 12:07 AM\n PFI: Status post evacuation right SDH with significant pneumocephalus and new\n small leftward shift of 4 mm.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 73-year-old man status post evacuation of right SDH postop\n changes.\n\n COMPARISON: \n\n TECHNIQUE: Non-contrast head CT\n\n FINDINGS: The patient is status post evacuation of large right subdural\n hematoma and there is significant pneumocephalus and small new leftward shift\n (series 3, image 20) of 4 mm. A small amount of extra-axial fluid remains\n (series 2, images 21). Hypodensity surrounding the posterior right lateral\n ventricle is more pronounced than before. Again seen is a 10 x 12 mm\n hyperdensity in the left frontal lobe, similar to prior, likely representing a\n left frontal intraparenchymal hemorrhage (series 3, image 20) and a small 5 mm\n subdural hematoma, more pronounced than on prior (series 3, image 23). The\n patient is status post right parietal craniotomy. The mastoid air cells and\n visualized paranasal sinuses are clear.\n\n IMPRESSION:\n 1. Status post right craniotomy and SDH evacuation with new small leftward\n shift of 4 mm.\n 2. More apparent hypodensity around the apparently dilated posterior right\n lateral ventricle.\n 3. Similar size of left frontal intraparenchymal hemorrhage.\n 4. More apparent left frontal subdural hematoma.\n\n NOTE ADDED AT ATTENDING REVIEW: The tension pneumocephalus noted above has\n resulted in substantially increased mass effect, compression of the right\n lateral ventricle, and midline shift.\n\n This finding was discussed with Dr. at 8:55 am on . Aparently the\n patient is doing quite well, and observation with follow up imaging is\n planned.\n (Over)\n\n 9:42 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: post-op changes\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2201-03-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1072735, "text": ", C. NSURG SICU-B 9:42 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: post-op changes\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p evacuation right SDH\n REASON FOR THIS EXAMINATION:\n post-op changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT (REVISED)\n PFI: Status post evacuation right SDH with significant pneumocephalus and new\n small leftward shift of 4 mm.\n\n" }, { "category": "Radiology", "chartdate": "2201-03-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1072682, "text": " 2:41 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for change / shift\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with SDH about 4.8 x 2.3 cm\n REASON FOR THIS EXAMINATION:\n please eval for change / shift\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JMGw SAT 3:24 PM\n unchanged large 4.3 right temporo/pariteal/occipital acute on chronic SHD with\n no shift of midline or herniation. severe right frontal encephalomalacia with\n dilation of the right frontal of lateral ventricle. compression of right\n lateral ventricle temporal . stable left frontal parenchymal hemorrhagic\n contusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old man with subdural hematoma measuring 4.8 x 2.3 cm,\n evaluate for change or shift.\n\n HEAD CT\n\n TECHNIQUE: Contiguous axial imaging was performed through the brain without\n administration of intravenous contrast. Coronal and sagittal reformats were\n obtained.\n\n COMPARISON: Outside reference head CT from performed\n approximately three hours prior to the study.\n\n FINDINGS: There is a large volume of hyperdense and isodense extra-axial\n material layering along the right convexity along the frontal, temporal,\n parietal, and occipital lobes. The appearance of this is consistent with an\n acute on chronic subdural hematoma. In greatest transverse dimension, the\n subdural hematoma measures 4.3 cm, which appears grossly stable in size\n compared to the previous study. Hemorrhage layers along the tentorium. An\n additional 13 mm area of high-density material layering along the right falx\n related to falcine subdural hematoma. Along the left frontal convexity is a 5-\n mm area of intermediate density (2:20) which may represent a chronic subdural\n hematoma, which is stable compared to the prior CT. In the left frontal lobe\n (2:15) is a 7-mm area of hyperdense material likely representing an area of\n intraparenchymal injury, which may be due to a contusion type injury. There\n is extra-axial hyperdense material adjacent to this, which may represent a\n small acute subdural hematoma.\n\n The left lateral ventricle appears normal in size. The frontal of the\n right lateral ventricle is enlarged, compatible with ex vacuo dilatation.\n There is severe encephalomalacia of the right frontal lobe. The posterior \n of the right lateral ventricle is compressed by the large subdural hematoma\n with anterior displacement of the right choroid plexus. There is no evidence\n for shift of midline and no evidence for herniation. No evidence for acute\n territorial infarction. No fracture is seen. The paranasal sinuses appear\n clear.\n (Over)\n\n 2:41 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for change / shift\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Unchanged large acute on chronic right subdural hematoma. No significant\n shift of midline. There is compression of the temporal of the right\n lateral ventricle.\n 2. Severe encephalomalacia of the right frontal lobe compatible with prior\n infarction.\n 3. Hemorrhagic contusion in the left frontal lobe with small adjacent area of\n acute subdural hematoma.\n 4. Unchanged chronic left frontal subdural hematoma.\n\n" }, { "category": "Radiology", "chartdate": "2201-03-21 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1072698, "text": " 3:47 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ;l for trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p fall, large head bleed\n REASON FOR THIS EXAMINATION:\n ;l for trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc SAT 4:37 PM\n No traumatic injury to the torso.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall with large head bleed, evaluate for trauma.\n\n CT TORSO WITH CONTRAST\n\n COMPARISON: Chest radiograph .\n\n TECHNIQUE: Contiguous axial imaging was performed from the thoracic inlet\n through the pubic symphysis following administration of IV contrast. Oral\n contrast was not administered. Sagittal and coronal reformats were obtained.\n\n CT CHEST WITH CONTRAST: There is bilateral predominantly apical emphysematous\n change with bibasilar dependent atelectasis. No masses, nodules or pleural\n effusions were seen. Airways are patent to the segmental levels bilaterally.\n There is diffuse atherosclerotic calcification of the coronary\n arterial vasculature. The thoracic aorta appears normal. No significant\n axillary, hilar, or mediastinal adenopathy is present. No pneumothorax.\n\n CT ABDOMEN WITH CONTRAST: The spleen, adrenals, pancreas, gallbladder, and\n liver appear normal. The kidneys enhance and excrete contrast symmetrically\n without stones, masses, or hydronephrosis. The abdominal aorta and its\n branches are widely patent, although there is atherosclerotic calcification of\n the abdominal aorta, renal arteries, and superior mesenteric artery.\n Calcifications are also present within the splenic artery. Stomach and\n abdominal loops of small bowel appear normal. No free air and no free fluid\n is seen. No retroperitoneal or mesenteric adenopathy is present.\n\n CT PELVIS WITH CONTRAST: There is a Foley present in a decompressed bladder.\n Tiny foci of air are seen in the bladder, likely related to the presence of a\n Foley catheter. There is thickening of the bladder wall, which may be due to\n its decompressed state. The rectum appears normal. There are scattered\n sigmoid diverticula without evidence for diverticulitis. Pelvic loops of\n small and large bowel otherwise appear normal. No free air and no free fluid\n is seen. No pelvic or inguinal adenopathy is present. There is hernia repair\n material in the patient's right abdominal lower wall.\n\n BONE WINDOWS: There are degenerative changes throughout the thoracolumbar\n spine. No suspicious sclerotic or lytic lesions are identified. No fractures\n identified.\n (Over)\n\n 3:47 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ;l for trauma\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. No traumatic pathology identified and no evidence for hemorrhage.\n 2. Emphysematous change in bilateral lungs, predominantly in the apices.\n 3. Dense atherosclerotic calcification of the abdominal aorta and its\n mesenteric branches but no evidence for aneurysm or obstruction of flow.\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2201-03-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1072919, "text": " 10:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval CVL position\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p SDH, R IJ line partially pulled\n REASON FOR THIS EXAMINATION:\n eval CVL position\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:31 A.M. \n\n HISTORY: Subdural hematoma. Right IJ line repositioned. Please evaluate.\n\n IMPRESSION: AP chest compared to :\n\n Tip of the right internal jugular line ends just below the thoracic inlet,\n probably in the right internal jugular vein. Small left pleural effusion is\n new. No right pleural effusion, pneumothorax or mediastinal widening. Heart\n size normal. Lungs grossly clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-03-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1073035, "text": " 6:28 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval NGT placement for tube feeds\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p evacuation of large right subdural hematoma\n REASON FOR THIS EXAMINATION:\n eval NGT placement for tube feeds\n ______________________________________________________________________________\n WET READ: PXDb MON 7:13 PM\n NG tube in standard location. Interval removal of right IJ. Elevated\n appearanceof left hemidiaphragm, no other interval changes. ( )\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: For nasogastric tube placement.\n\n FINDINGS: In comparison with the earlier study of this date, the nasogastric\n tube has been placed with the tip in the upper portion of the stomach. The\n side hole is at about the level of the esophagogastric junction.\n\n The right IJ catheter has been removed.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-03-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1073591, "text": " 11:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for aspiration PNA:\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p crani for SDH; lethargic MS, high potential of\n Aspiration.\n REASON FOR THIS EXAMINATION:\n please evaluate for aspiration PNA:\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Craniotomy with possible aspiration.\n\n FINDINGS: In comparison with the study of , there is little change.\n Nasogastric tube again extends well into the stomach. There may be mild\n atelectatic changes at the left base, but no evidence of acute focal\n pneumonia.\n\n\n" }, { "category": "ECG", "chartdate": "2201-03-21 00:00:00.000", "description": "Report", "row_id": 243680, "text": "Baseline artifact. Sinus rhythm. Right bundle-branch block. Low voltage\nin the limb leads. Diffuse non-specific ST-T wave abnormalities. No previous\ntracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2201-03-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1073014, "text": " 4:34 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p crani for SDH\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DRT MON 5:59 PM\n 1. Status post recent extensive right frontotemporal craniotomy with\n evacuation of large subdural hematoma and residual extra-axial fluid\n collection with resolving pneumocephalus, but no evidence of reaccumulated\n hemorrhage.\n 2. Extensive right frontal cystic encephalomalacia, likely related to\n previous infarction or traumatic event, note that there is now small amount of\n layering hemorrhage within at least two posterior right frontal cystic spaces;\n while presumably intra-axial, these may reflect either contusions at this site\n or communication with the extra-axial compartment.\n 3. Small left frontal polar hemorrhagic contusion and scant left parietal\n vertex subarachnoid hemorrhage with small adjacent vasogenic edema, unchanged\n over the short interval, with no new hemorrhage seen. Thin, low-intermediate\n attenuation extra-axial collection layering over the left frontal convexity,\n not significantly changed; this may represent pre-existent chronic subdural\n hematoma or true hygroma.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD WITHOUT CONTRAST, \n\n HISTORY: 73-year-old man, status post craniotomy for subdural hematoma;\n evaluate for interval change.\n\n TECHNIQUE: Contiguous 5-mm axial MDCT sections were obtained from the skull\n base to the vertex and viewed in brain and bone window on the workstation;\n several acquisitions were significantly degraded by motion artifact and were\n repeated.\n\n FINDINGS: The study is compared with previous NECTs, all dated .\n\n As on the most recent study, the patient has undergone extensive right\n frontotemporal craniotomy, with evacuation of the very large subdural hematoma\n layering over the right cerebral convexity. There is continued resorption of\n post-operative pneumocephalus, admixed with predominantly fluid-attenuation in\n the right subdural space overlying that convexity. No reaccumulated blood is\n identified. There is a small amount of hemorrhage layering in cystic\n encephalomalacic cavities at the right parietovertex, suggesting communication\n with the extra- axial compartment, either at the time of surgery or previous\n trauma or, alternatively, small hemorrhagic contusions. No definite\n intraventricular hemorrhage is identified.\n\n As noted previously, there is extensive encephalomalacia involving the\n (Over)\n\n 4:34 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n predominantly the right frontal lobe with significant volume loss and ex vacuo\n dilatation of the frontal and, to a lesser extent, temporal horns and\n the atrium of that lateral ventricle. A small left frontal parenchymal\n contusion with very small associated zone of vasogenic edema is essentially\n unchanged over the short interval, as is scant subarachnoid hemorrhage\n layering in a few left parietovertex sulci. No new hemorrhage is seen.\n\n There is evidence of thin chronic subdural collection or hygroma layering over\n the left frontal convexity, without significant mass effect, as on the pre-\n operative studies. Incidentally noted are bilateral lens implants.\n\n IMPRESSION:\n 1. Status post recent extensive right frontotemporal craniotomy with\n evacuation of large subdural hematoma and residual extra-axial fluid\n collection with resolving pneumocephalus, but no evidence of reaccumulating\n hemorrhage.\n 2. Extensive right frontal cystic encephalomalacia, likely related to\n previous infarction or traumatic event; note that there is now small amount of\n layering hemorrhage within at least two posterior right frontal cystic spaces.\n While presumably intra-axial, these may reflect either contusions at this site\n or communication with the hemorrhage in the extra-axial compartment.\n 3. Small left frontal polar hemorrhagic contusion with small adjacent\n vasogenic edema, and scant left parietovertex subarachnoid hemorrhage,\n unchanged over the short interval, with no new hemorrhage seen.\n 4. Thin, low-intermediate attenuation extra-axial collection layering over\n the left frontal convexity, not significantly changed; this likely represents\n pre-existent chronic subdural hematoma or true hygroma.\n\n" }, { "category": "Radiology", "chartdate": "2201-03-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1073015, "text": ", C. NSURG SICU-B 4:34 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p crani for SDH\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Status post recent extensive right frontotemporal craniotomy with\n evacuation of large subdural hematoma and residual extra-axial fluid\n collection with resolving pneumocephalus, but no evidence of reaccumulated\n hemorrhage.\n 2. Extensive right frontal cystic encephalomalacia, likely related to\n previous infarction or traumatic event, note that there is now small amount of\n layering hemorrhage within at least two posterior right frontal cystic spaces;\n while presumably intra-axial, these may reflect either contusions at this site\n or communication with the extra-axial compartment.\n 3. Small left frontal polar hemorrhagic contusion and scant left parietal\n vertex subarachnoid hemorrhage with small adjacent vasogenic edema, unchanged\n over the short interval, with no new hemorrhage seen. Thin, low-intermediate\n attenuation extra-axial collection layering over the left frontal convexity,\n not significantly changed; this may represent pre-existent chronic subdural\n hematoma or true hygroma.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2159-01-22 00:00:00.000", "description": "Report", "row_id": 1608059, "text": "MICU ADMIT NOTE\nPT WAS ORIGINALLY ADMITTED SUN AM TO 11R, HE WAS TRANSFERRED TO OUR ER FROM WITH MENTAL STATUS CHANGES AND PER PT. WAS FOUND DOWN AT HOME SEIZING AND INC. OF URINE. DRUG SCREEN + FOR BENZOS AND NEG FOR OPIATES, ( FENTANYL DOES NOT SHOW UP ON TOX. MD'S NOTE). ON ADMISSION WBC WAS 19.7, ? INFILTRATE ON CXR WAS STARTED ON IV ABX. PMH OF WILSON'S DISEASE. DX. AT AGE 8, SPLENECTOMY FROM A SPONT. RUPTURE. CHRONIC MIGRAINES, GENERALIZED ANXIETY DISORDER, GIB, SPLENECTOMY, CONGENTIAL ADRENAL HERPLASIA, HYPOGONADOTROPIC, PSHYCHOSIS, S/P LEFT REPLACEMENT.\n\nWAS BROUGHT TO MICU SUN NIGHT DUE TO A SEIZURE ON 11R PT. WAS FOUND TO BE TWITCHING AND DROOLING, UNRESPONSIVE BROUGTH TO MICU FOR FURTHER OBSERVATION. ONCE PT. WAS SETTLED HE WAS GIVEN 50MCG OF FENTANYL AND HE SEEMED MORE APPROPRIATE WAS ANSWERING QUESTIONS APPROP. WHICH HE WAS NOT DOING, SO IT IS THOUGHT THAT THIS IS MORE OF A SEIZURES FROM MED WITHDRAWALS.\n\nNEURO: ON ARRIVAL TO MICU PT. VERY SOMULENT NOT MAKING ANY SENSE MUMBLING WORDS. PLACE ON CIWA SCALE AND WAS GIVEN 50MCG OF FENTANYL IV AND 200MCG FENTANYL PATCH ( 100MCG PATCH X2) AND PT. BECAME MORE CHERANT WAS APPROPIATE ABLE TO ANSWER QUESTIONS APPROP. RECEIVING 4MG OF IV ATIVAN APPROX. EVERY HR. CIWA SCALE HAS BEEN 12. CT SCAN WAS NEG. NO SEIZURE ACTIVITY NOTED, STARTED ON DILANTIN, AND FOLLOWING LEVELS WAS LOADED WITH 1000MG PEAK DILANTIN LEVEL WAS LOW WAS GIVEN ANOTHER 500MG AND WILL REPEAT LABS THIS AM.\n\nRESP: INTIALLY WAS ON 100% NON-REBREATHER MASK AND NOT SATING WELL, SEE CAREVUE FOR ABG, WAS EVENTUALLY PLACED IN NASAL CANNULA AT 2L AND SATING WELL. CXR SHOWED POSSIBLE INFILTRATE.\n\n\nCV: HR AND BP STABLE NO ECTOPY NOTED.\n\nGI: VERY OBESE WEIGHS APPROX. 360LBS. ? WHEN LAST BM WAS PT. DOES NOT REMEMBER, TAKING IN CLEAR LIQS. AND ICE CHIPS WELL.\n\nGU: FOLEY IN PLACE, URINE IS VERY CLOUDY, PINKISH/SLUDGE. REPEAT U/A SENT.\n\nSOCIAL: PARENTS IN , WAS UPDATED BY MD ON PT'S CARE, FATHER IS ? ON HIS WAY UP HERE ? DRIVING/FLYING, PT. IS UPSET THAT HIS FAMILY WAS CALLED.\n\nPLAN: CIWA SCALE, FOLLOW LABS, IV. ABX. SEIZURE PRECAUTIONS.\n\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2159-01-21 00:00:00.000", "description": "Report", "row_id": 113270, "text": "Sinus rhythm. Borderline left axis deviation. Baseline artifact. No other\nsignificant diagnostic abnormalities are noted. No previous tracing available\nfor comparison.\n\n" }, { "category": "Radiology", "chartdate": "2159-01-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 892772, "text": " 12:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for infiltrates\n Admitting Diagnosis: DEHYDRATION/CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 M with h/o Wilson's disease, found down, in status epilepticus\n\n REASON FOR THIS EXAMINATION:\n Eval for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Status post seizure.\n\n Cardiac and mediastinal contours are within normal limits for technique and\n stable allowing for technical differences between the studies. Within the\n right lung, there is a new area of opacity in the retrocardiac region,\n partially obscuring the right hemidiaphragm. The right heart border remains\n partially indistinct, but this is without change dating back to . There is elevation of the right hemidiaphragm, which also appears to be\n a chronic finding.\n\n IMPRESSION:\n\n New patchy right lower lobe opacity, which may relate to aspiration in this\n patient with history of recent seizure. Differential diagnosis includes focal\n atelectasis and infectious pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2159-01-23 00:00:00.000", "description": "PICC W/O PORT", "row_id": 892990, "text": " 1:18 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC line in 34 M with GPC bacteremia and no pe\n Admitting Diagnosis: DEHYDRATION/CELLULITIS\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with GPC baceteremia needs IV antibiotics.\n REASON FOR THIS EXAMINATION:\n Please place PICC line in 34 M with GPC bacteremia and no peripheral access\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 34-year-old man with GPC bacteremia, needs IV antibiotics.\n\n PROCEDURE: The procedure was performed by Dr. with Dr. \n , the attending radiologist present and supervising. The right upper\n arm was prepped in a sterile fashion. Since no suitable superficial veins\n were visible, ultrasound was used for localization of suitable vein. The\n brachial vein was patent and compressible. After local anesthesia with 2 ml\n of 1% lidocaine, the brachial vein was entered under ultrasonographic guidance\n with a 21-gauge needle. A 0.018-guidewire was advanced under fluoroscopy into\n the superior cava. Based on the markers of the guidewire, it was determined\n that a length of 41 cm would be suitable. The PICC line was trimmed to length\n and advanced over a 4-French introducer sheath under fluoroscopic guidance\n into the superior vena cava. The sheath was removed. The catheter was\n flushed. A final chest x-ray was obtained. It demonstrates the tip in the\n superior vena cava just above the atrium.\n\n The line is ready for use.\n\n A StatLock was applied and the line was heplocked.\n\n IMPRESSION: Successful placement of 41 cm total length right brachial single\n lumen PICC line with tip in the SVC, ready for use.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-01-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 892686, "text": " 4:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with wbc 19\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 34-year-old man with leukocytosis. Evaluate.\n\n COMPARISON: AP upright portable chest x-ray dated .\n\n AP UPRIGHT PORTABLE CHEST X-RAY: The patient is rotated. There is a new\n patchy opacity obscuring the right heart border. The pulmonary vasculature is\n normal. The left lung is grossly clear. The surrounding soft tissue and\n osseous structures are unremarkable.\n\n IMPRESSION: Limited study. Patchy consolidation involving right middle lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-01-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 892684, "text": " 3:36 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: R/O BLEED\n ______________________________________________________________________________\n WET READ: MMBn SUN 4:40 AM\n No ICH.\n WET READ VERSION #1 MMBn SUN 4:39 AM\n No ICH,\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Rule out intracranial hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Routine non-contrast head CT.\n\n FINDINGS: There is no evidence of hemorrhage, mass effect, or shift of\n normally midline structures. There is no major vascular territorial\n infarction. The remaining density values of the brain parenchyma are within\n normal limits. The -white matter differentiation is preserved. The\n surrounding soft tissue and osseous structures reveal mucosal polyps within\n the right maxillary sinus. Remaining paranasal sinuses and mastoid air cells\n are appropriately aerated.\n\n IMPRESSION: No intracranial hemorrhage.\n\n" } ]

[ { "category": "General", "chartdate": "2104-03-07 00:00:00.000", "description": "ICU Event Note", "row_id": 450901, "text": "Clinician: Nurse\n Spoke with family and MICU resident spoke with family. Family decided\n to withdraw care. Pt. started on Morphine gtt. for comfort. Pt.\n expired at appx. 10:45am. Pronounced by MICU resident. Family\n contact. autopsy requested.\n" }, { "category": "Nursing", "chartdate": "2104-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 450798, "text": "32 year old man with h/o anoxic brain injury resulting in vegetative\n state 9 years ago, s/p resp arrest and PEA arrest today with 25 minute\n resuscitation. Chest tube placed, sent by to on DA\n drip. In ED difficult to ventilate, had several cardiac arrests during\n ED course c/b chest tube placement and loss of suction and accidental\n removal, resulting in tension pneumothorax and widespread subcut\n emphysema. Chest tube replaced. pH 6.88. 3 pressors. Bloody resp\n secretions.\n Transferred to MICU7. Bronch demonstrated large\n polypoid mass of granulation tissue nearly obstructing distal tip of\n tracheostomy tube. BRB arising from RUL bronchi, not clearing with\n saline lavage. MD met with family including pt\ns parents, brother, and\n brother\ns girlfriend as well as resident Dr . Explained\n critically ill status and results of bronch. Pt\ns brother and mother\n expressed a desire to end his suffering, acknowledging futility of his\n care, but pt\ns father said he didn\nwant to let go.\n Pt is now\n DNR/DNI (from ED conversations after final resuscitation).\n" }, { "category": "Physician ", "chartdate": "2104-03-07 00:00:00.000", "description": "ICU Fellow Admission Note - MICU", "row_id": 450881, "text": "Chief Complaint: respiratory arrest\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 32 y/o M s/p anoxic brain injury at age 2, s/p additional brain injury\n 9 years ago resulting in persistent vegetative state, s/p trach, who\n developed respiratory arrest at his nursing home and was transferred to\n an OSH. There, had a PEA arrest and required 25 minutes of CPR and\n resuscitation, had chest tube placed for pneumothorax, sent by\n to . In our ED, was sent for CT scan and had another\n arrest on the scanner, which was felt to be due to tension pneumothorax\n as the chest tube had become dislodged.\n Bronchoscopy on arrival to the MICU last night revealed a large\n polypoid mass of presumably granulation tissue at the distal end of the\n trach, as well as bleeding from the right upper lobe. Hemodynamically\n unstable overnight requiring pressors. Has been difficult to oxygenate\n and ventilate.\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 10 mcg/Kg/min\n Amiodarone - 1 mg/min\n Norepinephrine - 0.2 mcg/Kg/min\n Other ICU medications:\n Other medications:\n protonix, SQ heparin\n Past medical history:\n Family history:\n Social History:\n - s/p anoxic brain injury at age 2\n - head injury 9 years ago\n nc\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: lives in nursing home\n Review of systems:\n Flowsheet Data as of 09:23 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: 90 (80 - 90) bpm\n BP: 113/43(58) {82/36(45) - 126/59(75)} mmHg\n RR: 18 (0 - 26) insp/min\n SpO2: 87%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,434 mL\n PO:\n TF:\n IVF:\n 1,434 mL\n Blood products:\n Total out:\n 0 mL\n 90 mL\n Urine:\n 90 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,344 mL\n Respiratory\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: PCV+Assist\n Vt (Set): 400 (300 - 300) mL\n PC : 20 cmH2O\n RR (Set): 34\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 30 cmH2O\n Plateau: 26 cmH2O\n SpO2: 87%\n ABG: 6.82/145/68\n Ve: 12.3 L/min\n PaO2 / FiO2: 68\n Physical Examination\n General Appearance: unresponsive, moving his mouth w/breaths\n Eyes / Conjunctiva: Pupils dilated, pupils 8 mm and nonreactive\n Head, Ears, Nose, Throat: trach in place\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: diffusely), subcutaneous emphysema\n Abdominal: Bowel sounds present, Distended, peg in place\n Extremities: Right: Trace, Left: Trace\n Skin: Cool\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Not assessed, no corneal reflexes\n Labs / Radiology\n 418 K/uL\n 38.8 %\n 11.7 g/dL\n 185 mg/dL\n 2.2 mg/dL\n 30 mg/dL\n 20 mEq/L\n 112 mEq/L\n 5.6 mEq/L\n 144 mEq/L\n 80.1 K/uL\n [image002.jpg]\n 02:28 AM\n 04:25 AM\n WBC\n 80.1\n Hct\n 38.8\n Plt\n 418\n Cr\n 2.2\n TropT\n 1.62\n TC02\n 27\n Glucose\n 185\n Other labs: PT / PTT / INR:32.4/84.4/3.4, CK / CKMB /\n Troponin-T:851/29/1.62, ALT / AST:150/263, Alk Phos / T Bili:284/0.7,\n Differential-Neuts:69.0 %, Band:12.0 %, Lymph:6.0 %, Mono:6.0 %,\n Eos:0.0 %, Fibrinogen:58 mg/dL, Albumin:3.0 g/dL, LDH:1810 IU/L,\n Ca++:8.6 mg/dL, Mg++:3.3 mg/dL, PO4:11.5 mg/dL\n Imaging: CXR with diffuse multifocal infiltrates\n Chest CT demonstrates tension pneumothorax, densely consolidated lung\n bilaterally, and trach appearing to end distally near posterior wall of\n trachea and ? of mass surrounding this\n Assessment and Plan\n 32 y/o M w/anoxic brain injury s/p trach, who presented with\n respiratory arrest leading to cardiac arrest. The most likely etiology\n of his respiratory failure was obstruction of his upper airway due to\n likely granulation tissue at the base of his trach. The etiology of\n his initial arrest was likely hypoxia, and subsequent arrests likely\n related to tension pneumothorax. Unclear how he developed pneumothorax\n - if related to line placement vs high pressures on ventilator.\n Currently has profound multi-organ system failure likely due to cardiac\n arrest, and exam concerning for loss of most brainstem reflexes\n (although does appear to be moving his mouth). Will discuss his grim\n prognosis again with his family and readdress goals of care.\n ICU Care\n Nutrition:\n Comments: npo\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 03:05 AM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2104-03-07 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 450796, "text": "Chief Complaint:\n HPI:\n Pt is a 32 yo M with anoxic brain injury, trachesostomy who presents\n from OSH after suffering a respiratory arrest. He presented to OSH in\n acute respiratory distress. He subsequently went into PEA arrest\n x25min receiving shocks, CPR, amio IV and gtt, epi, dopamine. He also\n received vanco/zosyn. WBC 69.4, Trop 2.72, ASA 300mg. Chest tube was\n placed and was to . At patient had another\n bradycardic arrest. He was rescuscitated with epi/atropine and CPR.\n He was noted to have ? granulation tissue at tip of tracheostomy. He\n was also noted to have subcutaneous air near chest tube. He was taken\n to CT scan and had another bradycardic arrest secondary to tension\n pneumothorax. Needle thoracostomy was attempted and chest tube was\n re-inserted. Patient throughout was very difficult to ventilate. ABG\n with pH 6.88, WBC 80s, Cr 1.7, Trop 1.34. After discussion with the\n family patient was made DNR.\n .\n On arrival to the MICU patient was bronched and found to have large\n polypoid mass at trach entrance. Bronchi was found to have blood that\n did notc clear with saline flushes.\n .\n ROS: Unable to obtain as patient is intubated.\n Allergies: NKDA\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 10 mcg/Kg/min\n Amiodarone - 1 mg/min\n Other ICU medications:\n Other medications:\n Fluticasone 50mcg 1 spray \n Glycopyrrolate 1mg q8\n Metoclopramide 10mg q8\n Protonix 40mg Daily\n Senna prn\n lactulose prn\n Tylenol 650mg q4 prn\n Albuterol 90mcg 6 puffs q2 prn\n Dulcolax prn\n lorazepam 2mg IM prn\n Milk of Mag\n Morphine 2-4mg q6 prn\n Past medical history:\n Family history:\n Social History:\n Anoxi Brain injury at age 2, s/p head injury 9 yrs ago\n Tracheostomy\n Non-contributory\n vegetative state, trach dependent. Lives in . No EtOH, tobacco,\n recreational drugs\n Review of systems:\n Flowsheet Data as of 04:46 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.1\nC (95.2\n Tcurrent: 35.1\nC (95.2\n HR: 90 (87 - 90) bpm\n BP: 106/45(59) {106/45(59) - 126/59(75)} mmHg\n RR: 17 (17 - 26) insp/min\n SpO2: 82%\n Total In:\n 118 mL\n PO:\n TF:\n IVF:\n 118 mL\n Blood products:\n Total out:\n 0 mL\n 90 mL\n Urine:\n 90 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 28 mL\n Respiratory\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 300 (300 - 300) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 39 cmH2O\n Plateau: 27 cmH2O\n SpO2: 82%\n ABG: 6.82/145/68//-16\n Ve: 8.6 L/min\n PaO2 / FiO2: 68\n Physical Examination\n VS: 95.2, 87, 125/59, 20, 82% AC, Fi02 100%, PEEP 10, RR 28\n Gen: Intubated, sedated\n HEENT: eyes closed, pupils dilated, slightly reactive on L\n Neck: Trach in place with oozing\n Heart: Regular, no m/r/g\n Lung: Coarse vented BS bilat\n Abd: distended\n Ext: cool, no pitting edema\n Neuro: Completely unresponsive with no CN reflexes\n Labs / Radiology\n [image002.jpg]\n Trop-T: 1.34\n 143 / 108 / 25 / 266 AGap=16\n 5.5 / 25 / 1.7\n CK: 559 MB: 25 MBI: 4.5\n WBC 83.7 Plt 549\n Hct 43.1\n N:74 Band:6 L:9 M:4 E:1 Bas:0 Metas: 6\n PT: 23.6 PTT: 72.0 INR: 2.3\n pH 6.82 pCO2 145 pO2 68 HCO3 27 BaseXS\n .\n Imaging:\n CT Torso:\n CHEST: Large left tension pneumothorax with rightward mediastinal shift\n and LLL collapse. Posterior RUL opacities likely sequelae of aspiration\n but infection also possible. Left chest tube terminates at left apex in\n region of collapse. Extensive subcutaneous emphysema centered along\n left chest wall. Tracheostomy tube appears to abut the posterior wall\n of the trachea, possibly occluding the lumen. Scattered small\n mediastinal lymph nodes.\n .\n ABDOMEN: Trace perihepatic ascites. Subq gas tracks from left chest\n wall. No acute abnormalities. Scattered small retroperitoneal lymph\n nodes.\n .\n PELVIS: Markedly distended urinary bladder with foley catheter balloon\n inflated in the urethra. Pocket of subcutaneous gas adjacent to scrotum\n likely extends from chest wall but the scrotum is not imaged -\n recommend clinical correlation to r/o scrotal infection.\n \n 2:33 A4/3/ 02:28 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 27\n Assessment and Plan\n A/P: 32 yo M with anoxic brain injury, trach dependent, s/p respiratory\n arrest complicated by multiple PEA arrests, tension pneumothorax, and\n chest tube placement.\n .\n .\n Respiratory failure: Likely related to polypoid mass obstructing\n trach. Unclear as to how long in respiratory arrest. Based on ABG\n here, extremely acidotic and difficult to ventilate. ? aspiration.\n Also had tension PTX now with chest tube\n - Cont vent on AC and maximize oxygenation\n - Check VBG\n - VAP bundle\n - Would ideally ask IP to assess trach, though current status is grave\n - Cont chest tube to constant suction -> thoracics following\n - ? broad spectrum antbx pending reviewing goals of care\n - Discuss with family their decision in AM\n .\n Hypotension: Likely related to multiple arrests and acidosis.\n - Cont Dopamine\n - Volume resuscitation prn\n .\n Acidosis: likely related to overwhelming hypoperfusion and respiratory\n arrest\n - Check VBG\n - ? bicarb, as would be futile given grave status\n .\n ARF: Likely pre-renal/ATN given code\n - Cont to trend\n .\n Elevated Trop: Likely demand ischemia and direct injury given defib at\n OSH and chest compressions\n - Cont to trend\n .\n Leukocytosis: Elevated in setting of overwhelming respiratory arrest\n .\n Coagulopathy: Arrest, ? DIC\n - Cont to monitor\n .\n FEN: NPO:\n .\n Access: Right subclavian\n .\n Code: DNR, confirmed with family\n .\n Dispo: Dr. and I had extensive discussion with the family,\n outlining the patient's grave prognosis. Told family he may not last\n the day. They stated that at baseline he is vegetative, but his\n brother and mother echoed that he would not want to live like this.\n Father did not want to \"let him go.\" The family understands that he\n will likely not survive this catasrophe. They will see patient tonight\n and make a decision, hopefully in the AM. Will keep patient stable\n during this time and hold on escalation of care for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:05 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Family meeting held Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n" }, { "category": "Respiratory ", "chartdate": "2104-03-07 00:00:00.000", "description": "Generic Note", "row_id": 450840, "text": "TITLE:\n Resp Care: Pt admitted from ED trached and placed on vent support with\n a/c, marginal oxygenation/ventilation with high PIP/Plat, bloody\n secretions; bronch done for ?placement of trach tube: noted large\n granulomatous mass @ end of tube, will cont support as tol.\n" }, { "category": "Physician ", "chartdate": "2104-03-07 00:00:00.000", "description": "ICU Attending Note", "row_id": 450788, "text": "Clinician: Attending\n 32 year old man with h/o anoxic brain injury resulting in vegetative\n state 9 years ago, s/p resp arrest and PEA arrest today with 25 minute\n resuscitation. Chest tube placed, sent by to on DA\n drip. In ED difficult to ventilate, had several cardiac arrests during\n ED course c/b chest tube placement and loss of suction and accidental\n removal, resulting in tension pneumothorax and widespread subcut\n emphysema. Chest tube replaced.\n pH 6.88. 3 pressors. Bloody resp secretions.\n Transferred to MICU7. Bronch demonstrated large polypoid mass of\n granulation tissue nearly obstructing distal tip of tracheostomy tube.\n BRB arising from RUL bronchi, not clearing with saline lavage.\n Met with family including pt\ns parents, brother, and brother\n girlfriend as well as resident Dr . Explained critically ill\n status and results of bronch. Pt\ns brother and mother expressed a\n desire to end his suffering, acknowledging futility of his care, but\n pt\ns father said he didn\nwant to let go.\n Pt is now DNR/DNI (from\n ED conversations after final resuscitation).\n Total time spent: 80 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2104-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 450838, "text": "32 year old man with h/o anoxic brain injury resulting in vegetative\n state 9 years ago, s/p resp arrest and PEA arrest today with 25 minute\n resuscitation. Chest tube placed, sent by to on DA\n drip. In ED difficult to ventilate, had several cardiac arrests during\n ED course c/b chest tube placement and loss of suction and accidental\n removal, resulting in tension pneumothorax and widespread subcut\n emphysema. Chest tube replaced. pH 6.88. 3 pressors. Bloody resp\n secretions.\n Transferred to MICU7. Bronch demonstrated large polypoid\n mass of granulation tissue nearly obstructing distal tip of\n tracheostomy tube. BRB arising from RUL bronchi, not clearing with\n saline lavage. MD met with family including pt\ns parents, brother, and\n brother\ns girlfriend as well as resident Dr . Explained\n critically ill status and results of bronch. Pt\ns brother and mother\n expressed a desire to end his suffering, acknowledging futility of his\n care, but pt\ns father said he didn\nwant to let go.\n Pt is now\n DNR/DNI (from ED conversations after final resuscitation).\n Pneumothorax, Other (not hospital acquired or traumatic)\n Assessment:\n Left sided chest tube draining serosanguiness connected to suction.\n Has mild bleeding from the chest tube site.\n Action:\n Dressing intact.\n Response:\n Cont to be oozing.\n Plan:\n Cont to monitor chest tube site.\n Respiratory failure, chronic\n Assessment:\n Pt is unresponsive, Pupils dialated and non reactive, tarch vented, ABG\n from ED 6.82 PCO2- 148, PO2- 68.\n Action:\n Urgent bronch done showed granuloma tissue blocking the airway. No vent\n changes, Bicarb drip started @ 250ml/hr. MD talked w/ family to\n readdress code status pt father did not agree to withdraw care.\n Response:\n Pending\n Plan:\n Family meeting in AM regarding withdrawing care.\n Hypotension (not Shock)\n Assessment:\n BP in 80\ns received the pt w/ ongoing dopamine 10mics/kg/min, Still\n cont to drop BP to 70\n Action:\n Levophed 0.2mics/kg/min started\n Response:\n Currently SBP maintaining in 100\ns MAP >60.\n Plan:\n Titrate pressers as needed.\n e\n" }, { "category": "Nursing", "chartdate": "2104-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 450828, "text": "32 year old man with h/o anoxic brain injury resulting in vegetative\n state 9 years ago, s/p resp arrest and PEA arrest today with 25 minute\n resuscitation. Chest tube placed, sent by to on DA\n drip. In ED difficult to ventilate, had several cardiac arrests during\n ED course c/b chest tube placement and loss of suction and accidental\n removal, resulting in tension pneumothorax and widespread subcut\n emphysema. Chest tube replaced. pH 6.88. 3 pressors. Bloody resp\n secretions.\n Transferred to MICU7. Bronch demonstrated large\n polypoid mass of granulation tissue nearly obstructing distal tip of\n tracheostomy tube. BRB arising from RUL bronchi, not clearing with\n saline lavage. MD met with family including pt\ns parents, brother, and\n brother\ns girlfriend as well as resident Dr . Explained\n critically ill status and results of bronch. Pt\ns brother and mother\n expressed a desire to end his suffering, acknowledging futility of his\n care, but pt\ns father said he didn\nwant to let go.\n Pt is now\n DNR/DNI (from ED conversations after final resuscitation).\n Pneumothorax, Other (not hospital acquired or traumatic)\n Assessment:\n Left sided chest tube draining serosanguiness connected to suction.\n Has mild bleeding from the chest tube site.\n Action:\n Dressing intact.\n Response:\n Cont to be oozing.\n Plan:\n Cont to monitor chest tube site.\n Respiratory failure, chronic\n Assessment:\n Pt is tarch vented, ABG from ED 6.82 PCO2- 148, PO2- 68.\n Action:\n Urgent bronch done showed granuloma tissue blocking the airway. No vent\n changes, Bicarb drip started @ 250ml/hr.\n Response:\n Pending\n Plan:\n Family meeting in AM regarding withdrawing care.\n" }, { "category": "General", "chartdate": "2104-03-07 00:00:00.000", "description": "ICU Event Note", "row_id": 450907, "text": "Clinician: Resident\n Total time spent: 20 minutes\n Patient is critically ill.\n I spoke with the brother this AM. He is acting as the spokesperson for\n the family. After seeing him last night, they decided to withdraw care\n and focus on comfort. They understood the gravity of his condition and\n that he would likely not survive regardless of the actions taken. They\n accepted his condition and understood what comfort measures meant.\n They\njust wanted him to be comfortable.\n I was called to the bedside to examine the patient at 11AM. He was\n transitioned to a morphine drip. He was without pulse and without\n spontaneous breaths. The patient was pronounced dead at 11AM on\n . Cause of death acute respiratory failure with cardiac arrest\n and multiorgan system failure.\n The family was contact and all questions were answered. The\n admitting office and medical examiner will be contact. The autopsy\n was accepted by the medical examiner\n" }, { "category": "ECG", "chartdate": "2104-03-07 00:00:00.000", "description": "Report", "row_id": 240516, "text": "Sinus tachycardia. Right bundle-branch block. No previous tracing available\nfor comparison.\n\n" }, { "category": "Radiology", "chartdate": "2104-03-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1071195, "text": " 1:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: chest tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with resp failure\n REASON FOR THIS EXAMINATION:\n chest tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old man with respiratory failure and repositioning of\n chest tube.\n\n COMPARISON: Chest radiograph obtained approximately two hours earlier.\n\n SINGLE SUPINE VIEW OF THE CHEST AT 1:30 A.M.: Since the prior study, the left\n chest tube has been advanced and now terminates at the left apex. There has\n been slight interval decrease in left apical pneumothorax and the extent of\n mediastinal shift, although a large basilar component persists.\n Severe consolidation has advanced throughout the entire left lung and\n persists in the right upper lobe, could be due to pneumonia or pulmonary\n hemorrhage. The right lower lobe is newly collapsed. There is no\n apprecialble pleural effusion.\n\n Tracheostomy tube cuff remains severely hyperinflated. A left subclavian\n catheter terminates at the brachiocephalic confluence.\n\n Extensive subcutaneous emphysema persists in the left chest wall and neck.\n\n IMPRESSION: Interval repositioning of left chest tube, now terminating at the\n left apex, moderate to large left pneumothorax improved, with persistent large\n basilar component and decrease in previously severe rightward mediastinal\n shift indicating tension.\n\n New right lower lobe collapse. Severe consolidation or bleeding worsened in\n left lung, stable in right upper lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-03-07 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1071190, "text": " 12:03 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ?pneumo, acute process\n Field of view: 42\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with trach, s/p arrest @ OSH, has L sub clav, L chest tube,\n REASON FOR THIS EXAMINATION:\n ?pneumo, acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc FRI 2:04 AM\n CHEST: Large left tension pneumothorax with rightward mediastinal shift and\n LLL collapse. Posterior RUL opacities likely sequelae of aspiration but\n infection also possible. Left chest tube terminates at left apex in region of\n collapse. Extensive subcutaneous emphysema centered along left chest wall.\n Tracheostomy tube appears to abut the posterior wall of the trachea, possibly\n occluding the lumen. Scattered small mediastinal lymph nodes.\n\n ABDOMEN: Trace perihepatic ascites. Subq gas tracks from left chest wall. No\n acute abnormalities. Scattered small retroperitoneal lymph nodes.\n\n PELVIS: Markedly distended urinary bladder with foley catheter balloon\n inflated in the urethra. Pocket of subcutaneous gas adjacent to scrotum likely\n extends from chest wall but the scrotum is not imaged - recommend clinical\n correlation to r/o scrotal infection.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old man with respiratory failure and likely sepsis, with\n transfer from outside hospital with left chest tube and pneumothorax. Chronic\n tracheostomy.\n\n COMPARISON: CT torso obtained at approximately four hours\n earlier.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the chest,\n abdomen and pelvis following administration of intravenous contrast material.\n Multiplanar reformatted images were generated.\n\n CT CHEST WITH IV CONTRAST: There is a large left pneumothorax, unchanged in\n size from the prior exam. Compared to the prior study, there is increased\n consolidation of the left lower lobe and left upper lobe, consistent with\n lobar atelectasis. A left chest tube terminates near the left apex, in a\n region of atelectasis. There is marked rightward shift of the heart and\n mediastinum, indicating tension pneumothorax. This is unchanged in degree\n since the prior study. Dependend consolidation or collapse within the right\n lung, is increased compared to the prior study. Multifocal heterogeneous\n opacification is also present in the right upper lung. This could be due to\n atelectasis, although infection is not excluded.\n\n The heart size is normal, without pericardial effusion. Great vessels are\n unremarkable, with no acute abnormality. Scattered lymph nodes are present in\n (Over)\n\n 12:03 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ?pneumo, acute process\n Field of view: 42\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the mediastinum, in a pretracheal and prevascular distribution, measuring up\n to 7 mm, not enlarged by CT criteria.\n\n A tracheostomy tube is in place. It terminates at the thoracic inlet, and\n appears to contact the posterior tracheal wall, partially occluding its lumen.\n However, the tracheobronchial tree is patent, although compressed in the areas\n of atelectasis distally.\n\n There is extensive subcutaneous emphysema, centered along the left chest wall\n in the region of the left chest tube. Air extends cranially into the neck,\n where it also extends posteriorly to the back. Air also extends across the\n right anterior chest wall.\n\n CT ABDOMEN WITH IV CONTRAST: There is a small amount of perihepatic ascites.\n The liver, pancreas, spleen, adrenal glands, stomach and duodenum are\n unremarkable. The kidneys enhance and excrete contrast symmetrically without\n hydronephrosis or masses. There is no free intraperitoneal air. However,\n subcutaneous and intrafascial and intermuscular air extends throughout the\n abdomen bilaterally. A percutaneous gastrostomy tube is in place. The\n abdominal aorta and its major branches are unremarkable.\n\n CT PELVIS WITH IV CONTRAST: Multiple loops of large and small bowel\n demonstrate high-density material within the colon. The ascending colon and\n cecum demonstrates wall thickening, likely related to relative collapse.\n Otherwise, there is no focal bowel abnormality. There is no free fluid in the\n pelvis.\n\n The urinary bladder is markedly distended. A Foley catheter is present within\n the penile urethra, with the balloon inflated within the urethra. A small\n amount of high-density material consistent with excreted contrast is seen\n adjacent to the balloon.\n\n Subcutaneous air extends along the anterior pelvic wall and overlying the\n proximal scrotum. The scrotum itself is not imaged.\n\n There is no inguinal, pelvic, mesenteric or retroperitoneal lymphadenopathy by\n size criteria. Scattered, small lymph nodes are seen in the retroperitoneal\n area adjacent to the aorta, but are not enlarged by size criteria.\n\n OSSEOUS STRUCTURES: There is no fracture or worrisome lytic or sclerotic bony\n lesion.\n\n IMPRESSION:\n 1. Large left tension pneumothorax, with rightward mediastinal shift and\n interval worsening of left lower lobe collapse. Left chest tube terminates at\n (Over)\n\n 12:03 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ?pneumo, acute process\n Field of view: 42\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the left apex, in a region of atelectasis.\n 2. Dependent opacities in the right lung are likely atelectasis, but sequela\n of aspiration and infection remain a possibility.\n 3. Tracheostomy tube apparently abuts the posterior wall of the trachea,\n possibly partially occluding the lumen.\n 4. Extensive subcutaneous emphysema centered along the left chest wall, and\n tracking through the anterior abdominal and pelvic walls. Subcutaneous gas\n adjacent to the scrotum likely extends from the chest wall, but the scrotum is\n not imaged. Recommend clinical correlation to rule out scrotal infection.\n 5. Trace perihepatic ascites.\n 6. Scattered small retroperitoneal and mediastinal lymph nodes, not enlarged\n by size criteria.\n 7. Markedly distended urinary bladder with Foley catheter balloon inflated in\n the urethra.\n\n" }, { "category": "Radiology", "chartdate": "2104-03-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1071188, "text": " 11:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?placement, pneumo\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with L chest tube, large airleak, trach, L subclav\n REASON FOR THIS EXAMINATION:\n ?placement, pneumo\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old man with acute respiratory distress and PEA arrest,\n history of tracheostomy. Evaluate line placement. Known pneumothorax.\n\n COMPARISON: None.\n\n SINGLE SUPINE VIEW OF THE CHEST AT 11:45 P.M.: The cuff of a tracheostomy\n tube severely distends the trachea. There is a left chest tube terminating\n near the left lung apex. A left subclavian catheter terminates at the\n junction of the brachiocephalic veins, at the origin of the SVC.\n\n There is a large left pneumothorax with apical and basilar components. The\n patient is rotated, somewhat limiting assessment of mediastinal position, but\n there is substantial rightward mediastinal shift. The left lower lobe and\n right upper lobe are severely consolidated. A right pleural effusion is small.\n Heart is not enlarged.\n\n Subcutaneous air in the left chest wall and neck is severe.\n\n IMPRESSION:\n 1. Large left pneumothorax despite left chest tube in place, consistent with\n tension.\n\n 2. Right upper and left lower lobe consolidation, could be bleeding or\n pneumonia.\n\n 3. Extensive subcutaneous air predominantly of the left chest wall, tracking\n through the neck and right chest.\n\n Findings discussed with ED and MICU residents at 12:30 a.m.\n\n" }, { "category": "Radiology", "chartdate": "2104-03-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1071203, "text": " 4:30 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with trach, s/p multiple cardiac arrests and tension\n pneumothorax\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:56 A.M.\n\n HISTORY: 82-year-old man with tracheostomy, multiple cardiac arrests and\n previous tension pneumothorax.\n\n IMPRESSION: AP chest compared to and at 1:49 a.m.\n\n Volume of the left pneumothorax, predominantly basal, has decreased\n substantially and rightward mediastinal shift is less severe, now due largely\n to right lower lobe collapse. Consolidation in the right upper lobe has\n improved, but severe consolidation throughout the left lung has not. Relative\n contributions of pulmonary hemorrhage, pneumonia, and large scale aspiration\n are difficult to determine. Heart size is normal. Tracheostomy tube is in\n standard placement, but the cuff remains severely overinflated, perhaps a\n necessity from chronic tracheostomy. Clinical examination advised. Left\n apical pleural tube and left subclavian line in standard placement, unchanged.\n Subcutaneous emphysema in the left chest wall and neck is receding, presumably\n a result of thoracostomy placement.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2128-10-05 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 1204958, "text": " 12:14 AM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # \n Reason: TYLENOL OVERDOSE PLEASE EVAL LIVER WITH DOPPLERS\n Admitting Diagnosis: TYLENOL OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman s/p tylenol OD, please eval liver with dopplers.\n REASON FOR THIS EXAMINATION:\n please eval liver with dopplers.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw TUE 1:25 AM\n 1. Patent hepatic vasculature.\n\n 2. Marked gallbladder wall thickening likely related to hepatic dysfunction\n in the setting of Tylenol overdose.\n\n 3. Trace abdominal ascites.\n\n 4. Liver cysts.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tylenol overdose, evaluate liver with Doppler.\n\n LIVER AND GALLBLADDER ULTRASOUND.\n\n COMPARISON: None.\n\n FINDINGS: The liver appears slightly coarse in echotexture. Within the left\n lobe of the liver is a septated cyst measuring 2 x 1.4 x 1.6 cm. In the right\n lobe is a simple-appearing cyst measuring 1.5 x 1 x 1 cm. No solid lesions\n are identified within the liver. There is normal hepatopetal flow within the\n main portal vein. Hepatic vasculature including the portal veins, and the\n hepatic veins are patent. The hepatic arteries are patent. Direction of flow\n is normal. The IVC is patent. The splenic vein is patent and the superior\n mesenteric vein is patent. There is trace abdominal ascites. The spleen is\n normal in size measuring 10 cm. The right and left kidneys are normal in\n echotexture measuring 12.2 and 12.1 cm, left and right respectively.\n\n There is marked gallbladder wall thickening, particularly along the contour of\n the liver with the thickness of the gallbladder wall measuring up to 1.1 cm.\n However, there is no son elicited and no stones within the\n gallbladder.\n\n IMPRESSION:\n\n 1. Patent hepatic vasculature.\n\n 2. Marked gallbladder wall thickening likely related to hepatic dysfunction\n in the setting of Tylenol overdose.\n\n 3. Trace abdominal ascites.\n\n 4. Liver cysts.\n (Over)\n\n 12:14 AM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # \n Reason: TYLENOL OVERDOSE PLEASE EVAL LIVER WITH DOPPLERS\n Admitting Diagnosis: TYLENOL OVERDOSE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2128-10-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1205107, "text": " 10:19 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o midline shift given tylenol OD\n Admitting Diagnosis: TYLENOL OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with frontotemporal dementia, admitted to MICU for tylenol\n OD, neuro following\n REASON FOR THIS EXAMINATION:\n r/o midline shift given tylenol OD\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old woman with frontotemporal dementia, admitted to the\n NICU for Tylenol overdose.\n\n COMPARISON: NECT (), .\n\n FINDINGS: No hemorrhage, large territorial infarction, edema, mass, or shift\n of normally midline structures is present. The ventricles and sulci are\n prominent consistent with cortical atrophy. The basal cisterns are widely\n patent. The visualized paranasal sinuses and mastoid air cells are well\n aerated.\n\n IMPRESSION: No acute intracranial process; bilateral frontal more than\n temporal lobar atrophy, consistent with the given history.\n\n COMMENT: Findings were discussed with Dr. via phone at 11 p.m. on , .\n\n" }, { "category": "Radiology", "chartdate": "2128-10-05 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1204986, "text": " 8:15 AM\n CHEST (PA & LAT) Clip # \n Reason: ? pulmonary status\n Admitting Diagnosis: TYLENOL OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with tylenol OD, eval pulmonary status to be done at 0800.\n REASON FOR THIS EXAMINATION:\n ? pulmonary status to be done at 0800.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate pulmonary status after Tylenol overdose.\n\n COMPARISON: .\n\n FINDINGS: Upright AP and lateral views of the chest show new small bilateral\n pleural effusions. Otherwise, the exam is unchanged. The cardiamediastinal\n and pulmonary structures are unremarkable. No pneumothorax.\n\n IMPRESSION: New small bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2128-10-05 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 1204959, "text": ", MED MICU-7 12:14 AM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # \n Reason: TYLENOL OVERDOSE PLEASE EVAL LIVER WITH DOPPLERS\n Admitting Diagnosis: TYLENOL OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman s/p tylenol OD, please eval liver with dopplers.\n REASON FOR THIS EXAMINATION:\n please eval liver with dopplers.\n ______________________________________________________________________________\n PFI REPORT\n 1. Patent hepatic vasculature.\n\n 2. Marked gallbladder wall thickening likely related to hepatic dysfunction\n in the setting of Tylenol overdose.\n\n 3. Trace abdominal ascites.\n\n 4. Liver cysts.\n\n" }, { "category": "Radiology", "chartdate": "2128-10-05 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1205098, "text": " 7:51 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: confirm picc placement: 41cm R sided\n Admitting Diagnosis: TYLENOL OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with dementia admitted to MICU for tylenol overdose\n REASON FOR THIS EXAMINATION:\n confirm picc placement: 41cm R sided\n ______________________________________________________________________________\n WET READ: SJBj TUE 10:19 PM\n PICC tip in low-mid SVC. R>L basilar atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:49 P.M. ON .\n\n HISTORY: 60-year-old woman with dementia, admitted for Tylenol overdose.\n Assess PICC line placement.\n\n IMPRESSION: AP chest compared to :\n\n Right PIC line ends just above the level of the superior cavoatrial junction.\n The opacification at the lung bases, left greater than right, is probably\n atelectasis. Upper lungs clear. No pneumothorax or pleural effusion. Heart\n size normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-10-09 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1205644, "text": " 8:10 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: RUE SWELLING, R/O DVT\n Admitting Diagnosis: TYLENOL OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman here for tylenol OD, with PICC line in R arm and now R\n swollen arm.\n REASON FOR THIS EXAMINATION:\n r/o DVT or right upper extremity\n ______________________________________________________________________________\n WET READ: PBec SAT 8:49 PM\n no dvt. r basilic vein picc line in place. pbishop\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent right PICC line placement, now with right arm swelling.\n Please evaluate for deep vein thrombosis in the right upper extremity.\n\n COMPARISON: No prior studies available for comparison.\n\n FINDINGS: -scale and Doppler son was performed of the right internal\n jugular, subclavian, axillary, brachial, basilic, and cephalic veins. Normal\n compressibility, flow, and augmentation are noted throughout. Note a right\n basilic vein PICC line.\n\n IMPRESSION: No deep vein thrombosis in the right upper extremity.\n\n\n" }, { "category": "Echo", "chartdate": "2128-10-05 00:00:00.000", "description": "Report", "row_id": 91538, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 64\nWeight (lb): 155\nBSA (m2): 1.76 m2\nBP (mm Hg): 116/62\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 09:52\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n Billing status corrected. No changes made in findings. WJM\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler.\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 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: Normal mitral valve leaflets with trivial MR. No MVP. No MS.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No TS.\nNormal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. The diameters of aorta at the sinus, ascending and arch levels are\nnormal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis\nis not present. No aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. The estimated pulmonary artery systolic pressure is normal.\nThere is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2128-10-05 00:00:00.000", "description": "Report", "row_id": 250224, "text": "Sinus rhythm. Compared to the previous tracing no change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2128-10-04 00:00:00.000", "description": "Report", "row_id": 250225, "text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Echo", "chartdate": "2101-12-09 00:00:00.000", "description": "Report", "row_id": 64048, "text": "PATIENT/TEST INFORMATION:\nIndication: F/u pericardial effusion.\nHeight: (in) 67\nWeight (lb): 185\nBSA (m2): 1.96 m2\nBP (mm Hg): 108/68\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 09:28\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and no color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLarge left pleural effusion present.\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Mildly depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nOverall left ventricular systolic function is mildly depressed with inferior\nhypokinesis. Right ventricular chamber size and free wall motion are normal.\nThere is a small pericardial effusion. There are no echocardiographic signs of\ntamponade.\n\nCompared with the prior study (images reviewed) of , no change.\n\n\n" }, { "category": "Echo", "chartdate": "2101-12-20 00:00:00.000", "description": "Report", "row_id": 63975, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 67\nWeight (lb): 182\nBSA (m2): 1.94 m2\nBP (mm Hg): 112/63\nHR (bpm): 73\nStatus: Outpatient\nDate/Time: at 15:02\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mild regional\nLV systolic dysfunction. Mildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - hypo; mid inferoseptal - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. There is mild regional left ventricular systolic dysfunction with\nmid septal hypokinesis. Overall left ventricular systolic function is mildly\ndepressed. Right ventricular chamber size and free wall motion are normal. The\naortic valve leaflets (3) are mildly thickened. There is no aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Moderate (2+) mitral regurgitation is seen. There is a small\npericardial effusion (seen mainly around the right atrium). There are no\nechocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , the pericardial\neffusion is now probably slightly larger.\n\n\n" }, { "category": "Echo", "chartdate": "2101-12-15 00:00:00.000", "description": "Report", "row_id": 63976, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion. Right ventricular function. Valvular heart disease.\nHeight: (in) 67\nWeight (lb): 185\nBSA (m2): 1.96 m2\nBP (mm Hg): 106/78\nHR (bpm): 131\nStatus: Inpatient\nDate/Time: at 08:14\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Normal LV cavity size. Mild regional LV systolic dysfunction.\nTVI E/e' >15, suggesting PCWP>18mmHg. Abnormal systolic flow contour at rest,\nbut no LVOT obstruction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\ninferoseptal - hypo; septal apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate to\nsevere (3+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Left pleural effusion. Ascites.\n\nConclusions:\nThe left and right atria are moderately dilated. The left ventricular cavity\nsize is normal. There is mild regional left ventricular systolic dysfunction\nwith hypokinesis of the mid- and distal septum. Tissue velocity imaging E/e'\nis elevated (>15) suggesting increased left ventricular filling pressure\n(PCWP>18mmHg). There is an abnormal systolic flow contour at rest, but no left\nventricular outflow obstruction. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nModerate to severe (3+) mitral regurgitation is seen. Moderate [2+] tricuspid\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is a small pericardial effusion, seen posterior to the\nright atrium with the patient supine. There are no echocardiographic signs of\ntamponade.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction.\nModerate-to-severe mitral regurgitation. Mild aortic regurgitation. Moderate\ntricuspid regurgitation. Moderate pulmonary hypertension. Small pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , the findings\nare similar.\n\n\n" }, { "category": "Echo", "chartdate": "2101-12-12 00:00:00.000", "description": "Report", "row_id": 63977, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 67\nWeight (lb): 185\nBSA (m2): 1.96 m2\nBP (mm Hg): 120/60\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 10:47\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: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild regional LV\nsystolic dysfunction. Mildly depressed LVEF. [Intrinsic LV systolic function\nlikely depressed given the severity of valvular regurgitation.] No resting\nLVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - hypo; mid inferoseptal - hypo; septal apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate to severe (3+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Small pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is markedly dilated.\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. There is mild regional left ventricular systolic\ndysfunction with mid/distal septal hypokinesis. Overall left ventricular\nsystolic function is mildly depressed (intnsic left ventricular function may\nbe more depressed given severity of mitral regurgitation). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets are\nmildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is\nseen. Moderate [2+] tricuspid regurgitation is seen. There is moderate\npulmonary artery systolic hypertension. There is a very small pericardial\neffusion with no echocardiographic evidence of tamponade.\n\nCompared with the prior study (images reviewed) of , left\nventricular systolic function is probably similar (views are technically\nsuboptimal for comparison). Moderate to severe mitral regurgitation and\nmoderate tricuspid regurgitation are now noted. Pericardial effusion appears\nsmaller. A large pleural effusion is again noted.\n\n\n" }, { "category": "Echo", "chartdate": "2101-12-02 00:00:00.000", "description": "Report", "row_id": 63978, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion. Wall motion abnormality. S/p tap.\nHeight: (in) 65\nWeight (lb): 150\nBSA (m2): 1.75 m2\nBP (mm Hg): 130/72\nHR (bpm): 92\nStatus: Inpatient\nDate/Time: at 10:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Mild regional\nLV systolic dysfunction. No LV mass/thrombus. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\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. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Dilated main PA.\n\nPERICARDIUM: Small pericardial effusion. No RA or RV diastolic collapse.\nEchocardiographic signs of tamponade may be absent in the presence of elevated\nright sided pressures.\n\nConclusions:\nThe left atrium is elongated. There is moderate symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. There is mild\nregional left ventricular systolic dysfunction with inferior and\ninfero-lateral hypokinesis. No masses or thrombi are seen in the left\nventricle. There is mild global right ventricular free wall hypokinesis. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. The mitral valve leaflets are\nstructurally normal. Mild (1+) mitral regurgitation is seen. There is mild\npulmonary artery systolic hypertension. The main pulmonary artery is dilated.\nThere is a small pericardial effusion. No right atrial or right ventricular\ndiastolic collapse is seen. There is significant (30%) respiratory variation\nof mitral inflow.\n\nCompared with the prior study (images reviewed) of , the pericardial\neffusion is smaller and RA collapse is no longer seenh. Regional LV and RV\nsystolic dysfunction persist.\n\n\n" }, { "category": "Echo", "chartdate": "2101-12-05 00:00:00.000", "description": "Report", "row_id": 64049, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 67\nWeight (lb): 185\nBSA (m2): 1.96 m2\nBP (mm Hg): 100/65\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 11:13\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\nLEFT VENTRICLE: Symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThere is symmetric left ventricular hypertrophy. The left ventricular cavity\nsize is normal. Overall left ventricular systolic function is normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThere is a small pericardial effusion. There are no echocardiographic signs of\ntamponade.\n\nCompared with the prior study (images reviewed) of , the pericardial\neffusion appears slightly smaller than immediately post-tap.\n\n\n" }, { "category": "Echo", "chartdate": "2101-12-02 00:00:00.000", "description": "Report", "row_id": 64050, "text": "PATIENT/TEST INFORMATION:\nIndication: ? Pericardial effusion; ? STEMI\nWeight (lb): 180\nBP (mm Hg): 120/70\nHR (bpm): 120\nStatus: Inpatient\nDate/Time: at 08:14\nTest: TTE (Focused views)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Moderate symmetric LVH. Mild regional LV systolic dysfunction.\nNo LV mass/thrombus.\n\nRIGHT VENTRICLE: RV function depressed.\n\nAORTIC VALVE: No AR.\n\nPERICARDIUM: Moderate to large pericardial effusion. No RV diastolic collapse.\nSustained RA diastolic collapse, c/w low filling pressures or early tamponade.\n\nConclusions:\nThere is moderate symmetric left ventricular hypertrophy. There is mild\nregional left ventricular systolic dysfunction with inferior and\ninfero-lateral hypokinesis. No masses or thrombi are seen in the left\nventricle. Right ventricular systolic function appears depressed. No aortic\nregurgitation is seen. There is a moderate to large sized pericardial\neffusion. No right ventricular diastolic collapse is seen. There is sustained\nright atrial collapse, consistent with low filling pressures or early\ntamponade.\n\nIMPRESSION: Inferior infarct with RV dysfunction. Moderate to large\ncircumfirential pericardial effusion with early tamponade.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-07 00:00:00.000", "description": "Report", "row_id": 1372192, "text": "CCU NPN 1900-0700\nS: \" I'm so sick of all of this \"\nO: pt. verbalizing anxiety and frustration of prolonged hospitalization. did not sleep well despite trazadone in eve. lower back pain relieved with morphine 2mg in eve and 3mg at 0400.\nalso PIV red/tender and required d/c and reinsertion of new PIV: this is extremetly anxiety provoking for pt. venous access team RN placed #22. pt. eating toast at 0430 and feeling better.\n\nHR 71-77 NSR. lopressor 25mg po BID contin. BP 94-106/60's.\npulsus paradox 10. pericardial drain site D/I. no c/o pain/tenderness at site. decreased drainage tonight. flushed x2 easily with heparinized saline per policy. 0-1cc aspirated.\n\nResp: LS clear. sats 96-97% on 4lnc. c/o SOB with any activity. needs to sit upright most of the time. difficulty sleeping d/t difficulty getting comfortable. dry cough.\n\nGU: OOB to commode.\nGI: LBM , small. given senna and colace tongight. abd soft, pos. BS. ate toast at 0430. encouraged pt. to ask family/friends to bring in food from the outside. pt. very discouraged with quality of food here.\n\nA: increase anxiety tonight r/t prolonged hosp.\n contin. SOB/cough r/t pericard. effusion.\npossible pericard. window today.\nP: NPO now. morphine prn. resperidal due in AM. social service also involved.\n(+) biopsy results. Dr to speak with pt. yet.\nNSR s/p successful CDV .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-04 00:00:00.000", "description": "Report", "row_id": 1372186, "text": "CCU Nursing Progress Note\nS-\"I am so disapointed that I get so winded just washing my face.\"\nO-Neuro alert and oriented x3, very pleasant and cooperative. Asking appropiate questions today even though she is scared. Not able to process everything that is being told her and might be selectively forgetting things but is less emotional today. Received her effexor and resperidol with good calming effect. Still upset and talking about how much pain she had when the pericardial drain was place. Therefore she is apprehensive about any procedures.\nCV-VSS having moderate amount of ventricular ectopy and PAC's. c/o feeling palpitations at times. Pulsus parodox increased 16 this am with louder friction rub. Found pericardial drain was clotted this am and able to flush/aspirate and removed a long clot. Then able to aspirate 150cc serosang fluid.The total drainage since midnight 556cc. Plan for repeat echo in am.\nResp-LS clear with bronchial bs LLL. O2 sats 90-91% on RA and 96-100% when she puts on O2 3lnp. Easily SOB with minimal activity.\nID afebrile on vanco for positive culture from pericardial fluid.\nGU-voiding small amounts, having urgency but not frequency. Peridium is working well for her c/o burning.\nGI-appetite good, LBM , h/o constipation.\nAccess- 2 PIV\nSkin-right groin DSD no hematoma or bleeding at site. Pedal pulses intact.\nPOC-General Surgery into evaluate and plan to remove a small node near left clavicle at bedside in am, under local. Pt just asks for something for pain.\n friends visiting and she was happy to see them.\nA/P-Pericardial effusion still draining moderate amount, remains symptomatic despite drain.\nContinue to follow pulsus paradox q4hrs and aspirate pericardial drain q4hrs. Observe for increase in fluid accumulation. MOnitor for increase in VEA and check potassium qd. Allow pt to vent her concerns. COntinue to keep pt informed of POC and results of testing as discussed in multi disciplanary rounds.\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-05 00:00:00.000", "description": "Report", "row_id": 1372187, "text": "Nursing Progress Note\n7 pm - 7 am\nPericardial Effusion/LAD Stent/New Lymphadenopathy\nVoicing extreme concern and anxiety regarding planned bedside bx today by the general surgery service. Reports extreme pain during cath and pericardial drain placement, screaming out with pain. ( She was given 300 mcgs of fentanyl and 2.5 mg of versed ) She has an extremely low tolerance to pain, and has an aversion to needles at baseline.\nCV HR 70-80's...SR ....SBP 90-110's/50's...Pericardial drain intact flushing/aspirate per protocal. Minimal aspirates..See flowsheet.\nResp ..wearing 02 ..on and off ..Lungs diminished at the bases.\nGU to bedside commode with assist\nGI no issues.\nPsyche ..Baseline anxiety/depressive disorder. Has been in recovery 5 months. Emotional foundation ( her grown son ) is stationed in state in the . To be deployed soon. She may require psyche and/or pain service input to assist her in dealing with her new diagnosis and procedures she may have to undergo in the near future.\nSuggest conscious sedation for today's procedure.\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-02 00:00:00.000", "description": "Report", "row_id": 1372182, "text": "CCU NSG ADMIT\n\n\n59 yo female presented to BIDH last noc w/ wk hx ^ SOB, chest heaviness x few days. .^ inferiorly, runs SVT, ck flat, troponin .8. transfused to . In EW ECHO-> lg pericardial effusion and RA collapse. Pulsus 25. Taken to cath lab, where 800cc serosanguinous fluid removed and drain placed. cath -> 80% LAD lesion stented, RCA 50%. transferred to CCU for further care.\n\nPMH: disc surgery, depression prior heavy ETOH use, + smoking.hysterectomy\n\nNKDA\n\nArrived to CCU ~ 0900.\n\nneuro: alert, oriented x3 cooperative w/ care\ncv: hr 80-90's sr w/ frequent runs svt (rate low 100's) until ~ 1200. bp stable 115-130's/50-70. Pericardial drain in place, draining serosanguinous fluid ~ 400cc since admit. Initially c/o severe cp, reportedly not like pain she had at home. EKG w/o changes. Medicated w/ total 5 mg mso4 w/ little effect. given 30 mg torodol w/ good effect. Swan and arterial sheath removed at 1300 w/o difficulty. r groin d/i, distal pulses easily palpabable. Receiving d5w w/ 150 meq Na Bicarbonate d/t dye load w/ CTA and cath. ck 45 this am. Pulsus in CCU . ECHO in CCU -> sm pericardial effusion, preserved EF. Started on lopressor 12.5 mg .\nresp: SATs 94-98% on 4lnp. lungs cta\ngi: no issues\ngu: foley draining CYU qs\nid: afebrile\nskin: intact\nsocial: lives by self in , works at registration at Med Assoc. has son, daughter in law in Calif. They called and have been updated as to events since admission.\nA: lg pericardial effusion, w/ 800cc out initially, 400cc since.\nLAD lesion stented. Signifigant pain associated w/ pericardial drain, now improved.\nP: Monitor drainage from pericardial effusion, cycle ck's, monitor response to cv meds, Monitor groin, pain, ECHO in am.\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-03 00:00:00.000", "description": "Report", "row_id": 1372183, "text": "Nursing Progress Note\n11 pm - 7 am\nPercardial Effusion with LAD stent\nCV HR80-100's..frequent self limiting episodes of svt,,patient asymptomatic. SBP 90-110's/50's...Percardial drain open to drainage bag ..flushed per protocal. Output ~~250 cc sero-sang drainage.\nResp 02 5l with 02 sats 98-100%..RR 18-22 ..Faint cxs to right base. Awoke at 0100 \" feeling out of sorts\".. requesting resparidol (1 mg) ..Tearing....Refusing effexor/trazadone. Awoke again at 0600 ..c/o SOB ..02 sat 90% on 5L NP..Refusing mask 02...^^cxs to right lower lobe...DR aware..CXR ordered. Urine culture sent ..cloudy in appearance.\nA Remains with significant Pericardial drain output..SVT\nP CXR/ECHO today\n" }, { "category": "Nursing/other", "chartdate": "2101-12-03 00:00:00.000", "description": "Report", "row_id": 1372184, "text": "CCU Nursing Progress Note\nS-\"I don't want to die, why is God doing this to me?\"\nO-Neuro alert and oriented x3, anxious and apprehensive with periods of crying and unable to calm herself. Despite sitting with pt and consoling her for long periods of time. Pt takes Effexor 225mg QD which she has not received for 2 days. Recevied risperidol 1mg and effexor at 1030 after some discussion of doses with her pharmacy.\nPt was told about her \"enlarged lymph nodes\" and became very upset expectably.\nCV-HR 70-90's NSR, SBP 100-120's with pulsus parodox , MR murmur very prominent. c/o pleuritic chest pain with deep inspiration. Receiving morphine 2mg IVB for pain not relieved with tylenol. Pericardial drain in place with moderate amount of drainage by gravity\ntotal 250cc over past 10hours. Drainage bag changed and sent for cytology. Aspirated 1 long clot, easily flushes without pressure.\nResp-LS BBR with some atelectasis noted on xray with blunting of angles large pleural effusion left >right. Easily SOB with minimal activity, rr 24-30 O2 4lnp with sats 92-95%.\nID afebrile low grade temp 99.9 po started on vanco for GPC in pericardial fluid. u/a sent for cloudy urine, one set of blood cultures sent.\nGU-foley draining fair with 20-30cc/hr concentrated urine.\nGI-appetite good, received senecot/colace with good results OB-.\nActivity-bedrest maintained although pt adament about using commode for BM this eve.\n son in the living in with family. Friends visiting pt today. Anxious to go visit for on -plane ticket already bought.\nPOC-thorasic surgery in to speak to pt regarding obtaining a node sample surgically.\nA/P-59yof with new onset of SOB over past month, developed chest pain resulting in stents placed LAD and also noted large pericardial effusion. Continues to drain serosang fluid large amounts since drain placed ~2 liters over past 24hrs. Newly found enlarged lymph nodes by CTA and +palpable nodes groin and cervical. Awaiting pathology of surgical removal of node ?possibly Monday.\nCOntinue to follow sterile procedure aspirating and flush pericardial drain. Follow pulsus paradox q 6hrs. Maintain O2 sats.\nFollow low urine output. Start IS exercises for atelectasis.\nContinue to keep pt informed of POC and results of testing as discussed in multi disciplanary rounds. Offer emotional support as needed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-04 00:00:00.000", "description": "Report", "row_id": 1372185, "text": "Nursing Progress Note\n7 pm - 7 am\nPericardial Effusion/Positive Lymphe Nodes\nCV HR 70's..occas short runs of svt.. SBP 90-110's/60's...Pericardial drain flushed per protocal..output sero/sang ...\nResp on room air ..02 sat 94%.. lungs with cxs left base...non-prod cough ..\nC/O burning from foley...thus D/C'd ...pyridium begun .. Cranberry given throughout the night. OOB to commode with assist ..\nTrazadone for sleep\nLabs pndg\nABX's given\n" }, { "category": "Nursing/other", "chartdate": "2101-12-05 00:00:00.000", "description": "Report", "row_id": 1372188, "text": "Patient's Psychiatrist is Dr. from Hosp. Patient is in recovery for Valium/Vicodin Abuse..using ETOH as a trigger.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-05 00:00:00.000", "description": "Report", "row_id": 1372189, "text": "CCU Nursing Progress Note\nS-\"I hope the procedure goes well, I am really nervous.\"\nO-Neuro alert and oriented x3, very pleasant and cooperative. Anxious about upcoming procedure but otherwise comfortable. c/o lower back ache from bedrest recieved morphine 2mg IVB with good effect. Received total ativan 2mg IVB during bedside procedure with good calming effect.\nCV-VSS on lopressor 25mg , pulsus parodox has been WNl. Pericardial drain again was clotted with long fibrin tissue which was easily aspirated. Moderate amount of pericardial drainage from bag, total of 300cc since midnight but 100cc over 4 hours (). Cardiac echo completed with results pnd.\nResp-LS bronchial left base but otherwise clear. O2 RA 92%, pt still SOB with activity but feels alittle better today. Occ NPC\nID low grade temp on vanco for +culture of pericardial fluid.\nGI-appetite good soft BM today OB-\nGU-voiding small amounts urine.\nActivity-very active in bed with moving around. Bedrest maintained except for commode for BM.\nSkin-@ 1600 bedside surgical procedure by general surgery-left supraclavicular lymph node biposy completed without complication. Small incision line with disolvable sutures, DSD with tegaderm.\nA/P-CAD with LAD stent with large pericardial effusion requiring drain. Now with enlarged lymph nodes s/p biopsy of supraclavicular node to r/o lymphoma.\nContinue to monitor for increase in pericardial fluid, change in pulsus parodox or increase in SOB/desaturation.\nContinue to keep pt aware of POC and results of testing as discussed in multi disciplanary rounds.\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-06 00:00:00.000", "description": "Report", "row_id": 1372190, "text": "CCU NPN 1900-0700\nS/O:\nAfeb. contin. on vanco . blood Cx NGTD. pericard. fluid 3+PMNs.\nCV: HR with rhythm change at : new RAF rate 120-140's. BP stable. pt. with no c/o SOB, palps, dizziness, CP. EKG showing Afib. Rx with lopressor IV 5mg x2 , followed by 5mg IV at 2300 and 0130 with HR contin. 110-120's. also given additional po dose 25mg at 2300. pulses paradox 10. HO aware.\n0330: given 10mg IV dilt. IVP with good responce: HR down to 85-105 Afib. BP 90-100/. pt. sleeping.\n\npericardial drain site D/I. no c/o pain at site or with inspiration. drained total 100cc through passive draining and additional 8cc through aspiration. flushed q4hr per CCU protocol.\n\nResp: sats 94-99% on 4lnc. down to 89-91% on RA. LS clear. occas. dry cough. SOB with exertion.\n\nGU: using commode to void with one assist. 50-100cc/each void. denies any further burning/freq. refusing pryidium\n\nGI: sips of water. refusing offers of snack. LBM .\nNeuro: pt. reporting to still feel effects of ativan given during biopsy. drowsy, falling asleep freq. and easily. A/O x3. c/o lower back pain once in eve, given 2mg morphine IV with good effect.\ntrazadone for sleep. wakes easily to voice.\nanxious to get Bx results back.\n\nA: new RAF with poor rate control on prn lopressor and dilt IV> asymptomatic.\n pericardial drain intact and draining seroussang. fluid....\n\nP: biopsy results pnd. po lopressor dose increased. AM labs. pnd. contin vanco. monitor pulses paradox. OOB to commode with assist. SC heparin.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-02 00:00:00.000", "description": "Report", "row_id": 1372180, "text": "CCU NSG ADMIT\n~1800 pt c/o chest heaviness, not as severe as last noc, not as sharp as this am. EKG done w/ no changes. given toradol w/ good effect.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-02 00:00:00.000", "description": "Report", "row_id": 1372181, "text": "CCU NSG ADMIT\n~1800 pt c/o chest heaviness, not as severe as last noc, not as sharp as this am. EKG done w/ no changes. given toradol w/ good effect.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-06 00:00:00.000", "description": "Report", "row_id": 1372191, "text": "CCU NPN\n\n0700-1900\n\nms: alert, oriented x3, cooperative w/ care\ncv: in afib w/ rate 105-130. given ibutilide 1mg x2 w/ no effect. Cardioverted at 1700 X1 w/ 100j to sinus rhythm rate 75. Given total 70 mg propofol. bp 87-112/59-68. Pericardial drain w/ total 100cc serosanguinous fluid 0600-1800.\nresp: SATS 92-95% on RA, 97-99% on 4lnp. Becomes very sob w/ any activity.\ngi: NPO for cdv\ngu: vdg dk yellow urine\nid: afebrile, cont on vancomycin\nskin: intact\npain/comfort: medicated x1 w/ 2mg mso4 for back pain w/ good effect\nsocial: , social worker met w/ pt today.spoke w/ several friends on phone .\nA: continued drainage from pericardial drain\n sucessful cdv to sr\nP: Continue to monitor drainage from pericardial drain. Monitor rhythm,awaiting results from pathology. Emotional support to pt\n\n" }, { "category": "ECG", "chartdate": "2101-12-06 00:00:00.000", "description": "Report", "row_id": 126077, "text": "Baseline artifact. Probable sinus rhythm with atrial premature beats.\nBorderline left atrial abnormality. Late R wave progression. Inferior\nST segment elevation with T wave inversion. ST segment depression in\nleads I and aVL. T wave inversion in leads V4-V6. Q-T interval prolongation.\nSince the previous tracing sinus rhythm has been restored. The Q-T interval is\nlonger with changes suggestive of evolving inferior wall myocardial infarction\nwith lateral extension. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2101-12-06 00:00:00.000", "description": "Report", "row_id": 126078, "text": "Atrial fibrillation with rapid ventricular response\nLate R wave progression\nInferior ST elevation - repeat if myocardial injury is suspected\nExtensive ST-T changes\nSince previous tracing, atrial fibrillation new, inferior ST segment elevation\nmyocardial infarction persists\nClinical correlation is suggested\n\n" }, { "category": "ECG", "chartdate": "2101-12-03 00:00:00.000", "description": "Report", "row_id": 126079, "text": "Sinus rhythm. Compared to the previous tracing of inferolateral\nST-T wave persist.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2101-12-02 00:00:00.000", "description": "Report", "row_id": 126080, "text": "Sinus rhythm. Compared to tracing #1, patient is now in sinus rhythm without\narrhythmia. Inferolateral ST-T wave abnormalities suggestive of myocardial\nischemia/injury persist. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2101-12-02 00:00:00.000", "description": "Report", "row_id": 126081, "text": "Underlying rhythm is sinus with bust of atrial fibrillation and atrial\ntachycardia. Inferolateral ST-T wave changes suggstive of myocardial\nishcemia/injury pattern. Non-diagnostic poor R wave progression. Compared to\nthe previous tracing of burst of atrial fibrillation is new. Clinical\ncorrelation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2101-12-02 00:00:00.000", "description": "Report", "row_id": 126082, "text": "Sinus rhythm with atrial premature beats. Compared to the previous tracing\nof inferolateral myocardial ischemia/injury pattern persist. Clinical\ncorrelation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2101-12-14 00:00:00.000", "description": "Report", "row_id": 126028, "text": "Sinus rhythm\nDiffuse ST-T wave abnormalities with ST segment elevation - suggest\ninferoapical injury and possible myocardial infarction\nSince previous tracing of , ST-T wave changes slightly less prominent\n\n" }, { "category": "ECG", "chartdate": "2101-12-13 00:00:00.000", "description": "Report", "row_id": 126029, "text": "Sinus rhythm, rate 67. Since the previous tracing of the ST segment\nelevation over the inferolateral leads is less impressive. The compensatory\nST segment depression is also less impressive. The Q-T interval has shortened\nconsiderably. Improvement in the ST-T wave abnormalities is also noted.\n\n" }, { "category": "ECG", "chartdate": "2101-12-10 00:00:00.000", "description": "Report", "row_id": 126030, "text": "Sinus rhythm. Consider left atrial abnormality. Possible septal myocardial\ninfarction, age indeterminate. ST-T wave configuration consistent with\ninfero-apical-lateral injury/ischemia/possible infarction. Since the previous\ntracing of no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2101-12-09 00:00:00.000", "description": "Report", "row_id": 126031, "text": "Sinus rhythm. Consider left atrial abnormality. Possible septal myocardial\ninfarction of indeterminate age. ST-T wave configuration consistent with\ninfero-apical-lateral injury/ischemia/possible infarction. Since the previous\ntracing of further ST-T wave changes are present.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2101-12-02 00:00:00.000", "description": "Report", "row_id": 126083, "text": "Sinus rhythm with atrial ectopy. Inferolateral ST-T wave abnormalities\nsuggestive of myocardial ischemia/injury pattern. Low QRS voltage in the\nprecordial leads. Clinical correlation is suggested. No previous tracing\navailable for comparison.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-07 00:00:00.000", "description": "Report", "row_id": 1372193, "text": "CCU Progress Note:\n\nS- \" I am so short of breath\"!\n\nO- see flowsheet for all objective data.\n\ncv- Tele: SR no ectopy- HR 70's- NIBP 99-128/60-68- MAPs 71-81- pericardial drain site D&I- decreased drainage noted overnight & throughout day- flushes easily- Plan is for pericardial window tomorrow- Hct 28.1- K 4.1- Mg 2.1- INR 1.1\n\nresp- In O2 4L via NC this am- lung sounds with occ exp wheeze noted L otherwise clear- RR 16-20- c/o dyspnea with exertion- O2 removed this afternoon- SpO2 93-95% on room air- seen by thoracic surgery.\n\nneuro- very anxious- told by MD's she has lymphoma- emotional this afternoon- moving all extremities- cooperative- follows command- c/o back pain @ 1330- morphine 1mg IV given with fair effect- c/o same pain @ 1500- percocet 1 tab Po given with good effect.\n\ngi- abd soft (+) bowel sounds- taking Po without incident- 1 small formed brown stool today- on colace & senna.\n\ngu- voiding clear yellow colored urine qs- OOB to commode- BUN 22 Crea 1.0\n\nId- T max 99.1 Po- con't on vancomycin.\n\nA- pre-op for pericardial window tomorrow.\n\nP- NPO after 12am- con't present medical management- med for comfort-\noffer emotional support- con't to pericardial drain care/protocol.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-07 00:00:00.000", "description": "Report", "row_id": 1372194, "text": "Addendum: pericardial drain D/C'd @ 1815\n" }, { "category": "Nursing/other", "chartdate": "2101-12-08 00:00:00.000", "description": "Report", "row_id": 1372195, "text": "59 YR.OLD WOMAN S/P LG. PERICARDIAL EFFUSION & WITH NEW DG: B CELL LYMPHOMA. HEMODYNAMICALLY STABLE. PLAN IS FOR PICC LINE PLACEMENT BY IV TEAM FIRST THING THIS AM, THEN TRANSFER EAST TO ONCOLOGY SERVICE WHERE SHE WILL BEGIN CHEMOTHERAPY. SEE TRANSFER NOTE.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-08 00:00:00.000", "description": "Report", "row_id": 1372196, "text": "CCU NPN\n\nReceived pt extremely SOB. SATs 95% on 2lnp.Very anxious, received 2mg iv ativan w/ much improvementin resp status and anxiety level.Attempt at bedside PICC unsucessful, pt went to IR for PICC placement.\nHas remained hemodynamically stable.\nSeen by heme-onc team, and icu team discussed w/ her the plan which she understands. Her son is aware of the transfer to the .\nValuables from safe have been taken out and are being transported w/ pt.\n" }, { "category": "Radiology", "chartdate": "2101-12-09 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 940166, "text": " 8:52 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please assess for pneumothorax and assess for lung reexpansi\n Admitting Diagnosis: NSTEMI-PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman s/p left thoracentesis\n REASON FOR THIS EXAMINATION:\n please assess for pneumothorax and assess for lung reexpansion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:45 P.M. \n\n HISTORY: Left thoracentesis, assess for pneumothorax.\n\n IMPRESSION: AP chest compared to through 1:30 p.m. on :\n\n Previous moderate-sized left pleural effusion is now much smaller. There is\n no pneumothorax. Moderate right pleural effusion, enlargement of the\n cardiomediastinal silhouette, and bibasilar atelectasis are unchanged. Tip of\n the left PIC catheter can be traced as far as the right atrium but the tip is\n indistinct.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-12-02 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 939154, "text": " 4:42 AM\n CTA CHEST W&W/O C &RECONS; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: PERICARDIAL EFFUSION, T WAVE INVERSION,CONCERN FOR INFERIOR MI; DISSECTION\n Field of view: 38 Contrast: OPTIRAY Amt: 85\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with pericardial effusion, T wave inversions, concern for\n inferior MI\n REASON FOR THIS EXAMINATION:\n dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MJGe FRI 5:35 AM\n 1. no dissection.\n 2. large pericardial effusion.\n 3. mediastinal, retroperitoneal, axillary, and mesenteric lymphadenopathy.\n\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 59-year-old woman with pericardial effusion and chest pain.\n\n TECHNIQUE: Multidetector CT images were obtained through the chest and\n abdomen without and with intravenous contrast. Coronal, sagittal, and oblique\n sagittal reformatted images were obtained.\n\n CT ANGIOGRAM OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: There is a\n large pericardial effusion. The aorta is normal in caliber and there is no\n evidence of aneurysmal dilatation or dissection. The airways are patent to\n the segmental level bilaterally. There is bibasilar subsegmental atelectasis\n and a right pleural effusion. The main pulmonary artery is enlarged, which\n suggests pulmonary arterial hypertension. There are multiple enlarged\n bilateral axillary lymph nodes as well as a large 3 cm subcarinal lymph nodes\n and multiple small prevascular and precarinal lymph nodes in the mediastinum.\n\n CT ANGIOGRAM OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: There is a\n 50-mm rounded low-density focus in the right lobe of the liver, which are too\n small to characterize. There are no other focal liver lesions or biliary\n ductal dilatation. The gallbladder, pancreas, spleen, adrenal glands, and\n kidneys are normal in appearance. The stomach and intra-abdominal loops of\n small bowel are normal in appearance and caliber. There is multiple\n diverticuli of large bowel, but no evidence for diverticulitis. There is no\n free air or free fluid. There is extensive enlarged retroperitoneal and\n mesenteric lymph nodes throughout the abdomen.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n Degenerative changes are seen within the visualized thoracolumbar spine.\n\n IMPRESSION:\n 1. No evidence of aortic dissection or aneurysm.\n 2. Large pericardial effusion.\n 3. Multiple bilateral large mediastinal, axillary, retroperitoneal, and\n mesenteric lymph nodes of unclear etiology. This is concerning for lymphoma\n (Over)\n\n 4:42 AM\n CTA CHEST W&W/O C &RECONS; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: PERICARDIAL EFFUSION, T WAVE INVERSION,CONCERN FOR INFERIOR MI; DISSECTION\n Field of view: 38 Contrast: OPTIRAY Amt: 85\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n and correlation with hematologic profile or biopsy is recommended.\n 4. Bibasilar atelectasis with a small right pleural effusion.\n 5. Multiple diverticuli throughout the colon without evidence for\n diverticulitis.\n\n" }, { "category": "Radiology", "chartdate": "2101-12-08 00:00:00.000", "description": "FLUOR GUID PLCT/REPLCT/REMOVE", "row_id": 939928, "text": " 10:16 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC so that chemo canbe initiated\n Admitting Diagnosis: NSTEMI-PERICARDIAL EFFUSION\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with newly diagnosed lymphoma, needs chemo today\n REASON FOR THIS EXAMINATION:\n please place PICC so that chemo canbe initiated\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: This is a 59-year-old woman with lymphoma that needs\n chemotherapy.\n\n RADIOLOGISTS: The procedure was performed by Drs. and , the\n attending radiologist, who was present and supervising throughout the\n procedure.\n\n PROCEDURE AND FINDINGS: Since no suitable veins were visible, ultrasound was\n used to identify the left brachial vein, which was patent and compressible.\n The left arm of the patient was then prepped and draped in standard sterile\n fashion. After injection of 5 cc of 1% lidocaine, a 21-gauge needle was\n advanced into the left brachial vein under ultrasonographic guidance. Hard\n copies of the images before and after the venipuncture were obtained. A 0.018\n guide wire was then advanced through the needle into the distal part of the\n SVC under fluoroscopic guidance. The needle was then exchanged for a 4.5\n micropuncture sheath. Based on the markers on the guide wire, it was\n determined that a length of 47 cm would be suitable. The PICC line was then\n trimmed to this length and advanced over the wire into the distal part of the\n SVC under fluoroscopic guidance. The peel-away sheath and the wire were then\n removed. The line was flushed, heplocked, and statlocked. A final\n fluoroscopic image of the chest demonstrates tip of the catheter to be located\n in the distal part of the SVC.\n\n IMPRESSION: Successful placement of a 47-cm long double-lumen line with tip\n in distal part of the SVC placed via the left brachial vein. The line is\n ready for use.\n\n\n" } ]

[ { "category": "Physician ", "chartdate": "2104-05-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573419, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 10:30 AM\n PICC LINE - START 06:00 PM\n - started steroids as had no cuff leak and hx difficult extubation\n - increased lantus from 26 to 36 for high sugars\n - hct drop after hypotensive tachycardic episode, gave 1 Prbc, unable\n to get consent from family/hcp (no answer on phone). vitals resolved\n prior to unit\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Metronidazole - 05:38 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 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 07:36 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: 35.6\nC (96.1\n HR: 59 (55 - 118) bpm\n BP: 122/52(68) {83/36(49) - 137/105(110)} mmHg\n RR: 12 (12 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 2,382 mL\n 775 mL\n PO:\n TF:\n IVF:\n 2,382 mL\n 501 mL\n Blood products:\n 274 mL\n Total out:\n 2,060 mL\n 515 mL\n Urine:\n 2,060 mL\n 515 mL\n NG:\n Stool:\n Drains:\n Balance:\n 322 mL\n 260 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 550) mL\n Vt (Spontaneous): 488 (467 - 643) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 46\n PIP: 21 cmH2O\n Plateau: 16 cmH2O\n Compliance: 45.5 cmH2O/mL\n SpO2: 98%\n ABG: 7.40/44/103/26/1\n Ve: 6.1 L/min\n PaO2 / FiO2: 258\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\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: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, No(t) Tender: , Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 341 K/uL\n 8.1 g/dL\n 190 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 97 mEq/L\n 132 mEq/L\n 27.5 %\n 9.4 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n 08:27 PM\n 11:15 PM\n 04:18 AM\n WBC\n 12.5\n 9.4\n Hct\n 29\n 28.3\n 23.4\n 27.5\n Plt\n 397\n 341\n Cr\n 0.9\n 0.7\n TCO2\n 31\n 28\n Glucose\n 173\n 195\n 190\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:18/16, Alk Phos / T\n Bili:169/0.7, Albumin:3.2 g/dL, LDH:182 IU/L, Ca++:8.2 mg/dL, Mg++:1.5\n mg/dL, PO4:5.0 mg/dL\n Imaging: CXR: ET tube ~ 3.3cm from carina. R PICC in place at SVC.\n Heavily rotated, continued haziness at R base\n Microbiology: Sputum Gram stain :\n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND\n CLUSTERS.\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach s/p ERCP with removal of CBD stones\n and sphincterotomy.\n # Respiratory Failure/COPD/Asthma: s/p Steroids, still intubated.\n Sputum Gram Stain + for GPCs\n # CBD Stones\n - s/p ERCP now, will hold aspirin for now per advanced endoscopy team\n for now\n - will continue antibiotics for now peri-procedurally, and discuss with\n team for duration. Likely 24-48h and trend WBC since this has been\n managed interventionally. Cipro 400mg IV q12h and metronidazole 500mg\n IV q8h.\n - trend tbili, lfts\n # Diabetes: Type 1. Continue Home Lantus 28 units SC QHS and sliding\n scale given short steroid pulse.\n # Chronic Diastolic CHF: Holding lisinopril now, will readdress given\n blood pressure throughout the day.\n # h/o HTN: hold HCTZ/lisinopril overnight.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:07 PM\n PICC Line - 06:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "ECG", "chartdate": "2104-04-29 00:00:00.000", "description": "Report", "row_id": 265278, "text": "Sinus rhythm. Early precordial R wave transition. There is variation in\nprecordial lead placement as compared with previous tracing of .\nNo apparent diagnostic interim change.\n\n" }, { "category": "Nursing", "chartdate": "2104-05-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573866, "text": "Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate.\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n Impaired Skin Integrity\n Assessment:\n Patient came to us with bilateral gluteal decubiti both classified as\n stage 3.\n Action:\n Wound cleansed with wound wash and then filled with collenagase as\n recommended, dressed using a gauze and micropore tape. Wound is well\n rounded and sloughy in appearance.\n Response:\n Wound can be extremely weepy and thus dsg may come off. Changed twice\n this shift.\n Plan:\n Continue to document progression of wound. Monitor for any new areas of\n breakdown.\n Problem\n Respiratory failure.\n Assessment:\n Patient was extubated today at approximately 1040 successfully.\n Action:\n Transitioned from tent mask to nasal prongs at 4l/min\n Response:\n Maintaining saturations in the mid to upper 90\ns. She does have a\n productive cough with yellowish sputum, however mostly clear. Of note\n patient appears to have impaired swallowing and drools at times.\n Plan:\n Continue to with nebs as ordered. Monitor for respiratory\n deterioration. Follow lab trends.\n Hct 33.5 stable with no evidence of bleeding.\n" }, { "category": "Physician ", "chartdate": "2104-05-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573470, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 10:30 AM\n PICC LINE - START 06:00 PM\n - started steroids as had no cuff leak and hx difficult extubation\n - increased lantus from 26 to 36 for high sugars\n - hct drop after hypotensive tachycardic episode, gave 1 Prbc, unable\n to get consent from family/hcp (no answer on phone). vitals resolved\n prior to unit\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Metronidazole - 05:38 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 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 07:36 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: 35.6\nC (96.1\n HR: 59 (55 - 118) bpm\n BP: 122/52(68) {83/36(49) - 137/105(110)} mmHg\n RR: 12 (12 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 2,382 mL\n 775 mL\n PO:\n TF:\n IVF:\n 2,382 mL\n 501 mL\n Blood products:\n 274 mL\n Total out:\n 2,060 mL\n 515 mL\n Urine:\n 2,060 mL\n 515 mL\n NG:\n Stool:\n Drains:\n Balance:\n 322 mL\n 260 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 550) mL\n Vt (Spontaneous): 488 (467 - 643) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 46\n PIP: 21 cmH2O\n Plateau: 16 cmH2O\n Compliance: 45.5 cmH2O/mL\n SpO2: 98%\n ABG: 7.40/44/103/26/1\n Ve: 6.1 L/min\n PaO2 / FiO2: 258\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: S1 & S2 regular without murmur\n Peripheral Vascular: 1+ Distal pulses bilaterally\n Respiratory / Chest: Symmetric chest expansion, anterior exam clear\n Abdominal: Soft, nontender, obese, PEG in place.\n Extremities: Trace bilateral edema\n Skin: Not assessed\n Neurologic: Intubated & sedated, pupils reactive\n Labs / Radiology\n 341 K/uL\n 8.1 g/dL\n 190 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 97 mEq/L\n 132 mEq/L\n 27.5 %\n 9.4 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n 08:27 PM\n 11:15 PM\n 04:18 AM\n WBC\n 12.5\n 9.4\n Hct\n 29\n 28.3\n 23.4\n 27.5\n Plt\n 397\n 341\n Cr\n 0.9\n 0.7\n TCO2\n 31\n 28\n Glucose\n 173\n 195\n 190\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:18/16, Alk Phos / T\n Bili:169/0.7, Albumin:3.2 g/dL, LDH:182 IU/L, Ca++:8.2 mg/dL, Mg++:1.5\n mg/dL, PO4:5.0 mg/dL\n Imaging: CXR: ET tube ~ 3.3cm from carina. R PICC in place at SVC.\n Heavily rotated, continued haziness at R base\n Microbiology: Sputum Gram stain :\n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND\n CLUSTERS.\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach s/p ERCP with removal of CBD stones\n and sphincterotomy.\n # Respiratory Failure/COPD/Asthma: The patient remains intubated after\n ERCP. Given her lack of cuff leak yesterday, she was given a short\n course of glucocorticoids and today does have a cuff leak. Of note,\n her sputum is positive for GPCs in clusters and pairs. This could be\n HCAP, HAP or VAP or tracheobronchitis given her recent hospital courses\n and relatively short stay on a ventilator. She is tolerating PSV on\n well\n - Extubation today pending Hct stability (see below)\n - Vancomycin 1g Q12 with trough after dose three pending speciation of\n her sputum flora\n - NPO for extubation\n # Blood volume instability: The patient had physiology and laboratory\n studies consistent with blood loss yesterday night, but as of yet has\n not demonstrated a bleeding source. She was transfused 1 unit of blood\n and returned to within her pre-\nbleed\n hematocrit.\n - Hematocrit at 11am and 7pm (TID), transfusing as necessary\n - Active T&S\n - Guaiac stools\n - monitor lines for bleeding\n # CBD Stones: S/P ERCP day 2, will continue antibiotics and continue\n PEG tube feeds once she is extubated\n - Appreciated ERCP recs\n # Diabetes: Type 1. Continue Home Lantus 28 units SC QHS and sliding\n scale given short steroid pulse.\n # Chronic Diastolic CHF: Holding lisinopril now, will readdress given\n blood pressure throughout the day.\n # h/o HTN: hold HCTZ/lisinopril overnight.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:07 PM\n PICC Line - 06:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2104-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573526, "text": "Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate.\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n" }, { "category": "Nursing", "chartdate": "2104-05-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 573966, "text": "Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate.\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n Extubated yesterday, , without difficulty.\n Problem\n Respiratory failure\n Assessment:\n Extubated on L NC with Sp02 100%,weaned off to RA. Lung\n coarse clearing with cough, Good cough producing large amounts of\n thick yellow sputum. Hemodynamically stable with NBP 120\ns-160s/60\n SR\n with occasional PVC\ns. Skin warm, good pedal pulses. Abdomen soft with\n (+) bowel sounds,BM X 1, TF on goal via PEG. Urine clear and yellow,\n UO adequate\n Action:\n Chest PT, encouraging CDB, Albuterol and Atrovent nebs.\n Response:\n Pt remains on RA with Sp02 93-95%, secretions remain large in amount\n and pt able to clear by using yanker suction, Hemodynamically stable,\n TF\ns running at goal.\n Plan:\n Encourage CDB.\n Impaired Skin Integrity\n Assessment:\n Pt has bilateral stage 3 ulcers on buttocks. Tunneling present on both\n ulcers and both are also weeping purulent drainage. No odor noticed.\n Action:\n Changed each dsg at PM today - cleansed with wound cleanser and then\n collagenase ointment applied and covered with DSD. Frequent turns.\n Response:\n Pts skin remains impaired\n Plan:\n Change pressure ulcer dsgs as per wound recs\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n POST PROCEDURE ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAP\n Code status:\n Full code\n Height:\n Admission weight:\n 104.8 kg\n Daily weight:\n 101.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact\n PMH: Asthma, Diabetes - Insulin, Renal Failure, Smoker\n CV-PMH: CAD, CHF, Hypertension\n Additional history: emphysema (no records here)\n 2. Chronic, systolic, heart failur\n 5. Anxiety\n Surgery / Procedure and date: ERCP\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:61\n Temperature:\n 98.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 102 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 2% %\n 24h total in:\n 1,605 mL\n 24h total out:\n 1,560 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 05:55 AM\n Potassium:\n 3.3 mEq/L\n 05:55 AM\n Chloride:\n 107 mEq/L\n 05:55 AM\n CO2:\n 27 mEq/L\n 05:55 AM\n BUN:\n 7 mg/dL\n 05:55 AM\n Creatinine:\n 0.7 mg/dL\n 05:55 AM\n Glucose:\n 227 mg/dL\n 05:55 AM\n Hematocrit:\n 31.8 %\n 05:55 AM\n Finger Stick Glucose:\n 432\n 12:00 PM\n Valuables / Signature\n Patient valuables: eye glass\n Other valuables: none\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: MICU/SICU--406\n Transferred to: 1179\n Date & time of Transfer: 1730\n .\n Frequent turns.\n Keep blood sugar WNL for healing using standing lantus and sliding\n scale\n" }, { "category": "Nursing", "chartdate": "2104-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573527, "text": "Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate.\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n Has been kept npo for ? extubation this am\n Impaired Skin Integrity\n Assessment:\n Bilateral gluteal decubs, stage 3\n Action:\n Dsgs were changed using collaganase ointment and medipore dsg.\n Response:\n pending\n Plan:\n Continue with qd dsg changes\n Diabetes Mellitus (DM), Type I\n Assessment:\n Finger stick 53 this am\n Action:\n amp d50 given\n Response:\n See metavison for most up to date finger stick\n Plan:\n Continue to monitor finger sticks and treat accordingly\n" }, { "category": "Physician ", "chartdate": "2104-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573689, "text": "Chief Complaint:\n 24 Hour Events:\n - Repleting free water for hypernatremia (2.8L deficit)\n - Restarted tube feeds with free water bolus (1L)\n - Transfused 1 unit of blood for hct <25\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 08:51 PM\n Metronidazole - 05:59 AM\n Infusions:\n Propofol - 75 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:21 PM\n Dextrose 50% - 04:26 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 06:49 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: 80 (64 - 88) bpm\n BP: 123/51(67) {85/41(54) - 126/83(88)} mmHg\n RR: 18 (12 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 3,851 mL\n 1,682 mL\n PO:\n TF:\n 62 mL\n 6 mL\n IVF:\n 3,290 mL\n 1,659 mL\n Blood products:\n 259 mL\n 17 mL\n Total out:\n 4,125 mL\n 580 mL\n Urine:\n 4,125 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -274 mL\n 1,102 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 426 (333 - 426) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 24 cmH2O\n Plateau: 14 cmH2O\n Compliance: 61.1 cmH2O/mL\n SpO2: 99%\n ABG: ///30/\n Ve: 5.6 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 356 K/uL\n 8.4 g/dL\n 135 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 97 mEq/L\n 134 mEq/L\n 28.0 %\n 7.8 K/uL\n [image002.jpg]\n 02:54 AM\n 08:27 PM\n 11:15 PM\n 04:18 AM\n 01:59 PM\n 09:53 PM\n 10:19 PM\n 04:40 AM\n 03:12 PM\n 04:16 AM\n WBC\n 12.5\n 9.4\n 9.0\n 7.8\n Hct\n 28.3\n 23.4\n 27.5\n 25.0\n 27.0\n 25.1\n 24.6\n 28.0\n Plt\n 397\n 341\n 336\n 356\n Cr\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 28\n 34\n Glucose\n 195\n 190\n 105\n 43\n 135\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:18/13, Alk Phos / T\n Bili:156/0.4, Albumin:3.2 g/dL, LDH:182 IU/L, Ca++:8.0 mg/dL, Mg++:1.8\n mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: None\n Imaging: CXR pending\n Microbiology: Sputum Sensis Pending\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:58 PM\n PICC Line - 06:00 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": "2104-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573690, "text": "Chief Complaint:\n 24 Hour Events:\n - Repleting free water for hypernatremia (2.8L deficit)\n - Restarted tube feeds with free water bolus (1L)\n - Transfused 1 unit of blood for hct <25\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 08:51 PM\n Metronidazole - 05:59 AM\n Infusions:\n Propofol - 75 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:21 PM\n Dextrose 50% - 04:26 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 06:49 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: 80 (64 - 88) bpm\n BP: 123/51(67) {85/41(54) - 126/83(88)} mmHg\n RR: 18 (12 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 3,851 mL\n 1,682 mL\n PO:\n TF:\n 62 mL\n 6 mL\n IVF:\n 3,290 mL\n 1,659 mL\n Blood products:\n 259 mL\n 17 mL\n Total out:\n 4,125 mL\n 580 mL\n Urine:\n 4,125 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -274 mL\n 1,102 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 426 (333 - 426) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 24 cmH2O\n Plateau: 14 cmH2O\n Compliance: 61.1 cmH2O/mL\n SpO2: 99%\n ABG: ///30/\n Ve: 5.6 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: S1 & S2 regular without murmur\n Peripheral Vascular: 1+ Distal pulses bilaterally\n Respiratory / Chest: Symmetric chest expansion, anterior exam clear\n Abdominal: Soft, nontender, obese, PEG in place.\n Extremities: Trace bilateral edema\n Skin: Not assessed\n Neurologic: Intubated & sedated, pupils reactive, reacts to voice\n Labs / Radiology\n 356 K/uL\n 8.4 g/dL\n 135 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 97 mEq/L\n 134 mEq/L\n 28.0 %\n 7.8 K/uL\n [image002.jpg]\n 02:54 AM\n 08:27 PM\n 11:15 PM\n 04:18 AM\n 01:59 PM\n 09:53 PM\n 10:19 PM\n 04:40 AM\n 03:12 PM\n 04:16 AM\n WBC\n 12.5\n 9.4\n 9.0\n 7.8\n Hct\n 28.3\n 23.4\n 27.5\n 25.0\n 27.0\n 25.1\n 24.6\n 28.0\n Plt\n 397\n 341\n 336\n 356\n Cr\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 28\n 34\n Glucose\n 195\n 190\n 105\n 43\n 135\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:18/13, Alk Phos / T\n Bili:156/0.4, Albumin:3.2 g/dL, LDH:182 IU/L, Ca++:8.0 mg/dL, Mg++:1.8\n mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: None\n Imaging: CXR pending\n Microbiology: Sputum Sensis Pending\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach s/p ERCP with removal of CBD stones\n and sphincterotomy.\n # Respiratory Failure/COPD/Asthma: The patient remains intubated after\n ERCP. She continues to have a cuff leak post glucocorticoids, but her\n current respiratory status during a spontaneous breathing trial\n suggests that she will not be an easy intubation. We will rest her on\n A/C overnight and attempt extubation in the AM. Of note, her sputum is\n positive for Staph Aureus. - Extubation tomorrow AM\n - Vancomycin 1g Q12 with trough after dose #3 pending speciation of her\n sputum flora\n - Resume TF for now, NPO for extubation tomorrow\n - Lasix 20mg IV x1\n # Blood volume instability: The patient continues with a stable\n hematocrit and no bleeding source.\n - Hematocrits \n - Active T&S\n - Guaiac stools\n - monitor lines for bleeding\n # CBD Stones: S/P ERCP day 2, will continue antibiotics and continue\n PEG tube feeds once she is extubated\n - Appreciated ERCP recs\n # Diabetes: Type 1. Continue Home Lantus at 26 units SC QHS and\n sliding scale given short steroid pulse.\n # Chronic Diastolic CHF: Holding lisinopril now, will readdress given\n blood pressure throughout the day.\n # h/o HTN: hold HCTZ/lisinopril overnight.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:58 PM\n PICC Line - 06:00 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": "2104-05-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573925, "text": "Chief Complaint:\n 24 Hour Events:\n - Extubated in AM, doing well from respiratory standpoint\n - Restarted home antihypertensives (HCTZ 12.5mg and lisinopril 20mg)\n - Need to clarify course of cipro/flagyl with ERCP\n - Restarted tube feeds\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 07:51 PM\n Metronidazole - 10:17 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:17 PM\n Heparin Sodium (Prophylaxis) - 02:11 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 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.8\nC (98.3\n HR: 110 (82 - 117) bpm\n BP: 138/66(83) {113/47(68) - 175/101(104)} mmHg\n RR: 22 (16 - 31) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 1,501 mL\n 374 mL\n PO:\n TF:\n 79 mL\n 339 mL\n IVF:\n 1,262 mL\n 35 mL\n Blood products:\n Total out:\n 2,950 mL\n 680 mL\n Urine:\n 2,950 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,449 mL\n -306 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 350 (350 - 350) mL\n PS : 8 cmH2O\n RR (Spontaneous): 14\n PEEP: 0 cmH2O\n FiO2: 2%\n PIP: 8 cmH2O\n SpO2: 94%\n ABG: ///27/\n Ve: 11.8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 287 K/uL\n 10.4 g/dL\n 227 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 7 mg/dL\n 107 mEq/L\n 143 mEq/L\n 31.8 %\n 8.1 K/uL\n [image002.jpg]\n 01:59 PM\n 09:53 PM\n 10:19 PM\n 04:40 AM\n 03:12 PM\n 04:16 AM\n 03:20 PM\n 04:47 AM\n 03:13 PM\n 05:55 AM\n WBC\n 9.0\n 7.8\n 9.3\n 7.8\n 8.1\n Hct\n 25.0\n 27.0\n 25.1\n 24.6\n 28.0\n 31.5\n 32.0\n 33.5\n 31.8\n Plt\n 27\n 287\n Cr\n 0.6\n 0.7\n 0.6\n 0.6\n 0.7\n TCO2\n 34\n Glucose\n 105\n 43\n 135\n 140\n 227\n Other labs: PT / PTT / INR:13.3/24.4/1.1, ALT / AST:17/26, Alk Phos / T\n Bili:140/0.5, Albumin:3.2 g/dL, LDH:200 IU/L, Ca++:8.1 mg/dL, Mg++:1.4\n mg/dL, PO4:4.1 mg/dL\n Imaging: CXR: ET Tube removed. R PICC in place. RML Consolidation\n clearing but present. Overall improved\n Microbiology: BAL:\n GRAM STAIN (Final ):\n 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE\n COCCI. IN PAIRS AND CLUSTERS.\n RESPIRATORY CULTURE (Preliminary):\n ? OROPHARYNGEAL FLORA.\n STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML OF TWO\n COLONIAL MORPHOLOGIES.\n SENSITIVITIES PERFORMED ON CULTURE # 273-1147T ().\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii).\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 08:03 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 06:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2104-05-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573926, "text": "Chief Complaint:\n 24 Hour Events:\n - Extubated in AM, doing well from respiratory standpoint\n - Restarted home antihypertensives (HCTZ 12.5mg and lisinopril 20mg)\n - Need to clarify course of cipro/flagyl with ERCP\n - Restarted tube feeds\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 07:51 PM\n Metronidazole - 10:17 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:17 PM\n Heparin Sodium (Prophylaxis) - 02:11 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 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.8\nC (98.3\n HR: 110 (82 - 117) bpm\n BP: 138/66(83) {113/47(68) - 175/101(104)} mmHg\n RR: 22 (16 - 31) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 1,501 mL\n 374 mL\n PO:\n TF:\n 79 mL\n 339 mL\n IVF:\n 1,262 mL\n 35 mL\n Blood products:\n Total out:\n 2,950 mL\n 680 mL\n Urine:\n 2,950 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,449 mL\n -306 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 350 (350 - 350) mL\n PS : 8 cmH2O\n RR (Spontaneous): 14\n PEEP: 0 cmH2O\n FiO2: 2%\n PIP: 8 cmH2O\n SpO2: 94%\n ABG: ///27/\n Ve: 11.8 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese,\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: S1 & S2 regular without murmur\n Peripheral Vascular: 1+ Distal pulses bilaterally\n Respiratory / Chest: Symmetric chest expansion, anterior exam clear\n Abdominal: Soft, nontender, obese, PEG in place.\n Extremities: Trace bilateral edema\n Skin: Not assessed\n Neurologic: Intubated but awake and alert, responds to commands\n Labs / Radiology\n 287 K/uL\n 10.4 g/dL\n 227 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 7 mg/dL\n 107 mEq/L\n 143 mEq/L\n 31.8 %\n 8.1 K/uL\n [image002.jpg]\n 01:59 PM\n 09:53 PM\n 10:19 PM\n 04:40 AM\n 03:12 PM\n 04:16 AM\n 03:20 PM\n 04:47 AM\n 03:13 PM\n 05:55 AM\n WBC\n 9.0\n 7.8\n 9.3\n 7.8\n 8.1\n Hct\n 25.0\n 27.0\n 25.1\n 24.6\n 28.0\n 31.5\n 32.0\n 33.5\n 31.8\n Plt\n 27\n 287\n Cr\n 0.6\n 0.7\n 0.6\n 0.6\n 0.7\n TCO2\n 34\n Glucose\n 105\n 43\n 135\n 140\n 227\n Other labs: PT / PTT / INR:13.3/24.4/1.1, ALT / AST:17/26, Alk Phos / T\n Bili:140/0.5, Albumin:3.2 g/dL, LDH:200 IU/L, Ca++:8.1 mg/dL, Mg++:1.4\n mg/dL, PO4:4.1 mg/dL\n Imaging: CXR: ET Tube removed. R PICC in place. RML Consolidation\n clearing but present. Overall improved\n Microbiology: BAL:\n GRAM STAIN (Final ):\n 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND\n CLUSTERS.\n RESPIRATORY CULTURE (Preliminary):\n ? OROPHARYNGEAL FLORA.\n STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML OF TWO\n COLONIAL MORPHOLOGIES.\n SENSITIVITIES PERFORMED ON CULTURE # 273-1147T ().\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii).\n Assessment and Plan\n 76 y/oF s/p ERCP, MRSA PNA s/p intubation.\n # Respiratory Failure/COPD/Asthma: Extubated, continued MRSA PNA\n # CBD Stones: She did not have cholangitis, rather stones + pain. Now\n s/p ERCP day 4.\n - Continue Cipro/Flagyl (day 1=)\n - clarify antibiotic course with ERCP\n # Diabetes: Type 1.\n - Continue Home Lantus at 26 units SC QHS and sliding scale\n # Chronic Diastolic CHF/HTN: Restarted Lisinopril. HCTZ\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 08:03 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 06:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2104-05-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573963, "text": "Chief Complaint:\n 24 Hour Events:\n - Extubated in AM, doing well from respiratory standpoint\n - Restarted home antihypertensives (HCTZ 12.5mg and lisinopril 20mg)\n - Restarted tube feeds\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 07:51 PM\n Metronidazole - 10:17 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:17 PM\n Heparin Sodium (Prophylaxis) - 02:11 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 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.8\nC (98.3\n HR: 110 (82 - 117) bpm\n BP: 138/66(83) {113/47(68) - 175/101(104)} mmHg\n RR: 22 (16 - 31) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 1,501 mL\n 374 mL\n PO:\n TF:\n 79 mL\n 339 mL\n IVF:\n 1,262 mL\n 35 mL\n Blood products:\n Total out:\n 2,950 mL\n 680 mL\n Urine:\n 2,950 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,449 mL\n -306 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 350 (350 - 350) mL\n PS : 8 cmH2O\n RR (Spontaneous): 14\n PEEP: 0 cmH2O\n FiO2: 2%\n PIP: 8 cmH2O\n SpO2: 94%\n ABG: ///27/\n Ve: 11.8 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese,\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: S1 & S2 regular without murmur\n Peripheral Vascular: 1+ Distal pulses bilaterally\n Respiratory / Chest: Symmetric chest expansion, upper respiratory\n sounds, RLL rales with scant rhonchi\n Abdominal: Soft, nontender, obese, PEG in place.\n Extremities: Trace bilateral edema\n Neurologic: Awake and alert, responds to commands\n Labs / Radiology\n 287 K/uL\n 10.4 g/dL\n 227 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 7 mg/dL\n 107 mEq/L\n 143 mEq/L\n 31.8 %\n 8.1 K/uL\n [image002.jpg]\n 01:59 PM\n 09:53 PM\n 10:19 PM\n 04:40 AM\n 03:12 PM\n 04:16 AM\n 03:20 PM\n 04:47 AM\n 03:13 PM\n 05:55 AM\n WBC\n 9.0\n 7.8\n 9.3\n 7.8\n 8.1\n Hct\n 25.0\n 27.0\n 25.1\n 24.6\n 28.0\n 31.5\n 32.0\n 33.5\n 31.8\n Plt\n 27\n 287\n Cr\n 0.6\n 0.7\n 0.6\n 0.6\n 0.7\n TCO2\n 34\n Glucose\n 105\n 43\n 135\n 140\n 227\n Other labs: PT / PTT / INR:13.3/24.4/1.1, ALT / AST:17/26, Alk Phos / T\n Bili:140/0.5, Albumin:3.2 g/dL, LDH:200 IU/L, Ca++:8.1 mg/dL, Mg++:1.4\n mg/dL, PO4:4.1 mg/dL\n Imaging: CXR: ET Tube removed. R PICC in place. RML Consolidation\n clearing but present. Overall improved\n Microbiology: BAL:\n GRAM STAIN (Final ):\n 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND\n CLUSTERS.\n RESPIRATORY CULTURE (Preliminary):\n ? OROPHARYNGEAL FLORA.\n STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML OF TWO\n COLONIAL MORPHOLOGIES.\n SENSITIVITIES PERFORMED ON CULTURE # 273-1147T ().\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii).\n Assessment and Plan\n 76 y/oF s/p ERCP, MRSA PNA s/p intubation. She is doing well post\n extubation and actually has a decreased oxygen requirement from her\n reported baseline.\n # MRSA PNA c/b COPD, Asthma: The patient is doing well on room air\n after extubation. She has a known MRSA PNA for which she is receiving\n Vancomycin.\n - Continue vancomycin for 10 day course to end on Monday \n # CBD Stones: Patient s/p ERCP for stone removal. The plan is to\n continue Cipro/Flagyl for a 10 day total course, ending .\n # Diabetes: Type 1.\n - Continue Home Lantus at 26 units SC QHS and sliding scale\n # Chronic Diastolic CHF/HTN: Restarted Lisinopril & HCTZ and the\n patient is doing well.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 08:03 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 06:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2104-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573704, "text": "Chief Complaint:\n 24 Hour Events:\n - Repleting free water for hypernatremia (2.8L deficit) (148 to 134)\n - Restarted tube feeds with free water bolus (1L)\n - Transfused 1 unit of blood for hct <25 (up to 28 post-transfusion)\n - RISB this morning 130, changed from AC toe PS 10/5\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 08:51 PM\n Metronidazole - 05:59 AM\n Infusions:\n Propofol - 75 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:21 PM\n Dextrose 50% - 04:26 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 06:49 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: 80 (64 - 88) bpm\n BP: 123/51(67) {85/41(54) - 126/83(88)} mmHg\n RR: 18 (12 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 3,851 mL\n 1,682 mL\n PO:\n TF:\n 62 mL\n 6 mL\n IVF:\n 3,290 mL\n 1,659 mL\n Blood products:\n 259 mL\n 17 mL\n Total out:\n 4,125 mL\n 580 mL\n Urine:\n 4,125 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -274 mL\n 1,102 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 426 (333 - 426) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 24 cmH2O\n Plateau: 14 cmH2O\n Compliance: 61.1 cmH2O/mL\n SpO2: 99%\n ABG: ///30/\n Ve: 5.6 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: S1 & S2 regular without murmur\n Peripheral Vascular: 1+ Distal pulses bilaterally\n Respiratory / Chest: Symmetric chest expansion, anterior exam clear\n Abdominal: Soft, nontender, obese, PEG in place.\n Extremities: Trace bilateral edema\n Skin: Not assessed\n Neurologic: Intubated & sedated, pupils reactive, reacts to voice\n Labs / Radiology\n 356 K/uL\n 8.4 g/dL\n 135 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 97 mEq/L\n 134 mEq/L\n 28.0 %\n 7.8 K/uL\n [image002.jpg]\n 02:54 AM\n 08:27 PM\n 11:15 PM\n 04:18 AM\n 01:59 PM\n 09:53 PM\n 10:19 PM\n 04:40 AM\n 03:12 PM\n 04:16 AM\n WBC\n 12.5\n 9.4\n 9.0\n 7.8\n Hct\n 28.3\n 23.4\n 27.5\n 25.0\n 27.0\n 25.1\n 24.6\n 28.0\n Plt\n 397\n 341\n 336\n 356\n Cr\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 28\n 34\n Glucose\n 195\n 190\n 105\n 43\n 135\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:18/13, Alk Phos / T\n Bili:156/0.4, Albumin:3.2 g/dL, LDH:182 IU/L, Ca++:8.0 mg/dL, Mg++:1.8\n mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: None\n Imaging: CXR pending\n Microbiology: Sputum Sensis Pending\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach s/p ERCP with removal of CBD stones\n and sphincterotomy.\n # Respiratory Failure/COPD/Asthma: The patient remains intubated after\n ERCP. She continues to have a cuff leak post glucocorticoids, but her\n RISB is high and her current respiratory status during a spontaneous\n breathing trial suggests that she will not be an easy extubation. \n be fluids today. Of note, her sputum is positive for Staph Aureus.\n - Repeat SBT after PS trial\n - Continue Vancomycin but change dose from 1g Q12 to 1g q24 given high\n trough\n - Resume TF for now, NPO for extubation tomorrow\n - Lasix 20mg IV x1 for goal -500.\n # Blood volume instability: The patient bumped appropriately and has no\n identifiable bleeding source.\n - Hematocrit \n - Active T&S\n - Guaiac stools\n - monitor lines for bleeding\n -transfuse for HCT <24\n #Hypernatremia: Resolved with intiation of free water and tube feeds.\n .\n # CBD Stones: S/P ERCP day 3, will continue antibiotics and continue\n PEG tube feeds once she is extubated\n -Continue Cipro/Flagyl\n - Appreciated ERCP recs\n # Diabetes: Type 1. Continue Home Lantus at 26 units SC QHS and\n sliding scale given short steroid pulse.\n # Chronic Diastolic CHF: Holding lisinopril now, patient remains\n normotensive.\n # h/o HTN: hold HCTZ/lisinopril.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:58 PM\n PICC Line - 06:00 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": "2104-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573709, "text": "Chief Complaint:\n 24 Hour Events:\n - Repleting free water for hypernatremia (2.8L deficit) (148 to 134)\n - Restarted tube feeds with free water bolus (1L)\n - Transfused 1 unit of blood for hct <25 (up to 28 post-transfusion)\n - RISB this morning 130, changed from AC to PS 10/5 now PS 5/5\n -Vanco trough high, changed dose to 1g q24h.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 08:51 PM\n Metronidazole - 05:59 AM\n Infusions:\n Propofol - 75 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:21 PM\n Dextrose 50% - 04:26 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 06:49 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: 80 (64 - 88) bpm\n BP: 123/51(67) {85/41(54) - 126/83(88)} mmHg\n RR: 18 (12 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 3,851 mL\n 1,682 mL\n PO:\n TF:\n 62 mL\n 6 mL\n IVF:\n 3,290 mL\n 1,659 mL\n Blood products:\n 259 mL\n 17 mL\n Total out:\n 4,125 mL\n 580 mL\n Urine:\n 4,125 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -274 mL\n 1,102 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 426 (333 - 426) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 24 cmH2O\n Plateau: 14 cmH2O\n Compliance: 61.1 cmH2O/mL\n SpO2: 99%\n ABG: ///30/\n Ve: 5.6 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: S1 & S2 regular without murmur\n Peripheral Vascular: 1+ Distal pulses bilaterally\n Respiratory / Chest: Symmetric chest expansion, anterior exam clear\n Abdominal: Soft, nontender, obese, PEG in place.\n Extremities: Trace bilateral edema\n Skin: Not assessed\n Neurologic: Intubated & sedated, pupils reactive, reacts to voice\n Labs / Radiology\n 356 K/uL\n 8.4 g/dL\n 135 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 97 mEq/L\n 134 mEq/L\n 28.0 %\n 7.8 K/uL\n [image002.jpg]\n 02:54 AM\n 08:27 PM\n 11:15 PM\n 04:18 AM\n 01:59 PM\n 09:53 PM\n 10:19 PM\n 04:40 AM\n 03:12 PM\n 04:16 AM\n WBC\n 12.5\n 9.4\n 9.0\n 7.8\n Hct\n 28.3\n 23.4\n 27.5\n 25.0\n 27.0\n 25.1\n 24.6\n 28.0\n Plt\n 397\n 341\n 336\n 356\n Cr\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 28\n 34\n Glucose\n 195\n 190\n 105\n 43\n 135\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:18/13, Alk Phos / T\n Bili:156/0.4, Albumin:3.2 g/dL, LDH:182 IU/L, Ca++:8.0 mg/dL, Mg++:1.8\n mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: None\n Imaging: CXR pending\n Microbiology: Sputum Sensis Pending\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach s/p ERCP with removal of CBD stones\n and sphincterotomy.\n .\n # Respiratory Failure/COPD/Asthma: The patient remains intubated after\n ERCP though she did not have lung pathology (besides underlying lung\n disease) prior to intubation. She now has MRSA growing in her sputum\n and likely had too much volume overnight for her hypernatremia. Her\n RISB is high and her current respiratory status during a spontaneous\n breathing trial suggests that she will not be an easy extubation.\n Will aim for extubation tonight vs. tomorrow AM\n -ABG on after 3-4 hours\n -Bronch today to make sure her airway is clear before extubation\n - Continue Vancomycin but change dose from 1g Q12 to 1g q24 given high\n trough\n - Resume TF for now, NPO for extubation tomorrow\n - Stop d5@150.\n .\n # Blood volume instability: The patient bumped appropriately and has no\n identifiable bleeding source.\n - Hematocrit \n - Active T&S\n - Guaiac stools\n - monitor lines for bleeding\n - transfuse for HCT <24\n #Hypernatremia: Resolved with intiation of free water and tube feeds.\n -stop d5\n -continue free water with tube feeds\n -PM sodium\n .\n # CBD Stones: S/P ERCP day 3, will continue antibiotics and continue\n PEG tube feeds once she is extubated\n -Continue Cipro/Flagyl\n - Appreciated ERCP recs\n # Diabetes: Type 1. Continue Home Lantus at 26 units SC QHS and\n sliding scale given short steroid pulse.\n # Chronic Diastolic CHF: Holding lisinopril now, patient remains\n normotensive.\n # h/o HTN: hold HCTZ/lisinopril.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:58 PM\n PICC Line - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: To ICU while intubated\n" }, { "category": "Nutrition", "chartdate": "2104-05-05 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 573945, "text": "Subjective\n Patient extubated\n Objective\n Pertinent medications: ferrous sulfate, HISS, 40KCl, 2gm Mg\n Labs:\n Value\n Date\n Glucose\n 227 mg/dL\n 05:55 AM\n Glucose Finger Stick\n 224\n 04:00 AM\n BUN\n 7 mg/dL\n 05:55 AM\n Creatinine\n 0.7 mg/dL\n 05:55 AM\n Sodium\n 143 mEq/L\n 05:55 AM\n Potassium\n 3.3 mEq/L\n 05:55 AM\n Chloride\n 107 mEq/L\n 05:55 AM\n TCO2\n 27 mEq/L\n 05:55 AM\n PO2 (arterial)\n 92. mm Hg\n 09:53 PM\n PCO2 (arterial)\n 54 mm Hg\n 09:53 PM\n pH (arterial)\n 7.39 units\n 09:53 PM\n CO2 (Calc) arterial\n 34 mEq/L\n 09:53 PM\n Albumin\n 3.2 g/dL\n 02:54 AM\n Calcium non-ionized\n 8.1 mg/dL\n 04:47 AM\n Phosphorus\n 4.1 mg/dL\n 04:47 AM\n Magnesium\n 1.4 mg/dL\n 05:55 AM\n Current diet order / nutrition support: Fibersource HN at 60ml/hr x 24\n hours - provides 1728kcal and 76g protein\n GI: Abdomen obese/soft with positive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n 76 year old female now s/p ERCP with removal of CBD stone and\n sphincterotomy with intubation. Patient now extubated and on tube\n feedings of Fibersource HN at 60ml/hr. Noted patient with 2 Stage 3\n Pressure ulcers. Would consider changing tube feeding to provide more\n protein. Recommend goal of Replete with Fiber at 75ml/hr x 24 hours to\n provide 1800kcal and 111g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Consider changing tube feeding to Replete with Fiber at\n 75ml/hr x 24hours\n 2. Monitor residuals q4H and hold tube feeding if >150ml\n 3. Will follow and make adjustments to tube feedings PRN\n 11:22 AM\n" }, { "category": "Nursing", "chartdate": "2104-05-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 573951, "text": "Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate.\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n Extubated yesterday, , without difficulty.\n Problem\n Respiratory failure\n Assessment:\n s/p extubation , received pt on 2 L NC with Sp02 100%. Lung\n rhonchus clearing with cough, intermittent exp wheezes. Good cough\n producing large amounts of thick yellow white sputum. Hemodynamically\n stable with NBP 120\ns-160s/60\ns, ST most of night 100-110 with\n occasional PVC\ns. Skin warm, good pedal pulses. Abdomen soft with (+)\n bowel sounds, TF started again via PEG. Urine clear and yellow, UO\n 60-120 cc/hr.\n Action:\n Pulmonary toileting, encouraging CDB, Albuterol and Atrovent nebs,\n supplemental 02\n Response:\n Pt remains on 2 L NC with Sp02 93-95%, secretions remain large in\n amount and pt needs much encouragement to clear them, Hemodynamically\n stable, TF\ns running at goal.\n Plan:\n Supplemental 02 as needed. Encourage CDB.\n Impaired Skin Integrity\n Assessment:\n Pt has bilateral stage 3 ulcers on buttocks. Tunneling present on both\n ulcers and both are also weeping purulent drainage. No odor noticed.\n Action:\n Changed each dsg twice, each cleansed with wound cleanser and then\n collagenase ointment applied and covered with DSD. Frequent turns. Held\n standing lantus dose as FS 73 and TF\ns just started and ? tolerance at\n that point. Sliding scale insulin\n Response:\n Pts skin remains impaired\n Plan:\n Change pressure ulcer dsgs at least . Frequent turns. Keep blood\n sugar WNL for healing using standing lantus and sliding scale\n" }, { "category": "Physician ", "chartdate": "2104-05-05 00:00:00.000", "description": "MICU attending progress note", "row_id": 573953, "text": "TITLE:\n MICU ATTENDING PROGRESS NOTE\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. 76 yo obese F with DM,\n HTN, CAD, and recent hospitalization with pna/FTW s/p trach/peg (now\n decannulated) , on supp O2 at baseline who developed\n cholangitis s/p ercp with removal of stones. Intubated for\n procedure--difficult airway. Extubation initially limited by\n secretions/frequent suctioning/MRSA pna/and no cuff leak. Successfully\n extubated yesterday.\n PE: AF 82-117 113/65 94% RA\n alert in NAD\n improved air movement/coarse BS\n rr distant\n +BS soft\n warm, w/o edema\n LABS reviewed-- notable for wbc 8.1 hct 31, na 143, alkphose 140\n CXR: improvement in aeration , still with b/l atelectasis/PNA/edema\n Micro\nsputum/BAL + MRSA\n Agree with plan to continue vanco for MRSA pna. Continue nebs, chest\n PT. CXR appears with component of vascular congestion but pt is\n mobilizing fluids/autodiuresing, on RA so will hold on additional\n lasix. In terms of cholangitis\nis doing well. LFTs decreasing.\n Continue cipro/flagyl--day day. BP control with PO meds.\n Wound care for decubs. TFs via peg.\n Remainder as per housestaff note.\n Stable for floor transfer.\n Time spent: 40 min\n" }, { "category": "Nursing", "chartdate": "2104-05-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 573956, "text": "Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate.\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n Extubated yesterday, , without difficulty.\n Problem\n Respiratory failure\n Assessment:\n Extubated on L NC with Sp02 100%,weaned off to RA. Lung\n coarse clearing with cough, Good cough producing large amounts of\n thick yellow sputum. Hemodynamically stable with NBP 120\ns-160s/60\n SR\n with occasional PVC\ns. Skin warm, good pedal pulses. Abdomen soft with\n (+) bowel sounds, TF on goal via PEG. Urine clear and yellow, UO\n adequate\n Action:\n Chest PT, encouraging CDB, Albuterol and Atrovent nebs, supplemental 02\n Response:\n Pt remains on RA with Sp02 93-95%, secretions remain large in amount\n and pt needs much encouragement to clear them, Hemodynamically stable,\n TF\ns running at goal.\n Plan:\n Encourage CDB.\n Impaired Skin Integrity\n Assessment:\n Pt has bilateral stage 3 ulcers on buttocks. Tunneling present on both\n ulcers and both are also weeping purulent drainage. No odor noticed.\n Action:\n Changed each dsg twice, each cleansed with wound cleanser and then\n collagenase ointment applied and covered with DSD. Frequent turns.\n Response:\n Pts skin remains impaired\n Plan:\n Change pressure ulcer dsgs .\n Frequent turns.\n Keep blood sugar WNL for healing using standing lantus and sliding\n scale\n" }, { "category": "Physician ", "chartdate": "2104-05-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573832, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 01:30 PM\n - had bronchoscopy showing mucoid secretions\n - hct stable\n - sedation turned off this morning at 0730 in preparation for\n extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 07:42 PM\n Metronidazole - 05:11 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 01:39 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 06:55 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: 36.9\nC (98.5\n HR: 76 (66 - 100) bpm\n BP: 112/51(64) {94/43(55) - 134/93(103)} mmHg\n RR: 10 (10 - 40) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 3,938 mL\n 452 mL\n PO:\n TF:\n 6 mL\n IVF:\n 3,815 mL\n 452 mL\n Blood products:\n 17 mL\n Total out:\n 3,450 mL\n 1,190 mL\n Urine:\n 3,450 mL\n 1,190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 488 mL\n -738 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 550) mL\n Vt (Spontaneous): 506 (238 - 775) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 103\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 5 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese,\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: S1 & S2 regular without murmur\n Peripheral Vascular: 1+ Distal pulses bilaterally\n Respiratory / Chest: Symmetric chest expansion, anterior exam clear\n Abdominal: Soft, nontender, obese, PEG in place.\n Extremities: Trace bilateral edema\n Skin: Not assessed\n Neurologic: Intubated but awake and alert, responds to commands\n Labs / Radiology\n 327 K/uL\n 9.8 g/dL\n 140 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 4.2 mEq/L\n 8 mg/dL\n 102 mEq/L\n 133 mEq/L\n 32.0 %\n 7.8 K/uL\n [image002.jpg]\n 11:15 PM\n 04:18 AM\n 01:59 PM\n 09:53 PM\n 10:19 PM\n 04:40 AM\n 03:12 PM\n 04:16 AM\n 03:20 PM\n 04:47 AM\n WBC\n 9.4\n 9.0\n 7.8\n 9.3\n 7.8\n Hct\n 23.4\n 27.5\n 25.0\n 27.0\n 25.1\n 24.6\n 28.0\n 31.5\n 32.0\n Plt\n 30\n 327\n Cr\n 0.7\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 34\n Glucose\n 190\n 105\n 43\n 135\n 140\n Other labs: PT / PTT / INR:13.3/24.4/1.1, ALT / AST:14/25, Alk Phos / T\n Bili:138/0.5, Albumin:3.2 g/dL, LDH:200 IU/L, Ca++:8.1 mg/dL, Mg++:1.6\n mg/dL, PO4:4.1 mg/dL\n BAL: gram positive cocci in pairs and clusters\n blood cx: NGTD\n sputum: MRSA\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach s/p ERCP with removal of CBD stones\n and sphincterotomy.\n .\n # Respiratory Failure/COPD/Asthma: The patient remains intubated after\n ERCP though she did not have lung pathology (besides underlying lung\n disease) prior to intubation. She now has MRSA growing in her sputum\n and likely contribution from volume. Broncoscopy yesterday did not\n show any clear barrier to extubation. Good cough and + cuff leak.\n Currently on with 40% FiO2 and appears ready for extubation.\n - Extubate\n - Monitor respiratory status\n - Continue Vancomycin (day 1=, dose decreased , will need\n trough )\n - Change MDI to nebulizers, as she is unable to cooperate with MDI\n .\n # Blood volume instability: Hct stable yesterday without further\n transfusions. No identifiable source of bleeding.\n - Hematocrit \n - Active T&S\n - Guaiac stools\n - monitor lines for bleeding\n - transfuse for HCT <24\n #Hypernatremia: Resolved with intiation of free water and tube feeds.\n Currently mildly hyponatremic.\n - no further d5\n .\n # CBD Stones: She did not have cholangitis, rather stones + pain. Now\n s/p ERCP day 4.\n - Continue Cipro/Flagyl (day 1=)\n - clarify antibiotic course with ERCP\n # Diabetes: Type 1.\n - Continue Home Lantus at 26 units SC QHS and sliding scale\n # Chronic Diastolic CHF: Holding lisinopril now, patient remains\n normotensive.\n # h/o HTN: she has been normotensive\n - hold outpatient regmin of HCTZ and lisinopril\n ICU Care\n Nutrition: tube feeds (stopped at MN ), resume today, possible S&S\n evaluation tomorrow\n Glycemic Control: lantus + SS insulin\n Lines:\n 20 Gauge - 08:58 PM\n PICC Line - 06:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\n" }, { "category": "Physician ", "chartdate": "2104-05-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573835, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 01:30 PM\n - had bronchoscopy showing mucoid secretions\n - hct stable\n - sedation turned off this morning at 0730 in preparation for\n extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 07:42 PM\n Metronidazole - 05:11 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 01:39 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 06:55 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: 36.9\nC (98.5\n HR: 76 (66 - 100) bpm\n BP: 112/51(64) {94/43(55) - 134/93(103)} mmHg\n RR: 10 (10 - 40) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 3,938 mL\n 452 mL\n PO:\n TF:\n 6 mL\n IVF:\n 3,815 mL\n 452 mL\n Blood products:\n 17 mL\n Total out:\n 3,450 mL\n 1,190 mL\n Urine:\n 3,450 mL\n 1,190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 488 mL\n -738 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 550) mL\n Vt (Spontaneous): 506 (238 - 775) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 103\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 5 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese,\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: S1 & S2 regular without murmur\n Peripheral Vascular: 1+ Distal pulses bilaterally\n Respiratory / Chest: Symmetric chest expansion, anterior exam clear\n Abdominal: Soft, nontender, obese, PEG in place.\n Extremities: Trace bilateral edema\n Skin: Not assessed\n Neurologic: Intubated but awake and alert, responds to commands\n Labs / Radiology\n 327 K/uL\n 9.8 g/dL\n 140 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 4.2 mEq/L\n 8 mg/dL\n 102 mEq/L\n 133 mEq/L\n 32.0 %\n 7.8 K/uL\n [image002.jpg]\n 11:15 PM\n 04:18 AM\n 01:59 PM\n 09:53 PM\n 10:19 PM\n 04:40 AM\n 03:12 PM\n 04:16 AM\n 03:20 PM\n 04:47 AM\n WBC\n 9.4\n 9.0\n 7.8\n 9.3\n 7.8\n Hct\n 23.4\n 27.5\n 25.0\n 27.0\n 25.1\n 24.6\n 28.0\n 31.5\n 32.0\n Plt\n 30\n 327\n Cr\n 0.7\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 34\n Glucose\n 190\n 105\n 43\n 135\n 140\n Other labs: PT / PTT / INR:13.3/24.4/1.1, ALT / AST:14/25, Alk Phos / T\n Bili:138/0.5, Albumin:3.2 g/dL, LDH:200 IU/L, Ca++:8.1 mg/dL, Mg++:1.6\n mg/dL, PO4:4.1 mg/dL\n BAL: gram positive cocci in pairs and clusters\n blood cx: NGTD\n sputum: MRSA\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach s/p ERCP with removal of CBD stones\n and sphincterotomy.\n .\n # Respiratory Failure/COPD/Asthma: The patient remains intubated after\n ERCP though she did not have lung pathology (besides underlying lung\n disease) prior to intubation. She now has MRSA growing in her sputum\n and likely contribution from volume. Broncoscopy yesterday did not\n show any clear barrier to extubation. Good cough and + cuff leak.\n Currently on with 40% FiO2 and appears ready for extubation.\n - Extubate\n - Monitor respiratory status\n - Continue Vancomycin (day 1=, dose decreased , will need\n trough )\n - Change MDI to nebulizers, as she is unable to cooperate with MDI\n .\n # Blood volume instability: Hct stable yesterday without further\n transfusions. No identifiable source of bleeding.\n - Hematocrit \n - Active T&S\n - Guaiac stools\n - monitor lines for bleeding\n - transfuse for HCT <24\n #Hypernatremia: Resolved with intiation of free water and tube feeds.\n Currently mildly hyponatremic.\n - no further d5\n .\n # CBD Stones: She did not have cholangitis, rather stones + pain. Now\n s/p ERCP day 4.\n - Continue Cipro/Flagyl (day 1=)\n - clarify antibiotic course with ERCP\n # Diabetes: Type 1.\n - Continue Home Lantus at 26 units SC QHS and sliding scale\n # Chronic Diastolic CHF: Holding lisinopril now, patient remains\n normotensive.\n # h/o HTN: she has been normotensive\n - hold outpatient regmin of HCTZ and lisinopril\n ICU Care\n Nutrition: tube feeds (stopped at MN ), resume today, possible S&S\n evaluation tomorrow\n Glycemic Control: lantus + SS insulin\n Lines:\n 20 Gauge - 08:58 PM\n PICC Line - 06:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\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 is more awake on decreasing levels of sedation and oriented\n to simple commands. Bronchoscopy did reveal moderate secretions in\n lower lobes but without purulence.\n Exam notable for elderly BF who responds only to pain Tm 99.6 BP\n 134/70 HR of 88 RR of 24 with sats of 98% on 40% FiO2 . She has\n decreased BS at bases but no wheezing. There is minimal edema noted\n too. Her RSBI is 60\n Labs notable for WBC 7.8 K, HCT 32, K+ 4.2 , Cr 0.6 . CXR with\n bibasilar ASD ( R> L)\n Agree with plan to extubate today. She appears ready for this. She will\n need help with secretion clearance after extubation but hopefully with\n improved mentation and good cough she will be able to handle this.\n Antibioitics to be continued per culture review.\n Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 35 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: 16:02 ------\n" }, { "category": "Nursing", "chartdate": "2104-05-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573771, "text": " Problem - Description In Comments\n Assessment:\n Inutubated for procedure 5 days ago\n Action:\n Haved tried to extibate pt everyday post procedure, bronched yesterday\n to help with secreations\n Response:\n Unsuccessful at extubating pt, she is now on cpap/[ps 10, 40% fio2,\n peep of 5,\n Plan:\n Continue present plan, tried to extubated again today,, once extubated\n restarted tube feeds\n Impaired Skin Integrity\n Assessment:\n Decubs on both gluteals, stage 3\n Action:\n Dsg changes done as ordered with colloagnase oint and dsg.\n Response:\n pending\n Plan:\n Continue qd dsg changes\n" }, { "category": "Physician ", "chartdate": "2104-05-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573793, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 01:30 PM\n - not extubated\n - had bronchoscopy\n - hct stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 07:42 PM\n Metronidazole - 05:11 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 01:39 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 06:55 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: 36.9\nC (98.5\n HR: 76 (66 - 100) bpm\n BP: 112/51(64) {94/43(55) - 134/93(103)} mmHg\n RR: 10 (10 - 40) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 3,938 mL\n 452 mL\n PO:\n TF:\n 6 mL\n IVF:\n 3,815 mL\n 452 mL\n Blood products:\n 17 mL\n Total out:\n 3,450 mL\n 1,190 mL\n Urine:\n 3,450 mL\n 1,190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 488 mL\n -738 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 550) mL\n Vt (Spontaneous): 506 (238 - 775) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 103\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 5 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: S1 & S2 regular without murmur\n Peripheral Vascular: 1+ Distal pulses bilaterally\n Respiratory / Chest: Symmetric chest expansion, anterior exam clear\n Abdominal: Soft, nontender, obese, PEG in place.\n Extremities: Trace bilateral edema\n Skin: Not assessed\n Neurologic: Intubated & sedated, pupils reactive, reacts to voice\n Labs / Radiology\n 327 K/uL\n 9.8 g/dL\n 140 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 4.2 mEq/L\n 8 mg/dL\n 102 mEq/L\n 133 mEq/L\n 32.0 %\n 7.8 K/uL\n [image002.jpg]\n 11:15 PM\n 04:18 AM\n 01:59 PM\n 09:53 PM\n 10:19 PM\n 04:40 AM\n 03:12 PM\n 04:16 AM\n 03:20 PM\n 04:47 AM\n WBC\n 9.4\n 9.0\n 7.8\n 9.3\n 7.8\n Hct\n 23.4\n 27.5\n 25.0\n 27.0\n 25.1\n 24.6\n 28.0\n 31.5\n 32.0\n Plt\n 30\n 327\n Cr\n 0.7\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 34\n Glucose\n 190\n 105\n 43\n 135\n 140\n Other labs: PT / PTT / INR:13.3/24.4/1.1, ALT / AST:14/25, Alk Phos / T\n Bili:138/0.5, Albumin:3.2 g/dL, LDH:200 IU/L, Ca++:8.1 mg/dL, Mg++:1.6\n mg/dL, PO4:4.1 mg/dL\n BAL: gram positive cocci in pairs and clusters\n blood cx: NGTD\n sputum: MRSA\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach s/p ERCP with removal of CBD stones\n and sphincterotomy.\n .\n # Respiratory Failure/COPD/Asthma: The patient remains intubated after\n ERCP though she did not have lung pathology (besides underlying lung\n disease) prior to intubation. She now has MRSA growing in her sputum\n and likely had too much volume overnight for her hypernatremia. Her\n RISB is high and her current respiratory status during a spontaneous\n breathing trial suggests that she will not be an easy extubation.\n Will aim for extubation tonight vs. tomorrow AM\n -ABG on after 3-4 hours\n -Bronch today to make sure her airway is clear before extubation\n - Continue Vancomycin but change dose from 1g Q12 to 1g q24 given high\n trough\n - Resume TF for now, NPO for extubation tomorrow\n - Stop d5@150.\n .\n # Blood volume instability: Hct stable yesterday without further\n transfusions. No identifiable source of bleeding.\n - Hematocrit \n - Active T&S\n - Guaiac stools\n - monitor lines for bleeding\n - transfuse for HCT <24\n #Hypernatremia: Resolved with intiation of free water and tube feeds.\n Currently mildly hyponatremic.\n -stop d5\n -continue free water with tube feeds\n -PM sodium\n .\n # CBD Stones: S/P ERCP day 3, will continue antibiotics and continue\n PEG tube feeds once she is extubated\n -Continue Cipro/Flagyl\n - Appreciated ERCP recs\n # Diabetes: Type 1. Continue Home Lantus at 26 units SC QHS and\n sliding scale given short steroid pulse.\n # Chronic Diastolic CHF: Holding lisinopril now, patient remains\n normotensive.\n # h/o HTN: hold HCTZ/lisinopril.\n ICU Care\n Nutrition: tube feeds (stopped at MN )\n Glycemic Control:\n Lines:\n 20 Gauge - 08:58 PM\n PICC Line - 06:00 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": "2104-05-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573906, "text": "Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate.\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n Extubated yesterday, , without difficulty.\n Problem\n Respiratory failure\n Assessment:\n s/p extubation , received pt on 2 L NC with Sp02 100%. Lung\n rhonchus clearing with cough, intermittent exp wheezes. Good cough\n producing large amounts of thick tannish white sputum. Hemodynamically\n stable with NBP 120\ns-160s/60\ns, ST most of night 100-110 with\n occasional PVC\ns. Skin warm, good pedal pulses. Abdomen soft with (+)\n bowel sounds, TF started again via PEG. Urine clear and yellow, UO\n 60-120 cc/hr.\n Action:\n Pulmonary toileting, encouraging CDB, Albuterol and Atrovent nebs,\n supplemental 02\n Response:\n Pt remains on 2 L NC with Sp02 93-95%, secretions remain large in\n amount and pt needs much encouragement to clear them, Hemodynamically\n stable, TF\ns running at goal.\n Plan:\n Supplemental 02 as needed. Encourage CDB.\n Impaired Skin Integrity\n Assessment:\n Pt has bilateral stage 3 ulcers on buttocks. Tunneling present on both\n ulcers and both are also weeping purulent drainage. No odor noticed.\n Action:\n Changed each dsg twice, each cleansed with wound cleanser and then\n collagenase ointment applied and covered with DSD. Frequent turns. Held\n standing lantus dose as FS 73 and TF\ns just started and ? tolerance at\n that point. Sliding scale insulin\n Response:\n Pts skin remains impaired\n Plan:\n Change pressure ulcer dsgs at least . Frequent turns. Keep blood\n sugar WNL for healing using standing lantus and sliding scale.\n" }, { "category": "Respiratory ", "chartdate": "2104-05-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 573777, "text": "Demographics\n Day of mechanical ventilation: 6\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: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\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 Bedside Procedures: No morning abg results at this time.\n RSBI = 103 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing", "chartdate": "2104-05-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573897, "text": "Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate.\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n Extubated yesterday, , without difficulty.\n" }, { "category": "Nursing", "chartdate": "2104-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573195, "text": "Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate (now decanulated).\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP today had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n Diabetes Mellitus (DM), Type I\n :\n Pt\ns blood sugar was greater than 400 in the PACU\n Action:\n Treated with insulin prior to transfer to MSICU. BS has been slowly\n decreasing\n pt has received humalog x2 and glargine x1\n Response:\n BS is presently 209\n Plan:\n Continue to check BS q 6 hours and treat as ordered on sliding scale\n insulin order\n Impaired Skin Integrity\n :\n Pt has bilat gluteal pressure sores\n Action:\n Areas were assessed and dressed - need to be seen by wound care nurse\n on days\n Response:\n Turning pt side to side as tolerated. Dsgs are difficult to keep on\n due to area they are located.\n Plan:\n Contact wound care nurse and plan.\n Hypovolemia (Volume Depletion - without shock)\n :\n Pt\ns BP low after arrival from PACU\n Action:\n Given 2 bolus\n of NS\n Response:\n BP responded very well to fluid and pt has not required any further\n action\n Plan:\n Continue to monitor hemodynamics closely and treat as ordered\n Difficult intubation\n :\n Pt was a difficult intubation and it was decided to keep pt intubated\n overnight to protect airway\n Action:\n Pt sedated with propofol\n titrated to keep pt comfortable with the\n ETT. See metavision for more details\n Response:\n When pt lightened\n very strong gag and has strong cough and large amt\n oral secretions. Suctioned q 1-2 hours for moderate amt thick and\n sometimes frothy blood tinged secretions. RISB is 85 and pt is\n tolerating SBT well.\n Plan:\n Extubate as tolerated. Pt may need much encouragement to deep breath\n" }, { "category": "Nursing", "chartdate": "2104-05-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573744, "text": "Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate.\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Patient has a known h/o of DM being managed on sliding scale with\n humalog coverage.\n Action:\n Blood glucose sticks being done q6hr. Also on scheduled dose of lantus,\n see for details.\n Response:\n Last blood glucose 108 requiring no coverage.\n Plan:\n Continue to monitor blood glucose levels.\n Impaired Skin Integrity\n Assessment:\n Patient with bilateral gluteal decubitus.\n Action:\n Wound cleansed with wound wash packed with idoform and covered with\n gauze. Dsg to be done daily.\n Response:\n Patient tolerated change of dsg fair. Unable to state whether wound has\n improved in appearance as this is the firs encounter.\n Plan:\n Follow up with wound care team, turn and reposition patient frequently.\n Problem\n post procedure intubation.\n Assessment:\n Patient was intubated for procedure course has been complicated by\n respiratory compromise. She is positive for MRSA in the sputum and is\n on contact precautions. She continues on propofol at 75mcg/hr where she\n is easily aroused.\n Action:\n Patient is s/p bronchoscopy today with mini BAL, sputum sent for\n culture.\n Response:\n Has been on PSV for most of the day and maintaining adequate\n oxygenation. For possible extubation in the morning. Tube feeds on hold\n as patient will have to be NPO from Midnight.\n Plan:\n Turn off sedation in the am around 7am. Rest on overnight then SBT\n in the am with sedation off.\n She is s/p one unit of PRBC with stable Hct at 31.5 goal is to keep hct\n >25\n" }, { "category": "Respiratory ", "chartdate": "2104-05-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 573746, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\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:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\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: Clear / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Tachypneic (RR> 35 b/min)\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Bronchoscopy (1340)\n Comments:\n" }, { "category": "Physician ", "chartdate": "2104-05-03 00:00:00.000", "description": "Cardiology Comprehensive Physician Note", "row_id": 573747, "text": "Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate.\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n Has been kept npo since midnight for ? extubation this am still with\n large amts of thick yellow sputum, ? if she will be able to be\n intubated, propofol at 75mcg/hr, she is still light and when she wakes\n up she is very agitated trying to pull at tubes\n Diabetes Mellitus (DM), Type I\n Assessment:\n Patient has a known h/o of DM being managed on sliding scale with\n humalog coverage.\n Action:\n Blood glucose sticks being done q6hr. Also on scheduled dose of lantus,\n see for details.\n Response:\n Last blood glucose 108 requiring no coverage.\n Plan:\n Continue to monitor blood glucose levels.\n Impaired Skin Integrity\n Assessment:\n Patient with bilateral gluteal decubitus.\n Action:\n Wound cleansed with wound wash packed with idoform and covered with\n gauze. Dsg to be done daily.\n Response:\n Patient tolerated change of dsg fair. Unable to state whether wound has\n improved in appearance as this is the firs encounter.\n Plan:\n Follow up with wound care team, turn and reposition patient frequently.\n ------ Protected Section------\n ------ Protected Section Error Entered By: , RN\n on: 18:38 ------\n" }, { "category": "Physician ", "chartdate": "2104-05-03 00:00:00.000", "description": "Cardiology Comprehensive Physician Note", "row_id": 573742, "text": "Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate.\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n Has been kept npo since midnight for ? extubation this am still with\n large amts of thick yellow sputum, ? if she will be able to be\n intubated, propofol at 75mcg/hr, she is still light and when she wakes\n up she is very agitated trying to pull at tubes\n Diabetes Mellitus (DM), Type I\n Assessment:\n Patient has a known h/o of DM being managed on sliding scale with\n humalog coverage.\n Action:\n Blood glucose sticks being done q6hr. Also on scheduled dose of lantus,\n see for details.\n Response:\n Last blood glucose 108 requiring no coverage.\n Plan:\n Continue to monitor blood glucose levels.\n Impaired Skin Integrity\n Assessment:\n Patient with bilateral gluteal decubitus.\n Action:\n Wound cleansed with wound wash packed with idoform and covered with\n gauze. Dsg to be done daily.\n Response:\n Patient tolerated change of dsg fair. Unable to state whether wound has\n improved in appearance as this is the firs encounter.\n Plan:\n Follow up with wound care team, turn and reposition patient frequently.\n" }, { "category": "Physician ", "chartdate": "2104-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573722, "text": "Chief Complaint:\n 24 Hour Events:\n - Repleting free water for hypernatremia (2.8L deficit) (148 to 134)\n - Restarted tube feeds with free water bolus (1L)\n - Transfused 1 unit of blood for hct <25 (up to 28 post-transfusion)\n - RISB this morning 130, changed from AC to PS 10/5 now PS 5/5\n -Vanco trough high, changed dose to 1g q24h.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 08:51 PM\n Metronidazole - 05:59 AM\n Infusions:\n Propofol - 75 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:21 PM\n Dextrose 50% - 04:26 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 06:49 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: 80 (64 - 88) bpm\n BP: 123/51(67) {85/41(54) - 126/83(88)} mmHg\n RR: 18 (12 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 3,851 mL\n 1,682 mL\n PO:\n TF:\n 62 mL\n 6 mL\n IVF:\n 3,290 mL\n 1,659 mL\n Blood products:\n 259 mL\n 17 mL\n Total out:\n 4,125 mL\n 580 mL\n Urine:\n 4,125 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -274 mL\n 1,102 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 426 (333 - 426) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 24 cmH2O\n Plateau: 14 cmH2O\n Compliance: 61.1 cmH2O/mL\n SpO2: 99%\n ABG: ///30/\n Ve: 5.6 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: S1 & S2 regular without murmur\n Peripheral Vascular: 1+ Distal pulses bilaterally\n Respiratory / Chest: Symmetric chest expansion, anterior exam clear\n Abdominal: Soft, nontender, obese, PEG in place.\n Extremities: Trace bilateral edema\n Skin: Not assessed\n Neurologic: Intubated & sedated, pupils reactive, reacts to voice\n Labs / Radiology\n 356 K/uL\n 8.4 g/dL\n 135 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 97 mEq/L\n 134 mEq/L\n 28.0 %\n 7.8 K/uL\n [image002.jpg]\n 02:54 AM\n 08:27 PM\n 11:15 PM\n 04:18 AM\n 01:59 PM\n 09:53 PM\n 10:19 PM\n 04:40 AM\n 03:12 PM\n 04:16 AM\n WBC\n 12.5\n 9.4\n 9.0\n 7.8\n Hct\n 28.3\n 23.4\n 27.5\n 25.0\n 27.0\n 25.1\n 24.6\n 28.0\n Plt\n 397\n 341\n 336\n 356\n Cr\n 0.9\n 0.7\n 0.6\n 0.7\n 0.6\n TCO2\n 28\n 34\n Glucose\n 195\n 190\n 105\n 43\n 135\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:18/13, Alk Phos / T\n Bili:156/0.4, Albumin:3.2 g/dL, LDH:182 IU/L, Ca++:8.0 mg/dL, Mg++:1.8\n mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: None\n Imaging: CXR pending\n Microbiology: Sputum Sensis Pending\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach s/p ERCP with removal of CBD stones\n and sphincterotomy.\n .\n # Respiratory Failure/COPD/Asthma: The patient remains intubated after\n ERCP though she did not have lung pathology (besides underlying lung\n disease) prior to intubation. She now has MRSA growing in her sputum\n and likely had too much volume overnight for her hypernatremia. Her\n RISB is high and her current respiratory status during a spontaneous\n breathing trial suggests that she will not be an easy extubation.\n Will aim for extubation tonight vs. tomorrow AM\n -ABG on after 3-4 hours\n -Bronch today to make sure her airway is clear before extubation\n - Continue Vancomycin but change dose from 1g Q12 to 1g q24 given high\n trough\n - Resume TF for now, NPO for extubation tomorrow\n - Stop d5@150.\n .\n # Blood volume instability: The patient bumped appropriately and has no\n identifiable bleeding source.\n - Hematocrit \n - Active T&S\n - Guaiac stools\n - monitor lines for bleeding\n - transfuse for HCT <24\n #Hypernatremia: Resolved with intiation of free water and tube feeds.\n -stop d5\n -continue free water with tube feeds\n -PM sodium\n .\n # CBD Stones: S/P ERCP day 3, will continue antibiotics and continue\n PEG tube feeds once she is extubated\n -Continue Cipro/Flagyl\n - Appreciated ERCP recs\n # Diabetes: Type 1. Continue Home Lantus at 26 units SC QHS and\n sliding scale given short steroid pulse.\n # Chronic Diastolic CHF: Holding lisinopril now, patient remains\n normotensive.\n # h/o HTN: hold HCTZ/lisinopril.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:58 PM\n PICC Line - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: To ICU while intubated\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 is slightly more awake on decreasing levels of sedation but\n not completely oriented as yet. Secretions may have increased from ETT\n without fever or increasing O2 need.\n Exam notable for elderly BF who reponds only to pain Tm99 BP 155/70 HR\n of 88 RR of 24 with sats of 98% on 40% FiO2 . She has decreased BS at\n bases but no wheezing. minimal edema noted too.\n Labs notable for WBC 7.8 K, HCT 28 , K+3.7 , Cr 0.6 . CXR with\n bibasilar ASD vs atelectasis\n Agree with plan to lighten sedation and continue prolonged PSV/ CPAP\n trial . She will benefit from bronchosocpy to aid with secretion\n clearance. Suspect if there are no hemodynamic setbacks in next 24 hrs,\n we will plan for extubation in am \n Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 35 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: 03:00 PM ------\n" }, { "category": "Nutrition", "chartdate": "2104-05-01 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 573450, "text": "Subjective: Intubated\n Objective:\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 65cm\n 104.8 kg\n 101.3 kg ( 12:00 AM)\n 37.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.8 kg\n 178%\n 68 kg\n Diagnosis: s/p ERCP with removal of CBD stones and sphincterectomy.\n PMH : HTN, Type 1 DM, CAD, COPD, PNA\n Pertinent medications: Fentanyl, Propofol, Lantus, HISS, Ciprofloxacin,\n Flagyl, Magnesium Sulfate (bolus)\n Labs:\n Value\n Date\n Glucose\n 190 mg/dL\n 04:18 AM\n Glucose Finger Stick\n 322\n 10:00 AM\n BUN\n 17 mg/dL\n 04:18 AM\n Creatinine\n 0.7 mg/dL\n 04:18 AM\n Sodium\n 132 mEq/L\n 04:18 AM\n Potassium\n 4.0 mEq/L\n 04:18 AM\n Chloride\n 97 mEq/L\n 04:18 AM\n TCO2\n 26 mEq/L\n 04:18 AM\n PO2 (arterial)\n 103 mm Hg\n 08:27 PM\n PCO2 (arterial)\n 44 mm Hg\n 08:27 PM\n pH (arterial)\n 7.40 units\n 08:27 PM\n CO2 (Calc) arterial\n 28 mEq/L\n 08:27 PM\n Albumin\n 3.2 g/dL\n 02:54 AM\n Calcium non-ionized\n 8.2 mg/dL\n 04:18 AM\n Phosphorus\n 5.0 mg/dL\n 04:18 AM\n Magnesium\n 1.5 mg/dL\n 04:18 AM\n ALT\n 18 IU/L\n 04:18 AM\n Alkaline Phosphate\n 169 IU/L\n 04:18 AM\n AST\n 16 IU/L\n 04:18 AM\n Total Bilirubin\n 0.7 mg/dL\n 04:18 AM\n WBC\n 9.4 K/uL\n 04:18 AM\n Hgb\n 8.1 g/dL\n 04:18 AM\n Hematocrit\n 27.5 %\n 04:18 AM\n Current diet order / nutrition support: NPO\n GI: Abd obese, -BS, Patient has baseline PEG\n Assessment of Nutritional Status\n 76F with multiple co-morbidities, most recently hospitalized with PNA,\n now s/p ERCP with removal of CBD stones and sphincterotomy. Patient\n is intubated and has baseline PEG. Given that patient is obese to\n bilateral decubitis ulcers, suggest Replete with Fiber supplemented\n with beneprotein to promote ulcer healing. Tube feeding at goal rate\n of 75ml/hr with 46 grams of Beneprotein, provides 1,964 kcal/day and\n 157 grams of protein meeting patients nutritional needs. Recommend\n additional supplementation x 10 days of Zinc Sulfate, Vitamin A and C,\n and multivitamin with minerals to promote wound healing. See recs\n below. Noted elevated BS and Alb of 3.2\n Pt at risk due to:\n Estimated Nutritional Needs\n Calories: (BEE x or / cal/kg) 20-25 kcal/kg (based on adjusted wt.)\n Protein: (1.3-1.5g/kg) d/t ulcers\n Fluid:\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Recommend Replete with fiber, start at 20ml/hr, if tolerated,\n advance toward goal of 75ml/hr. Add 46 grams of Beneprotein, providing\n 1964kcal and 156 grams of protein.\n 2. Suggest supplementation -10 days of 220 grams of zinc sulfate,\n 500mg of vitamin C, 25,000 IU of Vitamin A, and multivitamin with\n minerals to promote wound healing of decubitis ulcers.\n 3. Suggest abdominal exam Q4hrs for tube feeding tolerance.\n 4. Check BS Q4hrs, cover with RISS accordingly.\n 5.\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2104-05-01 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 573453, "text": "Subjective: Intubated\n Objective:\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 65cm\n 104.8 kg\n 101.3 kg ( 12:00 AM)\n 37.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.8 kg\n 178%\n 68 kg\n Diagnosis: s/p ERCP with removal of CBD stones and sphincterectomy.\n PMH : HTN, Type 1 DM, CAD, COPD, PNA\n Pertinent medications: Fentanyl, Propofol, Lantus, HISS, Ciprofloxacin,\n Flagyl, Magnesium Sulfate (bolus)\n Labs:\n Value\n Date\n Glucose\n 190 mg/dL\n 04:18 AM\n Glucose Finger Stick\n 322\n 10:00 AM\n BUN\n 17 mg/dL\n 04:18 AM\n Creatinine\n 0.7 mg/dL\n 04:18 AM\n Sodium\n 132 mEq/L\n 04:18 AM\n Potassium\n 4.0 mEq/L\n 04:18 AM\n Chloride\n 97 mEq/L\n 04:18 AM\n TCO2\n 26 mEq/L\n 04:18 AM\n PO2 (arterial)\n 103 mm Hg\n 08:27 PM\n PCO2 (arterial)\n 44 mm Hg\n 08:27 PM\n pH (arterial)\n 7.40 units\n 08:27 PM\n CO2 (Calc) arterial\n 28 mEq/L\n 08:27 PM\n Albumin\n 3.2 g/dL\n 02:54 AM\n Calcium non-ionized\n 8.2 mg/dL\n 04:18 AM\n Phosphorus\n 5.0 mg/dL\n 04:18 AM\n Magnesium\n 1.5 mg/dL\n 04:18 AM\n ALT\n 18 IU/L\n 04:18 AM\n Alkaline Phosphate\n 169 IU/L\n 04:18 AM\n AST\n 16 IU/L\n 04:18 AM\n Total Bilirubin\n 0.7 mg/dL\n 04:18 AM\n WBC\n 9.4 K/uL\n 04:18 AM\n Hgb\n 8.1 g/dL\n 04:18 AM\n Hematocrit\n 27.5 %\n 04:18 AM\n Current diet order / nutrition support: NPO\n GI: Abd obese, -BS, Patient has baseline PEG\n Assessment of Nutritional Status\n 76F with multiple co-morbidities, most recently hospitalized with PNA,\n now s/p ERCP with removal of CBD stones and sphincterotomy. Patient\n is intubated and has baseline PEG. Given that patient is obese to\n bilateral decubitis ulcers, suggest Replete with Fiber supplemented\n with beneprotein to promote ulcer healing. Tube feeding at goal rate\n of 75ml/hr with 46 grams of Beneprotein, provides 1,964 kcal/day and\n 157 grams of protein meeting patients nutritional needs. Recommend\n additional supplementation x 10 days of Zinc Sulfate, Vitamin A and C,\n and multivitamin with minerals to promote wound healing. See recs\n below. Noted elevated BS and Alb of 3.2\n Pt at risk due to:\n Estimated Nutritional Needs\n Calories: (BEE x or / cal/kg) 20-25 kcal/kg (based on adjusted wt.)\n Protein: (1.3-1.5g/kg) d/t ulcers\n Fluid:\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Recommend Replete with fiber, start at 20ml/hr, if tolerated,\n advance toward goal of 75ml/hr. Add 46 grams of Beneprotein, providing\n a total of 1,964kcal and 156 grams of protein.\n 2. Suggest supplementation -10 days of 220 grams of zinc sulfate,\n 500mg of vitamin C, 25,000 IU of Vitamin A, and multivitamin with\n minerals to promote wound healing of decubitis ulcers.\n 3. Suggest abdominal exam Q4hrs for tube feeding tolerance.\n 4. Check BS Q4hrs, cover with RISS accordingly.\n 5. Will continue to follow with plan of care.\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2104-05-01 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 573455, "text": "Subjective: Intubated\n Objective:\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 65\n 104.8 kg\n 101.3 kg ( 12:00 AM)\n 37.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.8 kg\n 178%\n 68 kg\n Diagnosis: s/p ERCP with removal of CBD stones and sphincterectomy.\n PMH : HTN, Type 1 DM, CAD, COPD, PNA\n Pertinent medications: Fentanyl, Propofol at 37.7ml/hr (provides\n 995kcal/day), Lantus, HISS, Ciprofloxacin, Flagyl, Magnesium Sulfate\n (bolus)\n Labs:\n Value\n Date\n Glucose\n 190 mg/dL\n 04:18 AM\n Glucose Finger Stick\n 322\n 10:00 AM\n BUN\n 17 mg/dL\n 04:18 AM\n Creatinine\n 0.7 mg/dL\n 04:18 AM\n Sodium\n 132 mEq/L\n 04:18 AM\n Potassium\n 4.0 mEq/L\n 04:18 AM\n Chloride\n 97 mEq/L\n 04:18 AM\n TCO2\n 26 mEq/L\n 04:18 AM\n PO2 (arterial)\n 103 mm Hg\n 08:27 PM\n PCO2 (arterial)\n 44 mm Hg\n 08:27 PM\n pH (arterial)\n 7.40 units\n 08:27 PM\n CO2 (Calc) arterial\n 28 mEq/L\n 08:27 PM\n Albumin\n 3.2 g/dL\n 02:54 AM\n Calcium non-ionized\n 8.2 mg/dL\n 04:18 AM\n Phosphorus\n 5.0 mg/dL\n 04:18 AM\n Magnesium\n 1.5 mg/dL\n 04:18 AM\n Current diet order / nutrition support: NPO\n GI: Abdomen obese with absent bowel sounds, Patient has baseline PEG\n Assessment of Nutritional Status\n Pt at risk due to:\n NPO status, pressure ulcer\n Estimated Nutritional Needs\n based on adjusted body weight\n Calories: 1470-1830 kcal (20-25 kcal/kg)\n Protein: 80-102g (1.3-1.5g/kg) d/t ulcers\n Fluid: per team\n Specifics:\n 76 year old female with multiple co-morbidities, most recently\n hospitalized with PNA, now s/p ERCP with removal of CBD stones and\n sphincterotomy. Patient is intubated and has PEG. Currently propofol\n is providing 995kcal/day. While propofol is running, would recommend\n tube feeding of Replete with Fiber with 40g beneprotein at 35ml/hr x 24\n hours which provides 983kcal and 86g protein (propofol provides\n additional 995kcal/day). Once propofol less than 10ml/hr, suggest tube\n feeding of Replete with Fiber at 75ml/hr x 24 hours to provide 1800kcal\n and 112g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. With propofol, suggest Replete with Fiber with 40g beneprotein\n at 35ml/hr x 24 hours. Start at 10ml and advance by 20ml q6H to goal\n rate of 35ml/hr.\n 2. Once propofol less than 10ml/hr, change tube feeding to\n Replete with Fiber at 75ml/hr and discontinue beneprotein\n 3. Check residuals q4H and hold tube feedings if greater than\n 150ml.\n 4. Check BS Q4hrs, cover with RISS accordingly.\n 5. Will continue to follow with plan of care.\n 12:40 PM\n" }, { "category": "Nutrition", "chartdate": "2104-05-01 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 573447, "text": "Subjective\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n cm\n 104.8 kg\n 101.3 kg ( 12:00 AM)\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n Diagnosis:\n PMH :\n Food allergies and intolerances:\n Pertinent medications:\n Labs:\n Value\n Date\n Glucose\n 190 mg/dL\n 04:18 AM\n Glucose Finger Stick\n 322\n 10:00 AM\n BUN\n 17 mg/dL\n 04:18 AM\n Creatinine\n 0.7 mg/dL\n 04:18 AM\n Sodium\n 132 mEq/L\n 04:18 AM\n Potassium\n 4.0 mEq/L\n 04:18 AM\n Chloride\n 97 mEq/L\n 04:18 AM\n TCO2\n 26 mEq/L\n 04:18 AM\n PO2 (arterial)\n 103 mm Hg\n 08:27 PM\n PCO2 (arterial)\n 44 mm Hg\n 08:27 PM\n pH (arterial)\n 7.40 units\n 08:27 PM\n CO2 (Calc) arterial\n 28 mEq/L\n 08:27 PM\n Albumin\n 3.2 g/dL\n 02:54 AM\n Calcium non-ionized\n 8.2 mg/dL\n 04:18 AM\n Phosphorus\n 5.0 mg/dL\n 04:18 AM\n Magnesium\n 1.5 mg/dL\n 04:18 AM\n ALT\n 18 IU/L\n 04:18 AM\n Alkaline Phosphate\n 169 IU/L\n 04:18 AM\n AST\n 16 IU/L\n 04:18 AM\n Total Bilirubin\n 0.7 mg/dL\n 04:18 AM\n WBC\n 9.4 K/uL\n 04:18 AM\n Hgb\n 8.1 g/dL\n 04:18 AM\n Hematocrit\n 27.5 %\n 04:18 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": "Physician ", "chartdate": "2104-04-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 573281, "text": "Chief Complaint: post ercp, 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: 76 yo F here from ERCP for prolonged MV following removal of CBD\n stones.\n Pt has complicated MH with diastolic CHF, HBP, DM, COPD\n -\n hospit with PNA\n intubated with trach and prolonged\n wean. Decannulated since discharge to Rehab/ Rehab.\n N,V, Abd pain on . Abdom US neg but abdom CT showed CBD stones and\n she was transferred for ERCP with general anaesthesia with elective\n intubation.\n ERCP uncomplicated and she was transferred to the MICU intubated for\n close monitoring and planned extubation in AM.\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:50 PM\n EKG - At 11:00 PM\n remained intubated overnight\n now with freq sx needs Q 1 hr--thick and white\n History obtained from ho\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:02 AM\n Ciprofloxacin - 08:58 AM\n Infusions:\n Other ICU medications:\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:53 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: 36.8\nC (98.3\n HR: 82 (60 - 100) bpm\n BP: 131/78(91) {95/56(67) - 156/78(91)} mmHg\n RR: 24 (14 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,570 mL\n 749 mL\n PO:\n TF:\n IVF:\n 1,570 mL\n 749 mL\n Blood products:\n Total out:\n 582 mL\n 1,020 mL\n Urine:\n 282 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n 988 mL\n -271 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 85\n PIP: 27 cmH2O\n Plateau: 14 cmH2O\n Compliance: 61.1 cmH2O/mL\n SpO2: 99%\n ABG: 7.47/42/91/29/6\n Ve: 11.4 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal 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: coarse, sym air movement\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 9.2 g/dL\n 397 K/uL\n 195 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 5.0 mEq/L\n 22 mg/dL\n 101 mEq/L\n 138 mEq/L\n 28.3 %\n 12.5 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n WBC\n 12.5\n Hct\n 29\n 28.3\n Plt\n 397\n Cr\n 0.9\n TCO2\n 31\n Glucose\n 173\n 195\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:32/26, Alk Phos / T\n Bili:234/0.6, Albumin:3.2 g/dL, Ca++:9.6 mg/dL, Mg++:1.7 mg/dL, PO4:4.2\n mg/dL\n Imaging: cxr--et ok, b/l haziness--prob edema with loss of r and l\n hemidiaph\n Microbiology: no data (need 0Sh records)\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n 76 yo obese F with DM, HTN, CAD, and recent hospitalization with\n pna/FTW s/p trach (now decannulated) and peg, on supp O2 at baseline\n who developed cholangitis and was transferred from OSH for ercp with\n removal of CBD stones which required general anesthesia and intubation.\n Pt was a difficult intubation and now has no cuff leak and sig thick\n secretions requiring Q 1 hr suctioning impacting ability to extubate at\n this time.\n Agree with plan to hold on extubation for now--Will send sputum cx\n perform aggressive chest pt and sx and continue MDIs. Has # 7 ET so\n may not allow for cuff leak but given reportedly difficult intubation\n and recent ICU course with prior trach--will give 24 hrs of steroids\n and reassess for cuff leak tomorrow. Currently being\n overventilated\nWould change to PSV and if unable to tolerate would\n adjust MV to optimize abg by reducing TV on vent. Pending reassessment\n in am, may attempt to extubate with anesthesia present or over cook\n cath. Also reportedly completing course of antbx (levo) for resp\n infectious\nneed to clarify this via osh records.\n In terms of cholangitis\nis doing well. cbd stones now removed.\n Remains HD stable. LFTs decreasing.\n Wound care for decubs.\n Remainder as per housestaff note.\n ICU Care\n Nutrition: restart TFs\n Glycemic Control: SSI\n Lines:\n 20 Gauge - 09:07 PM\noicc consult\n Prophylaxis:\n DVT: boots\n Stress ulcer: TFs\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : critically ill/remains in icu\n Total time spent: 40\n" }, { "category": "Nursing", "chartdate": "2104-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573284, "text": "Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate (now decanulated).\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP today had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n Diabetes Mellitus (DM), Type I\n Assessment:\n BS 400\ns in PACU. Pt has been started on HISS and lantus insulin and\n FSBS have been trending down.\n Action:\n Pt remains NPO for now. Following FSBS q6hr and covering w/ HISS as\n ordered.\n Response:\n BS have continued to trend down to 190\n Plan:\n Continue to check BS q 6 hours and treat as ordered on sliding scale\n insulin order.\n Impaired Skin Integrity\n Assessment:\n Pt has bilat gluteal pressure sores\n see flowsheet for detailed\n assessment.\n Action:\n Dsngs changed to pressure sores to bilat gluteal area. Wound care has\n been in on consult\n recommends dsng to R gluteal area w/ collagenase\n ointment and 2x2 packing covered w/ DSD. Dsng to L gluteal area w/ AMD\n 1\n packing moist to dry packing covered w/ DSD. See wound care\n recommendations. Continued side to side positioning q2hr and routine\n skin care measures.\n Response:\n Pt remains free of further s/s impaired skin integrity. Pressure ulcers\n to bilat gluteal area will need continued monitoring and tx.\n Plan:\n Continue daily dsng changes to pressure ulcers to bilat gluteal area as\n per wound care recommendations. These dsngs will need to be rechanged\n tonight. Continue q2hr side to side repositioning and continue routine\n skin care measures.\n Difficult intubation\n Assessment:\n Pt was a difficult intubation and it was decided to keep pt intubated\n overnight to protect airway. This am RSBI 85; however, no cuff leak\n present and pt requiring snx q1-hr.\n Action:\n Pt has been started on hydrocortisone 50mg IV Qh4 X 3 doses. Sputum cx\n has been sent. Monitoring respiratory status closely. Pt continues on\n propofol sedation as ordered. Bilat soft wrist restraints in place for\n safety.\n Response:\n Pt continues to require frequent snx. Pt became increasingly\n tachycardic and tachypneic on CPAP/PS settings and vent settings were\n returned to AC mode by RT. Pt continued to be tachycardic w/ HR 1teens\n to 120\n SR w/ increasing restlessness despite propofol infusing at\n 60mcg/kg/min. Orders obtained for Fentanyl gtt which was started at\n 25mcg/hr, HR improved to 90\ns SR w/ pt lightly sedated and indicating\n feeling more comfortable.\n Plan:\n Continue to monitor respiratory and hemodynamic status closely. Monitor\n for s/s infection. Continue hydrocortisone as ordered and reassess\n readiness to extubated in am. Continue propofol and Fentanyl sedation\n for now and continue bilat soft wrist restraints for safety. If pt\n demonstrates readiness to extubated in am will likely need anesthesia\n present at bedside given hx of very difficult intubation.\n" }, { "category": "Nursing", "chartdate": "2104-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573348, "text": "Diabetes Mellitus (DM), Type I\n Assessment:\n FBS at 2200 = 199\n Action:\n Treated with lantus 26 units and humalog regular 2 units sc\n Response:\n Blood sugar in better control\n Plan:\n Continue to monitor blood sugar q 6 hrs and cover with sliding scale\n restlessness\n Assessment:\n Pt medicated on propofol at 60 mcg/kg/min and fentanyl 25 mcg /hr\n Pt denies pain\n Pt restless and attempting to pull out ETT\n Pt attempting to mouth words, but not understandable, and becoming\n agitated\n Action:\n Propofol increased to 75 mcg/kg/min\n Response:\n Pt wakes at times, but comfortably sedated, and no longer restless\n Plan:\n Wean propofol in the am to be ready for ventilator weaning and\n extubation\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Bp dropped to 80\ns systolic, HO notified\n u/o dropped to 25-30 cc/hr\n LOS fluid balance is -250 cc\n Action:\n NS bolus 500 cc over 1 hour\n Response:\n Bp returned to 110/50\n Plan:\n Monitor bp q 30 mins. Monitor u/o q 1 hr.\n" }, { "category": "Physician ", "chartdate": "2104-05-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573418, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 10:30 AM\n PICC LINE - START 06:00 PM\n - started steroids as had no cuff leak and hx difficult extubation\n - increased lantus from 26 to 36 for high sugars\n - hct drop after hypotensive tachycardic episode, gave 1 Prbc, unable\n to get consent from family/hcp (no answer on phone). vitals resolved\n prior to unit\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Metronidazole - 05:38 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 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 07:36 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: 35.6\nC (96.1\n HR: 59 (55 - 118) bpm\n BP: 122/52(68) {83/36(49) - 137/105(110)} mmHg\n RR: 12 (12 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 2,382 mL\n 775 mL\n PO:\n TF:\n IVF:\n 2,382 mL\n 501 mL\n Blood products:\n 274 mL\n Total out:\n 2,060 mL\n 515 mL\n Urine:\n 2,060 mL\n 515 mL\n NG:\n Stool:\n Drains:\n Balance:\n 322 mL\n 260 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 550) mL\n Vt (Spontaneous): 488 (467 - 643) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 46\n PIP: 21 cmH2O\n Plateau: 16 cmH2O\n Compliance: 45.5 cmH2O/mL\n SpO2: 98%\n ABG: 7.40/44/103/26/1\n Ve: 6.1 L/min\n PaO2 / FiO2: 258\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 341 K/uL\n 8.1 g/dL\n 190 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 97 mEq/L\n 132 mEq/L\n 27.5 %\n 9.4 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n 08:27 PM\n 11:15 PM\n 04:18 AM\n WBC\n 12.5\n 9.4\n Hct\n 29\n 28.3\n 23.4\n 27.5\n Plt\n 397\n 341\n Cr\n 0.9\n 0.7\n TCO2\n 31\n 28\n Glucose\n 173\n 195\n 190\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:18/16, Alk Phos / T\n Bili:169/0.7, Albumin:3.2 g/dL, LDH:182 IU/L, Ca++:8.2 mg/dL, Mg++:1.5\n mg/dL, PO4:5.0 mg/dL\n Imaging: CXR: ET tube ~ 3.3cm from carina. R PICC in place at SVC.\n Heavily rotated, continued haziness at R base\n Microbiology: Sputum Gram stain :\n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND\n CLUSTERS.\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:07 PM\n PICC Line - 06:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2104-05-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573420, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:50 PM\n Continued Ventilation, small fluid requirements to maintain blood\n pressure\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 09:00 PM\n Metronidazole - 06:02 AM\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 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: 36.7\nC (98\n HR: 75 (60 - 92) bpm\n BP: 132/60(77) {95/56(67) - 132/69(83)} mmHg\n RR: 14 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,570 mL\n 442 mL\n PO:\n TF:\n IVF:\n 1,570 mL\n 442 mL\n Blood products:\n Total out:\n 582 mL\n 800 mL\n Urine:\n 282 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 988 mL\n -358 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 85\n PIP: 32 cmH2O\n Plateau: 24 cmH2O\n Compliance: 28.9 cmH2O/mL\n SpO2: 100%\n ABG: 7.47/42/91/29/6\n Ve: 5.1 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\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: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, No(t) Tender: , Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 397 K/uL\n 9.2 g/dL\n 195 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 5.0 mEq/L\n 22 mg/dL\n 101 mEq/L\n 138 mEq/L\n 28.3 %\n 12.5 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n WBC\n 12.5\n Hct\n 29\n 28.3\n Plt\n 397\n Cr\n 0.9\n TCO2\n 31\n Glucose\n 173\n 195\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:32/26, Alk Phos / T\n Bili:234/0.6, Albumin:3.2 g/dL, Ca++:9.6 mg/dL, Mg++:1.7 mg/dL, PO4:4.2\n mg/dL\n Imaging: CXR 9:00pm: Slight improvement in LLL consolidation. ET\n Tube ~ 2cm from carina\n Microbiology: MRSA Screen P\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach found to have CBD stones base on CT\n from now undergoing ERCP with removal of stones and\n sphincterotomy. There is no record of fever in the accompanying notes,\n and the white count in the OSH records seems to be mildly elevated but\n stable. She does not clinically meet the criteria for cholangitis at\n this time.\n # CBD Stones\n - s/p ERCP now, will hold aspirin for now per advanced endoscopy team\n for now\n - will continue antibiotics for now per-procedurally, and discuss with\n team for duration. Likely 24-48h and trend WBC since this has been\n managed interventionally. Cipro 400mg IV q12h and metronidazole 500mg\n IV q8h.\n - trend tbili, lfts\n # Respiratory Failure/COPD\n - Patient underwent procedure under anesthesia and was intubated for\n this procedure.\n - on AC for now, will change to CPAP/PS and aim for extubation tomorrow\n after SBT\n # Diabetes\n - Noted to be type one, had\n dose glargine last night, and received\n glucagon during ERCP which could elevate BS. For now will continue the\n glargine 13 units sc at bedtime, and cover with humalog sliding scale.\n If difficult to control sugars, we can change over to nph and humalog\n coverage to allow for tighter titration.\n # Chronic Diastolic CHF\n - compensated and stable at this time. Will hold dose of lisinopril\n overnight given her lower bps requiring fluid boluses of 1 liter total,\n and restart tomorrow.\n # h/o possible but not confirmed c. diff, not recently on treatment.\n Will send c.diff if suspicion is raised by diarrhea.\n # Asthma: can try MDI if necessary\n # h/o HTN: hold HCTZ/lisinopril overnight.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:07 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 07:43 ------\n" }, { "category": "Nursing", "chartdate": "2104-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573628, "text": " Problem - Description In Comments\n Assessment:\n Remains intubated. Periods of apnea noted. Increased secretions. Low\n hct\n Action:\n Pt. on ps of and then . periods of low min volumes and apnea.\n Placed back on CMV\n Suctioned for thick white secretions.\n Sats 98-100%. Rsbi 90.\n Bs\ns clear, dim in bases.\n Neuro: attempt to wean propofol , but pt. became increasingly agitated\n and attempted to pull out ett.\n Propofol presently at 75mcqs. Pt. nodding interm. Eyes open.\n Cv: hemodynamaically stable.\n Endoc: k+ and mg+ repleted x2. bs\ns low at 16pm and given\n amp d50\n ivp. Repeat bs was 84. na 148-d5w instituted at 150cc/hr x 2L.\n Gi: pt. was npo x meds. Tf\nings now ordered.\n Renal: given 20mg lasix ivp with moderate diuresis.\n Hem: hct 24.6 at 15pm.\n Id: cont. on antibiotics. Afebrile.\n Social: no contact with family.\n Response:\n Unable to extubate today.\n Plan:\n Start tf\nings at 20cc/hr. transfuse with 1u pc\ns. needs new periph iv.\n Recheck lytes if cont. to diurese. Replete.\n" }, { "category": "Nursing", "chartdate": "2104-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573344, "text": "Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate (now decanulated).\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP today had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n Diabetes Mellitus (DM), Type I\n Assessment:\n BS 400\ns in PACU. Pt has been started on HISS and lantus insulin and\n FSBS have been trending down.\n Action:\n Pt remains NPO for now. Following FSBS q6hr and covering w/ HISS as\n ordered.\n Response:\n BS have continued to trend down to 190\n Plan:\n Continue to check BS q 6 hours and treat as ordered on sliding scale\n insulin order.\n Impaired Skin Integrity\n Assessment:\n Pt has bilat gluteal pressure sores\n see flowsheet for detailed\n assessment.\n Action:\n Dsngs changed to pressure sores to bilat gluteal area. Wound care has\n been in on consult\n recommends dsng to R gluteal area w/ collagenase\n ointment and 2x2 packing covered w/ DSD. Dsng to L gluteal area w/ AMD\n 1\n packing moist to dry packing covered w/ DSD. See wound care\n recommendations. Continued side to side positioning q2hr and routine\n skin care measures.\n Response:\n Pt remains free of further s/s impaired skin integrity. Pressure ulcers\n to bilat gluteal area will need continued monitoring and tx.\n Plan:\n Continue daily dsng changes to pressure ulcers to bilat gluteal area as\n per wound care recommendations. These dsngs will need to be rechanged\n tonight. Continue q2hr side to side repositioning and continue routine\n skin care measures.\n Difficult intubation\n Assessment:\n Pt was a difficult intubation and it was decided to keep pt intubated\n overnight to protect airway. This am RSBI 85; however, no cuff leak\n present and pt requiring snx q1-hr.\n Action:\n Pt has been started on hydrocortisone 50mg IV Qh4 X 3 doses. Sputum cx\n has been sent. Monitoring respiratory status closely. Pt continues on\n propofol sedation as ordered. Bilat soft wrist restraints in place for\n safety.\n Response:\n Pt continues to require frequent snx. Pt became increasingly\n tachycardic and tachypneic on CPAP/PS settings and vent settings were\n returned to AC mode by RT. Pt continued to be tachycardic w/ HR 1teens\n to 120\n SR w/ increasing restlessness despite propofol infusing at\n 60mcg/kg/min. Orders obtained for Fentanyl gtt which was started at\n 25mcg/hr, HR improved to 90\ns SR w/ pt lightly sedated and indicating\n feeling more comfortable.\n Plan:\n Continue to monitor respiratory and hemodynamic status closely. Monitor\n for s/s infection. Continue hydrocortisone as ordered and reassess\n readiness to extubated in am. Continue propofol and Fentanyl sedation\n for now and continue bilat soft wrist restraints for safety. If pt\n demonstrates readiness to extubated in am will likely need anesthesia\n present at bedside given hx of very difficult intubation.\n" }, { "category": "Nursing", "chartdate": "2104-04-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573166, "text": "75 yo F transferred to from OSH for ERCP. Admitted to 4 MICU\n s/p ERCP (had sphincterotomy and removal of 2 stones) for closer\n monitoring.\n PMH: HTN, DM, Asthma, CAD, CHF, Gout, OA, Obesity, decub, HX of PNA\n w/intubation, failure to wean, Trached and peged.\n Pt intubated for procedure. Upon arrival to the unit, intubated,\n vented, sedated, sats at 100%. B/P in 80\ns. NS 500cc bolus given,\n sedation decreased. Hr at 70\ns SR. Abd soft, positive for Bs and\n flatus, re-eval by GI team done. C/Y/U via foley adequate amnt.\n Decubitus ulcer x2 on B/L buttocks\n dressings applied. Will need a\n wound care consult. RT PIV 20G patent (hard stick).\n" }, { "category": "Physician ", "chartdate": "2104-04-29 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 573167, "text": "Chief Complaint: RUQ pain and Fever\n HPI:\n Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate (now decanulated).\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP today had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n She had taken\n of her lantus dose last evening (13 units where she\n regularly takes 26 units sc each evening) and had an elevated blood\n glucose after ERCP above 400.\n She remains sedated with propofol.\n Patient admitted from: ERCP\n History obtained from Medical records, GI Unit\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Home Medications\n Social History:\n CHF (EF 55% )\n HTN\n CAD (per records)\n DM - noted type I (Novolin 70/30 45 units sc q8h)\n Asthma\n Obesity\n Gout\n Osteoarthritis\n Recent Hospitalization\n Decubitus Ulcers (h/o)\n h/o recent pneumonia (noted aspiration), CHF exacerbation, vent\n dependent resp failure\n Intubated \n s/p trach/peg (). Trach decanulated.\n h/o recent candidal esophagitis treated with diflucan.\n h/o + H/ pylori s/p amox/clarithro/esomeprazole x10d\n Treated for C. difficile colitis during that hospitalization.\n ALBUTEROL - - Dosage uncertain\n ESOMEPRAZOLE MAGNESIUM [NEXIUM] - - 40 mg Capsule, Delayed\n Release(E.C.) - Capsule(s) PO once a day\n HYDROCHLOROTHIAZIDE - - 12.5 mg Capsule - 1 Capsule(s) via\n g-tube once a day\n INSULIN ASPART [NOVOLOG] - - 100 unit/mL Solution - 8u sc tid\n before meals\n INSULIN GLARGINE [LANTUS] - - 100 unit/mL Solution - 26u sc\n qHS\n IPRATROPIUM BROMIDE [ATROVENT HFA] - - 17 mcg/Actuation\n Aerosol - 6 puffs inhales four times a day\n LEVOFLOXACIN [LEVAQUIN] - - 250 mg Tablet - Tablet(s) PO qHS\n LD at \n LISINOPRIL [ZESTRIL] - - 20 mg Tablet - 1 Tablet(s) PO once a\n day\n ASPIRIN - - 81 mg Tablet, Chewable - 1 (One) Tablet(s) PO once\n a day\n FERROUS SULFATE [FERATAB] - - 300 mg (60 mg Iron) Tablet - 1\n (One) Tablet(s) PO once a day\n GUAIFENESIN [CHEST CONGESTION] - - 100 mg/5 mL Liquid - 2\n (Two) tsp PO four times a day PRN\n LACTOBACILLUS RHAMNOSUS (GG) [CULTURELLE] - - 10 billion cells\n Capsule - 1 Capsule(s) PO once a day may be sprinkled on food or given\n through g-tube\n Former Smoker\n Daughter \n \n Review of systems: unable to elicit\n Flowsheet Data as of 08:27 PM\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: 74 (74 - 92) bpm\n BP: 95/59(67) {95/59(67) - 99/63(70)} mmHg\n RR: 14 (14 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,080 mL\n PO:\n TF:\n IVF:\n 1,080 mL\n Blood products:\n Total out:\n 0 mL\n 332 mL\n Urine:\n 32 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 748 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 31 cmH2O\n SpO2: 100%\n Ve: 5 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\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: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, No(t) Tender: , Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n [image002.gif] [image003.gif]\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach found to have CBD stones base on CT\n from now undergoing ERCP with removal of stones and\n sphincterotomy. There is no record of fever in the accompanying notes,\n and the white count in the OSH records seems to be mildly elevated but\n stable. She does not clinically meet the criteria for cholangitis at\n this time.\n # CBD Stones\n - s/p ERCP now, will hold aspirin for now per advanced endoscopy team\n for now\n - will continue antibiotics for now per-procedurally, and discuss with\n team for duration. Likely 24-48h and trend WBC since this has been\n managed interventionally. Cipro 400mg IV q12h and metronidazole 500mg\n IV q8h.\n - trend tbili, lfts\n # Respiratory Failure/COPD\n - Patient underwent procedure under anesthesia and was intubated for\n this procedure.\n - on AC for now, will change to CPAP/PS and aim for extubation tomorrow\n after SBT\n # Diabetes\n - Noted to be type one, had\n dose glargine last night, and received\n glucagon during ERCP which could elevate BS. For now will continue the\n glargine 13 units sc at bedtime, and cover with humalog sliding scale.\n If difficult to control sugars, we can change over to nph and humalog\n coverage to allow for tighter titration.\n # Chronic Diastolic CHF\n - compensated and stable at this time. Will hold dose of lisinopril\n overnight given her lower bps requiring fluid boluses of 1 liter total,\n and restart tomorrow.\n # h/o possible but not confirmed c. diff, not recently on treatment.\n Will send c.diff if suspicion is raised by diarrhea.\n # Asthma: can try MDI if necessary\n # h/o HTN: hold HCTZ/lisinopril overnight.\n ICU Care\n Nutrition:\n Glycemic Control: Glargine\n Lines:\n 20 Gauge - 07:13 PM\n Prophylaxis:\n DVT: SQ UF Heparin\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": "2104-04-29 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 573168, "text": "Chief Complaint: RUQ pain and Fever\n HPI:\n Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate (now decanulated).\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP today had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n She had taken\n of her lantus dose last evening (13 units where she\n regularly takes 26 units sc each evening) and had an elevated blood\n glucose after ERCP above 400.\n She remains sedated with propofol.\n Patient admitted from: ERCP\n History obtained from Medical records, GI Unit\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Home Medications\n Social History:\n CHF (EF 55% )\n HTN\n CAD (per records)\n DM - noted type I (Novolin 70/30 45 units sc q8h)\n Asthma\n Obesity\n Gout\n Osteoarthritis\n Recent Hospitalization\n Decubitus Ulcers (h/o)\n h/o recent pneumonia (noted aspiration), CHF exacerbation, vent\n dependent resp failure\n Intubated \n s/p trach/peg (). Trach decanulated.\n h/o recent candidal esophagitis treated with diflucan.\n h/o + H/ pylori s/p amox/clarithro/esomeprazole x10d\n Treated for C. difficile colitis during that hospitalization.\n ALBUTEROL - - Dosage uncertain\n ESOMEPRAZOLE MAGNESIUM [NEXIUM] - - 40 mg Capsule, Delayed\n Release(E.C.) - Capsule(s) PO once a day\n HYDROCHLOROTHIAZIDE - - 12.5 mg Capsule - 1 Capsule(s) via\n g-tube once a day\n INSULIN ASPART [NOVOLOG] - - 100 unit/mL Solution - 8u sc tid\n before meals\n INSULIN GLARGINE [LANTUS] - - 100 unit/mL Solution - 26u sc\n qHS\n IPRATROPIUM BROMIDE [ATROVENT HFA] - - 17 mcg/Actuation\n Aerosol - 6 puffs inhales four times a day\n LEVOFLOXACIN [LEVAQUIN] - - 250 mg Tablet - Tablet(s) PO qHS\n LD at \n LISINOPRIL [ZESTRIL] - - 20 mg Tablet - 1 Tablet(s) PO once a\n day\n ASPIRIN - - 81 mg Tablet, Chewable - 1 (One) Tablet(s) PO once\n a day\n FERROUS SULFATE [FERATAB] - - 300 mg (60 mg Iron) Tablet - 1\n (One) Tablet(s) PO once a day\n GUAIFENESIN [CHEST CONGESTION] - - 100 mg/5 mL Liquid - 2\n (Two) tsp PO four times a day PRN\n LACTOBACILLUS RHAMNOSUS (GG) [CULTURELLE] - - 10 billion cells\n Capsule - 1 Capsule(s) PO once a day may be sprinkled on food or given\n through g-tube\n Former Smoker\n Daughter \n \n Review of systems: unable to elicit\n Flowsheet Data as of 08:27 PM\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: 74 (74 - 92) bpm\n BP: 95/59(67) {95/59(67) - 99/63(70)} mmHg\n RR: 14 (14 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,080 mL\n PO:\n TF:\n IVF:\n 1,080 mL\n Blood products:\n Total out:\n 0 mL\n 332 mL\n Urine:\n 32 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 748 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 31 cmH2O\n SpO2: 100%\n Ve: 5 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\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: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, No(t) Tender: , Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n [image002.gif] [image003.gif]\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach found to have CBD stones base on CT\n from now undergoing ERCP with removal of stones and\n sphincterotomy. There is no record of fever in the accompanying notes,\n and the white count in the OSH records seems to be mildly elevated but\n stable. She does not clinically meet the criteria for cholangitis at\n this time.\n # CBD Stones\n - s/p ERCP now, will hold aspirin for now per advanced endoscopy team\n for now\n - will continue antibiotics for now per-procedurally, and discuss with\n team for duration. Likely 24-48h and trend WBC since this has been\n managed interventionally. Cipro 400mg IV q12h and metronidazole 500mg\n IV q8h.\n - trend tbili, lfts\n # Respiratory Failure/COPD\n - Patient underwent procedure under anesthesia and was intubated for\n this procedure.\n - on AC for now, will change to CPAP/PS and aim for extubation tomorrow\n after SBT\n # Diabetes\n - Noted to be type one, had\n dose glargine last night, and received\n glucagon during ERCP which could elevate BS. For now will continue the\n glargine 13 units sc at bedtime, and cover with humalog sliding scale.\n If difficult to control sugars, we can change over to nph and humalog\n coverage to allow for tighter titration.\n # Chronic Diastolic CHF\n - compensated and stable at this time. Will hold dose of lisinopril\n overnight given her lower bps requiring fluid boluses of 1 liter total,\n and restart tomorrow.\n # h/o possible but not confirmed c. diff, not recently on treatment.\n Will send c.diff if suspicion is raised by diarrhea.\n # Asthma: can try MDI if necessary\n # h/o HTN: hold HCTZ/lisinopril overnight.\n FEN: PEG,\n ICU Care\n Nutrition:\n Glycemic Control: Glargine\n Lines:\n 20 Gauge - 07:13 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2104-04-29 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 573169, "text": "Chief Complaint: RUQ pain and Fever\n HPI:\n Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate (now decanulated).\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP today had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n She had taken\n of her lantus dose last evening (13 units where she\n regularly takes 26 units sc each evening) and had an elevated blood\n glucose after ERCP above 400.\n She remains sedated with propofol.\n Patient admitted from: ERCP\n History obtained from Medical records, GI Unit\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Home Medications\n Social History:\n CHF (EF 55% )\n HTN\n CAD (per records)\n DM - noted type I (Novolin 70/30 45 units sc q8h)\n Asthma\n Obesity\n Gout\n Osteoarthritis\n Recent Hospitalization\n Decubitus Ulcers (h/o)\n h/o recent pneumonia (noted aspiration), CHF exacerbation, vent\n dependent resp failure\n Intubated \n s/p trach/peg (). Trach decanulated.\n h/o recent candidal esophagitis treated with diflucan.\n h/o + H/ pylori s/p amox/clarithro/esomeprazole x10d\n Treated for C. difficile colitis during that hospitalization.\n ALBUTEROL - - Dosage uncertain\n ESOMEPRAZOLE MAGNESIUM [NEXIUM] - - 40 mg Capsule, Delayed\n Release(E.C.) - Capsule(s) PO once a day\n HYDROCHLOROTHIAZIDE - - 12.5 mg Capsule - 1 Capsule(s) via\n g-tube once a day\n INSULIN ASPART [NOVOLOG] - - 100 unit/mL Solution - 8u sc tid\n before meals\n INSULIN GLARGINE [LANTUS] - - 100 unit/mL Solution - 26u sc\n qHS\n IPRATROPIUM BROMIDE [ATROVENT HFA] - - 17 mcg/Actuation\n Aerosol - 6 puffs inhales four times a day\n LEVOFLOXACIN [LEVAQUIN] - - 250 mg Tablet - Tablet(s) PO qHS\n LD at \n LISINOPRIL [ZESTRIL] - - 20 mg Tablet - 1 Tablet(s) PO once a\n day\n ASPIRIN - - 81 mg Tablet, Chewable - 1 (One) Tablet(s) PO once\n a day\n FERROUS SULFATE [FERATAB] - - 300 mg (60 mg Iron) Tablet - 1\n (One) Tablet(s) PO once a day\n GUAIFENESIN [CHEST CONGESTION] - - 100 mg/5 mL Liquid - 2\n (Two) tsp PO four times a day PRN\n LACTOBACILLUS RHAMNOSUS (GG) [CULTURELLE] - - 10 billion cells\n Capsule - 1 Capsule(s) PO once a day may be sprinkled on food or given\n through g-tube\n Former Smoker\n Daughter \n \n Review of systems: unable to elicit\n Flowsheet Data as of 08:27 PM\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: 74 (74 - 92) bpm\n BP: 95/59(67) {95/59(67) - 99/63(70)} mmHg\n RR: 14 (14 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,080 mL\n PO:\n TF:\n IVF:\n 1,080 mL\n Blood products:\n Total out:\n 0 mL\n 332 mL\n Urine:\n 32 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 748 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 31 cmH2O\n SpO2: 100%\n Ve: 5 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\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: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, No(t) Tender: , Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n [image002.gif] [image003.gif]\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach found to have CBD stones base on CT\n from now undergoing ERCP with removal of stones and\n sphincterotomy. There is no record of fever in the accompanying notes,\n and the white count in the OSH records seems to be mildly elevated but\n stable. She does not clinically meet the criteria for cholangitis at\n this time.\n # CBD Stones\n - s/p ERCP now, will hold aspirin for now per advanced endoscopy team\n for now\n - will continue antibiotics for now per-procedurally, and discuss with\n team for duration. Likely 24-48h and trend WBC since this has been\n managed interventionally. Cipro 400mg IV q12h and metronidazole 500mg\n IV q8h.\n - trend tbili, lfts\n # Respiratory Failure/COPD\n - Patient underwent procedure under anesthesia and was intubated for\n this procedure.\n - on AC for now, will change to CPAP/PS and aim for extubation tomorrow\n after SBT\n # Diabetes\n - Noted to be type one, had\n dose glargine last night, and received\n glucagon during ERCP which could elevate BS. For now will continue the\n glargine 13 units sc at bedtime, and cover with humalog sliding scale.\n If difficult to control sugars, we can change over to nph and humalog\n coverage to allow for tighter titration.\n # Chronic Diastolic CHF\n - compensated and stable at this time. Will hold dose of lisinopril\n overnight given her lower bps requiring fluid boluses of 1 liter total,\n and restart tomorrow.\n # h/o possible but not confirmed c. diff, not recently on treatment.\n Will send c.diff if suspicion is raised by diarrhea.\n # Asthma: can try MDI if necessary\n # h/o HTN: hold HCTZ/lisinopril overnight.\n ICU Care\n Nutrition:\n Glycemic Control: Glargine\n Lines:\n 20 Gauge - 07:13 PM\n Prophylaxis:\n DVT: SQ UF Heparin\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": "2104-04-29 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 573171, "text": "Chief Complaint: RUQ pain and Fever\n HPI:\n Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate (now decanulated).\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP today had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n She had taken\n of her lantus dose last evening (13 units where she\n regularly takes 26 units sc each evening) and had an elevated blood\n glucose after ERCP above 400.\n She remains sedated with propofol.\n Patient admitted from: ERCP\n History obtained from Medical records, GI Unit\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Home Medications\n Social History:\n CHF (EF 55% )\n HTN\n CAD (per records)\n DM - noted type I (Novolin 70/30 45 units sc q8h)\n Asthma\n Obesity\n Gout\n Osteoarthritis\n Recent Hospitalization\n Decubitus Ulcers (h/o)\n h/o recent pneumonia (noted aspiration), CHF exacerbation, vent\n dependent resp failure\n Intubated \n s/p trach/peg (). Trach decanulated.\n h/o recent candidal esophagitis treated with diflucan.\n h/o + H/ pylori s/p amox/clarithro/esomeprazole x10d\n Treated for C. difficile colitis during that hospitalization.\n ALBUTEROL - - Dosage uncertain\n ESOMEPRAZOLE MAGNESIUM [NEXIUM] - - 40 mg Capsule, Delayed\n Release(E.C.) - Capsule(s) PO once a day\n HYDROCHLOROTHIAZIDE - - 12.5 mg Capsule - 1 Capsule(s) via\n g-tube once a day\n INSULIN ASPART [NOVOLOG] - - 100 unit/mL Solution - 8u sc tid\n before meals\n INSULIN GLARGINE [LANTUS] - - 100 unit/mL Solution - 26u sc\n qHS\n IPRATROPIUM BROMIDE [ATROVENT HFA] - - 17 mcg/Actuation\n Aerosol - 6 puffs inhales four times a day\n LEVOFLOXACIN [LEVAQUIN] - - 250 mg Tablet - Tablet(s) PO qHS\n LD at \n LISINOPRIL [ZESTRIL] - - 20 mg Tablet - 1 Tablet(s) PO once a\n day\n ASPIRIN - - 81 mg Tablet, Chewable - 1 (One) Tablet(s) PO once\n a day\n FERROUS SULFATE [FERATAB] - - 300 mg (60 mg Iron) Tablet - 1\n (One) Tablet(s) PO once a day\n GUAIFENESIN [CHEST CONGESTION] - - 100 mg/5 mL Liquid - 2\n (Two) tsp PO four times a day PRN\n LACTOBACILLUS RHAMNOSUS (GG) [CULTURELLE] - - 10 billion cells\n Capsule - 1 Capsule(s) PO once a day may be sprinkled on food or given\n through g-tube\n Former Smoker\n Daughter \n \n Review of systems: unable to elicit\n Flowsheet Data as of 08:27 PM\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: 74 (74 - 92) bpm\n BP: 95/59(67) {95/59(67) - 99/63(70)} mmHg\n RR: 14 (14 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,080 mL\n PO:\n TF:\n IVF:\n 1,080 mL\n Blood products:\n Total out:\n 0 mL\n 332 mL\n Urine:\n 32 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 748 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 31 cmH2O\n SpO2: 100%\n Ve: 5 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\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: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, No(t) Tender: , Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n [image002.gif] [image003.gif]\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach found to have CBD stones base on CT\n from now undergoing ERCP with removal of stones and\n sphincterotomy. There is no record of fever in the accompanying notes,\n and the white count in the OSH records seems to be mildly elevated but\n stable. She does not clinically meet the criteria for cholangitis at\n this time.\n # CBD Stones\n - s/p ERCP now, will hold aspirin for now per advanced endoscopy team\n for now\n - will continue antibiotics for now per-procedurally, and discuss with\n team for duration. Likely 24-48h and trend WBC since this has been\n managed interventionally. Cipro 400mg IV q12h and metronidazole 500mg\n IV q8h.\n - trend tbili, lfts\n # Respiratory Failure/COPD\n - Patient underwent procedure under anesthesia and was intubated for\n this procedure.\n - on AC for now, will change to CPAP/PS and aim for extubation tomorrow\n after SBT\n # Diabetes\n - Noted to be type one, had\n dose glargine last night, and received\n glucagon during ERCP which could elevate BS. For now will continue the\n glargine 13 units sc at bedtime, and cover with humalog sliding scale.\n If difficult to control sugars, we can change over to nph and humalog\n coverage to allow for tighter titration.\n # Chronic Diastolic CHF\n - compensated and stable at this time. Will hold dose of lisinopril\n overnight given her lower bps requiring fluid boluses of 1 liter total,\n and restart tomorrow.\n # h/o possible but not confirmed c. diff, not recently on treatment.\n Will send c.diff if suspicion is raised by diarrhea.\n # Asthma: can try MDI if necessary\n # h/o HTN: hold HCTZ/lisinopril overnight.\n FEN: PEG,\n ICU Care\n Nutrition:\n Glycemic Control: Glargine\n Lines:\n 20 Gauge - 07:13 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n 76 yr old woman here from ERCP for prolonged MV following removal of\n CBD stones.\n Pt has complicated MH with diastolic CHF, HBP, DM, COPD\n -\n hospit with PNA\n intubated with trach and prolonged\n wean. Decannulated since discharge inb Rehab/ Rehab.\n N,V, Abd pain on . Abdom US neg but abdom CT showed CBD stones and\n she was transferred for ERCP with general anaesthesia with elective\n intubation.\n ERCP uncomplicated and she was transferred to the MICU intubated for\n close monitoring and planned extubation in AM.\n PMH, Social, ROS, Meds are documented above in Dr \ns note.\n On Exam\n NAD/Intubated\n VS 90/50\ns BP which responded to fluids.\n Coarse BS\n Distant HS\n Abdomen soft, decr BS\n Trace edema\n Labs reviewed above.\n Impression:\n Elective intubation because of recent history of trach with difficult\n wean\nshould be extubatable in AM when off sedation. Keep on CMV\n overnight . Would check CXR before extubation to make certain LLL\n infiltrate not evolving into pneumonia. If okay, Would check SBT\n prior to extubation\n ABG: 7.47/42/91 on fio2 40%, 550/14\n CBD Stones\n no clear evidence of purulent cholangitisd\n LFT\n decreasing\n Other problems not acute.\n ------ Protected Section Addendum Entered By: , MD\n on: 22:12 ------\n" }, { "category": "Physician ", "chartdate": "2104-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573247, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:50 PM\n Continued Ventilation, small fluid requirements to maintain blood\n pressure\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 09:00 PM\n Metronidazole - 06:02 AM\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 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: 36.7\nC (98\n HR: 75 (60 - 92) bpm\n BP: 132/60(77) {95/56(67) - 132/69(83)} mmHg\n RR: 14 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,570 mL\n 442 mL\n PO:\n TF:\n IVF:\n 1,570 mL\n 442 mL\n Blood products:\n Total out:\n 582 mL\n 800 mL\n Urine:\n 282 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 988 mL\n -358 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 85\n PIP: 32 cmH2O\n Plateau: 24 cmH2O\n Compliance: 28.9 cmH2O/mL\n SpO2: 100%\n ABG: 7.47/42/91/29/6\n Ve: 5.1 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\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: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, No(t) Tender: , Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 397 K/uL\n 9.2 g/dL\n 195 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 5.0 mEq/L\n 22 mg/dL\n 101 mEq/L\n 138 mEq/L\n 28.3 %\n 12.5 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n WBC\n 12.5\n Hct\n 29\n 28.3\n Plt\n 397\n Cr\n 0.9\n TCO2\n 31\n Glucose\n 173\n 195\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:32/26, Alk Phos / T\n Bili:234/0.6, Albumin:3.2 g/dL, Ca++:9.6 mg/dL, Mg++:1.7 mg/dL, PO4:4.2\n mg/dL\n Imaging: CXR 9:00pm: Slight improvement in LLL consolidation. ET\n Tube ~ 2cm from carina\n Microbiology: MRSA Screen P\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach s/p ERCP with removal of CBD stones\n and sphincterotomy. She remains afebrile and stable overnight.\n # Respiratory Failure/COPD/Asthma: The patient has done well on A/C\n overnight and tolerated a Pressure support trial. She has a history\n difficult airway and currently has no cuff leak and copious secretion\n production. Concern for laryngeal edema versus pulmonary process as\n barriers to extubation. Recent gas demonstrates likely overventilation\n of a COPD patient.\n - Hydrocort 50mg TID x1 day, reassess cuff leak tomorrow for extubation\n with anesthesia present\n - Change to Pressure Support to allow for patient controlled\n ventillation, PCO2 will likely drift to 50-60 to normalize her pH.\n - Obtain OSH records re recent PNA to help interpret CXR and current\n findings, as well as recent micro and abx\n - Nebs PRN\n - Repeat CXR\n - Sputum cultures\n - Defer Bronch today\n # CBD Stones\n - s/p ERCP now, will hold aspirin for now per advanced endoscopy team\n for now\n - will continue antibiotics for now peri-procedurally, and discuss with\n team for duration. Likely 24-48h and trend WBC since this has been\n managed interventionally. Cipro 400mg IV q12h and metronidazole 500mg\n IV q8h.\n - trend tbili, lfts\n # Diabetes: Noted to be Type 1. Continue Home Lantus 28 units SC QHS\n and sliding scale given short steroid pulse.\n # Chronic Diastolic CHF: Holding lisinopril now, will readdress given\n blood pressure throughout the day.\n # h/o HTN: hold HCTZ/lisinopril overnight.\n ICU Care\n Nutrition: NPO with IVF PRN\n Glycemic Control: Regular insulin sliding scale, Home Lantus dose\n Lines:\n 20 Gauge - 09:07 PM\n PICC to be placed\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n ICU consent pending arrival of family today\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2104-05-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573604, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 04:15 PM\n - First repeat Hct 25, second hct 27.0\n - Blood repeated lipemic, added on Triglycerides\n - Likely extubate in AM with anesthesia present\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:07 PM\n Ciprofloxacin - 09:33 PM\n Metronidazole - 04:53 AM\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 04:53 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 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: 36.3\nC (97.3\n HR: 69 (56 - 81) bpm\n BP: 98/41(55) {93/38(53) - 130/73(84)} mmHg\n RR: 20 (12 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 2,821 mL\n 486 mL\n PO:\n TF:\n IVF:\n 2,547 mL\n 461 mL\n Blood products:\n 274 mL\n Total out:\n 2,405 mL\n 1,110 mL\n Urine:\n 2,405 mL\n 1,110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 416 mL\n -624 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 322 (322 - 522) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 92\n PIP: 10 cmH2O\n SpO2: 99%\n ABG: 7.39/54/92./29/5\n Ve: 6.4 L/min\n PaO2 / FiO2: 232\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: S1 & S2 regular without murmur\n Peripheral Vascular: 1+ Distal pulses bilaterally\n Respiratory / Chest: Symmetric chest expansion, anterior exam clear\n Abdominal: Soft, nontender, obese, PEG in place.\n Extremities: Trace bilateral edema\n Skin: Not assessed\n Neurologic: Intubated & sedated, pupils reactive, reacts to voice\n Labs / Radiology\n 336 K/uL\n 8.4 g/dL\n 105 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.1 mEq/L\n 10 mg/dL\n 112 mEq/L\n 149 mEq/L\n 25.1 %\n 9.0 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n 08:27 PM\n 11:15 PM\n 04:18 AM\n 01:59 PM\n 09:53 PM\n 10:19 PM\n 04:40 AM\n WBC\n 12.5\n 9.4\n 9.0\n Hct\n 29\n 28.3\n 23.4\n 27.5\n 25.0\n 27.0\n 25.1\n Plt\n 397\n 341\n 336\n Cr\n 0.9\n 0.7\n 0.6\n TCO2\n 31\n 28\n 34\n Glucose\n 173\n 195\n 190\n 105\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:18/13, Alk Phos / T\n Bili:156/0.4, Albumin:3.2 g/dL, LDH:182 IU/L, Ca++:8.1 mg/dL, Mg++:1.5\n mg/dL, PO4:3.2 mg/dL\n Microbiology: MRSA Screen +\n Staph Aureus in Sputum\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach s/p ERCP with removal of CBD stones\n and sphincterotomy.\n # Respiratory Failure/COPD/Asthma: The patient remains intubated after\n ERCP. She continues to have a cuff leak post glucocorticoids, but her\n current respiratory status during a spontaneous breathing trial\n suggests that she will not be an easy intubation. We will rest her on\n A/C overnight and attempt extubation in the AM. Of note, her sputum is\n positive for Staph Aureus. - Extubation tomorrow AM\n - Vancomycin 1g Q12 with trough after dose #3 pending speciation of her\n sputum flora\n - Resume TF for now, NPO for extubation tomorrow\n - Lasix 20mg IV x1\n # Blood volume instability: The patient continues with a stable\n hematocrit and no bleeding source.\n - Hematocrits \n - Active T&S\n - Guaiac stools\n - monitor lines for bleeding\n # CBD Stones: S/P ERCP day 2, will continue antibiotics and continue\n PEG tube feeds once she is extubated\n - Appreciated ERCP recs\n # Diabetes: Type 1. Continue Home Lantus at 26 units SC QHS and\n sliding scale given short steroid pulse.\n # Chronic Diastolic CHF: Holding lisinopril now, will readdress given\n blood pressure throughout the day.\n # h/o HTN: hold HCTZ/lisinopril overnight.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:07 PM\n PICC Line - 06:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments: Phone call with\n Granddaughter \n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2104-05-02 00:00:00.000", "description": "Physician Resident/attending Progress Note - MICU", "row_id": 573606, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 04:15 PM\n - First repeat Hct 25, second hct 27.0\n - Blood repeated lipemic, added on Triglycerides\n - Likely extubate in AM with anesthesia present\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:07 PM\n Ciprofloxacin - 09:33 PM\n Metronidazole - 04:53 AM\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 04:53 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 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: 36.3\nC (97.3\n HR: 69 (56 - 81) bpm\n BP: 98/41(55) {93/38(53) - 130/73(84)} mmHg\n RR: 20 (12 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 2,821 mL\n 486 mL\n PO:\n TF:\n IVF:\n 2,547 mL\n 461 mL\n Blood products:\n 274 mL\n Total out:\n 2,405 mL\n 1,110 mL\n Urine:\n 2,405 mL\n 1,110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 416 mL\n -624 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 322 (322 - 522) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 92\n PIP: 10 cmH2O\n SpO2: 99%\n ABG: 7.39/54/92./29/5\n Ve: 6.4 L/min\n PaO2 / FiO2: 232\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: S1 & S2 regular without murmur\n Peripheral Vascular: 1+ Distal pulses bilaterally\n Respiratory / Chest: Symmetric chest expansion, anterior exam clear\n Abdominal: Soft, nontender, obese, PEG in place.\n Extremities: Trace bilateral edema\n Skin: Not assessed\n Neurologic: Intubated & sedated, pupils reactive, reacts to voice\n Labs / Radiology\n 336 K/uL\n 8.4 g/dL\n 105 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.1 mEq/L\n 10 mg/dL\n 112 mEq/L\n 149 mEq/L\n 25.1 %\n 9.0 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n 08:27 PM\n 11:15 PM\n 04:18 AM\n 01:59 PM\n 09:53 PM\n 10:19 PM\n 04:40 AM\n WBC\n 12.5\n 9.4\n 9.0\n Hct\n 29\n 28.3\n 23.4\n 27.5\n 25.0\n 27.0\n 25.1\n Plt\n 397\n 341\n 336\n Cr\n 0.9\n 0.7\n 0.6\n TCO2\n 31\n 28\n 34\n Glucose\n 173\n 195\n 190\n 105\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:18/13, Alk Phos / T\n Bili:156/0.4, Albumin:3.2 g/dL, LDH:182 IU/L, Ca++:8.1 mg/dL, Mg++:1.5\n mg/dL, PO4:3.2 mg/dL\n Microbiology: MRSA Screen +\n Staph Aureus in Sputum\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach s/p ERCP with removal of CBD stones\n and sphincterotomy.\n # Respiratory Failure/COPD/Asthma: The patient remains intubated after\n ERCP. She continues to have a cuff leak post glucocorticoids, but her\n current respiratory status during a spontaneous breathing trial\n suggests that she will not be an easy intubation. We will rest her on\n A/C overnight and attempt extubation in the AM. Of note, her sputum is\n positive for Staph Aureus. - Extubation tomorrow AM\n - Vancomycin 1g Q12 with trough after dose #3 pending speciation of her\n sputum flora\n - Resume TF for now, NPO for extubation tomorrow\n - Lasix 20mg IV x1\n # Blood volume instability: The patient continues with a stable\n hematocrit and no bleeding source.\n - Hematocrits \n - Active T&S\n - Guaiac stools\n - monitor lines for bleeding\n # CBD Stones: S/P ERCP day 2, will continue antibiotics and continue\n PEG tube feeds once she is extubated\n - Appreciated ERCP recs\n # Diabetes: Type 1. Continue Home Lantus at 26 units SC QHS and\n sliding scale given short steroid pulse.\n # Chronic Diastolic CHF: Holding lisinopril now, will readdress given\n blood pressure throughout the day.\n # h/o HTN: hold HCTZ/lisinopril overnight.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:07 PM\n PICC Line - 06:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments: Phone call with\n Granddaughter \n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n MICU ATTENDING PROGRESS NOTE\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. 76 yo obese F with DM,\n HTN, CAD, and recent hospitalization with pna/FTW s/p trach/peg (now\n decannulated) , on supp O2 at baseline who developed\n cholangitis s/p ercp with removal of stones. Intubated for\n procedure--difficult airway. Extubation initially limited by\n secretions/frequent suctioning (gpc in sputum) and no cuff leak. Now\n remains sedated, with continued secretions and rapid shallow breathing\n on SBT.\n PE: AF 55-80 93-130/38-73 PS5/5 40% sats 98% rsbi 92\n sedated intubated\n coarse BS\n rr distant\n +BS soft\n warm, w/o edema\n LABS notable for wbc 9, hct 25, cr 0.6 na 149 (132)\n CXR: rotated, b/basilar atelectasis --some improvement at left base, R\n atelectasis/effusions\n Micro\nsputum cx--staph pending\n I/P: Does not appear optimized for extubation. Barriers to extubation\n include sedation/ms/secretions. Agree with plan to continue vanco for\n GPC PNA pending cx sensitivities. S/p steroids--and now with cuff\n leak. Continue aggressive sx/pulm toilet/mdis. Will need lightened\n sedation for wean attempts. Would rest on vent and reassess for\n extubation with sbt in am. Airway issues now clarified by anesthesia\n (difficulty with airway appears related to old trach). Hct has\n stabilized, keep t and c, and follow. Recheck na\nas bumped from\n 133-149-- if not spurious lab, initiate free water.\n In terms of cholangitis\nis doing well. LFTs decreasing. Continue\n current antibx.\n Wound care for decubs.\n Remainder as per housestaff note.\n Critcally ill/ICU\n Time spent: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 16:23 ------\n" }, { "category": "Physician ", "chartdate": "2104-04-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 573234, "text": "Chief Complaint: post ercp, 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: 76 yr old woman here from ERCP for prolonged MV following removal\n of CBD stones.\n Pt has complicated MH with diastolic CHF, HBP, DM, COPD\n -\n hospit with PNA\n intubated with trach and prolonged\n wean. Decannulated since discharge inb Rehab/ Rehab.\n N,V, Abd pain on . Abdom US neg but abdom CT showed CBD stones and\n she was transferred for ERCP with general anaesthesia with elective\n intubation.\n ERCP uncomplicated and she was transferred to the MICU intubated for\n close monitoring and planned extubation in AM.\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:50 PM\n EKG - At 11:00 PM\n remains intubated overnight\n rsbi in am 85\n with freq sx needs Q 1 hr--thick and white\n History obtained from ho\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:02 AM\n Ciprofloxacin - 08:58 AM\n Infusions:\n Other ICU medications:\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:53 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: 36.8\nC (98.3\n HR: 82 (60 - 100) bpm\n BP: 131/78(91) {95/56(67) - 156/78(91)} mmHg\n RR: 24 (14 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,570 mL\n 749 mL\n PO:\n TF:\n IVF:\n 1,570 mL\n 749 mL\n Blood products:\n Total out:\n 582 mL\n 1,020 mL\n Urine:\n 282 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n 988 mL\n -271 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 85\n PIP: 27 cmH2O\n Plateau: 14 cmH2O\n Compliance: 61.1 cmH2O/mL\n SpO2: 99%\n ABG: 7.47/42/91/29/6\n Ve: 11.4 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal 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: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 9.2 g/dL\n 397 K/uL\n 195 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 5.0 mEq/L\n 22 mg/dL\n 101 mEq/L\n 138 mEq/L\n 28.3 %\n 12.5 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n WBC\n 12.5\n Hct\n 29\n 28.3\n Plt\n 397\n Cr\n 0.9\n TCO2\n 31\n Glucose\n 173\n 195\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:32/26, Alk Phos / T\n Bili:234/0.6, Albumin:3.2 g/dL, Ca++:9.6 mg/dL, Mg++:1.7 mg/dL, PO4:4.2\n mg/dL\n Imaging: cxr--et ok, b/l haziness--prob edema with loss of r and l\n hemidiaph\n Microbiology: no data (need 0Sh records)\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n 76 yo obese F with DM, HTN, CAD, and recent hospitalization with\n pna/FTW s/p trach (now decannulated) and peg, on supp O2 at baseline\n who developed cholangitis and was transferred from OSH for ercp with\n removal of CBD stones which required general anesthsia and intubation.\n Pt was a difficult intubation and now has no cuff leak and sig thick\n secretions requiring Q 1 hr sx requirements.\n Agree with plan to hold on extubation. Will send sputum cx\ns. Will\n perform chest pt and sx to clear to obtimize for extubation. Has # 7\n ET so may not have cuff leak but given reportedly difficult intubation\n and recent resp hx will give 24 hrs of steroids and reassess for cuff\n leak tomorrow. Will trial on PSV or asdjust MV to obtimize abg. \n need to extubate with anesthesia present or over cook cath. Obtain\n osh records and clarify sputum/resp process as was on levoflox for resp\n infeciton.\n In terms of cholangitis\ncbd stones now removed. HD stable. LFTs\n decreasing.\n Wounds care for decubs.\n Remainder as per housestaff note.\n ICU Care\n Nutrition: restart TFs\n Glycemic Control: SSI\n Lines:\n 20 Gauge - 09:07 PM\noicc consult\n Prophylaxis:\n DVT: boots\n Stress ulcer: TFs\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : critically ill/remains in icu\n Total time spent: 40\n" }, { "category": "Physician ", "chartdate": "2104-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573240, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:50 PM\n Continued Ventilation, small fluid requirements to maintain blood\n pressure\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 09:00 PM\n Metronidazole - 06:02 AM\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 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: 36.7\nC (98\n HR: 75 (60 - 92) bpm\n BP: 132/60(77) {95/56(67) - 132/69(83)} mmHg\n RR: 14 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,570 mL\n 442 mL\n PO:\n TF:\n IVF:\n 1,570 mL\n 442 mL\n Blood products:\n Total out:\n 582 mL\n 800 mL\n Urine:\n 282 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 988 mL\n -358 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 85\n PIP: 32 cmH2O\n Plateau: 24 cmH2O\n Compliance: 28.9 cmH2O/mL\n SpO2: 100%\n ABG: 7.47/42/91/29/6\n Ve: 5.1 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\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: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, No(t) Tender: , Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 397 K/uL\n 9.2 g/dL\n 195 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 5.0 mEq/L\n 22 mg/dL\n 101 mEq/L\n 138 mEq/L\n 28.3 %\n 12.5 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n WBC\n 12.5\n Hct\n 29\n 28.3\n Plt\n 397\n Cr\n 0.9\n TCO2\n 31\n Glucose\n 173\n 195\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:32/26, Alk Phos / T\n Bili:234/0.6, Albumin:3.2 g/dL, Ca++:9.6 mg/dL, Mg++:1.7 mg/dL, PO4:4.2\n mg/dL\n Imaging: CXR 9:00pm: Slight improvement in LLL consolidation. ET\n Tube ~ 2cm from carina\n Microbiology: MRSA Screen P\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach s/p ERCP with removal of CBD stones\n and sphincterotomy. She remains afebrile and stable overnight.\n # Respiratory Failure/COPD/Asthma: The patient has done well on A/C\n overnight and tolerated a Pressure support trial. She has a history\n difficult airway and currently has no cuff leak and copious secretion\n production. Concern for laryngeal edema versus pulmonary process as\n barriers to extubation. Recent gas demonstrates likely overventilation\n of a COPD patient.\n - Hydrocort 50mg TID x1 day, reassess cuff leak tomorrow for extubation\n with anesthesia present\n - Change to Pressure Support to allow for patient controlled\n ventillation, PCO2 will likely drift to 50-60 to normalize her pH.\n - Obtain OSH records re recent PNA to help interpret CXR and current\n findings, as well as recent micro and abx\n - Nebs PRN\n - Repeat CXR\n - Sputum cultures\n - Defer Bronch today\n # CBD Stones\n - s/p ERCP now, will hold aspirin for now per advanced endoscopy team\n for now\n - will continue antibiotics for now peri-procedurally, and discuss with\n team for duration. Likely 24-48h and trend WBC since this has been\n managed interventionally. Cipro 400mg IV q12h and metronidazole 500mg\n IV q8h.\n - trend tbili, lfts\n # Diabetes: Noted to be Type 1. Continue Home Lantus 28 units SC QHS\n and sliding scale given short steroid pulse.\n # Chronic Diastolic CHF: Holding lisinopril now, will readdress given\n blood pressure throughout the day.\n # h/o HTN: hold HCTZ/lisinopril overnight.\n ICU Care\n Nutrition: NPO with IVF PRN\n Glycemic Control: Regular insulin sliding scale, Home Lantus dose\n Lines:\n 20 Gauge - 09:07 PM\n PICC to be placed\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n ICU consent pending arrival of family today\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2104-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573507, "text": " Problem - Description In Comments\n Assessment:\n Pt. remains intubated. Hemodymically stable.\n Action:\n Pt. cont. on propofol. No change. Fent. d/c\ned. pt. more awake at\n times. Opens eyes.\n Suctioned for thick yellow secretions. Bs\ns clear.\n On ps of since this afternoon and doing well.\n Repeat hct 25. no source of bleeding noted.\n u/o\ns good.\n Pt. turned frequently for skin issues.\n Blood cx\ns done x2.\n Pt. has double picc line.\n Bs\ns tx\ned with ssi.\n Mg+ repleted this am.\n Response:\n Stable.\n Plan:\n Keep on ps of throughout the night. With possible extubation in am.\n Buttuck drsgs at 20pm.\n Suction prn.\n" }, { "category": "Respiratory ", "chartdate": "2104-05-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 573673, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\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:\n Tube Type\n ETT:\n Position: 24cm at teeth\n Route:\n Type: Standard\n Size: 7mm\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: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments/Plan\n Pt remains intubated, fully vent supported. No changes made overnight.\n Administering MDI\ns as ordered. No spont RR this am for , \n attempt later this am again. See flowsheet for further pt data. Will\n follow.\n 06:08\n" }, { "category": "Physician ", "chartdate": "2104-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573219, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:50 PM\n Continued Ventilation, small fluid requirements to maintain blood\n pressure\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 09:00 PM\n Metronidazole - 06:02 AM\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 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: 36.7\nC (98\n HR: 75 (60 - 92) bpm\n BP: 132/60(77) {95/56(67) - 132/69(83)} mmHg\n RR: 14 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,570 mL\n 442 mL\n PO:\n TF:\n IVF:\n 1,570 mL\n 442 mL\n Blood products:\n Total out:\n 582 mL\n 800 mL\n Urine:\n 282 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 988 mL\n -358 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 85\n PIP: 32 cmH2O\n Plateau: 24 cmH2O\n Compliance: 28.9 cmH2O/mL\n SpO2: 100%\n ABG: 7.47/42/91/29/6\n Ve: 5.1 L/min\n PaO2 / FiO2: 228\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 397 K/uL\n 9.2 g/dL\n 195 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 5.0 mEq/L\n 22 mg/dL\n 101 mEq/L\n 138 mEq/L\n 28.3 %\n 12.5 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n WBC\n 12.5\n Hct\n 29\n 28.3\n Plt\n 397\n Cr\n 0.9\n TCO2\n 31\n Glucose\n 173\n 195\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:32/26, Alk Phos / T\n Bili:234/0.6, Albumin:3.2 g/dL, Ca++:9.6 mg/dL, Mg++:1.7 mg/dL, PO4:4.2\n mg/dL\n Imaging: CXR 9:00pm: Slight improvement in LLL consolidation. ET\n Tube ~ 2cm from carina\n Microbiology: MRSA Screen P\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:07 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2104-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573222, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:50 PM\n Continued Ventilation, small fluid requirements to maintain blood\n pressure\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 09:00 PM\n Metronidazole - 06:02 AM\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 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: 36.7\nC (98\n HR: 75 (60 - 92) bpm\n BP: 132/60(77) {95/56(67) - 132/69(83)} mmHg\n RR: 14 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,570 mL\n 442 mL\n PO:\n TF:\n IVF:\n 1,570 mL\n 442 mL\n Blood products:\n Total out:\n 582 mL\n 800 mL\n Urine:\n 282 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 988 mL\n -358 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 85\n PIP: 32 cmH2O\n Plateau: 24 cmH2O\n Compliance: 28.9 cmH2O/mL\n SpO2: 100%\n ABG: 7.47/42/91/29/6\n Ve: 5.1 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\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: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, No(t) Tender: , Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 397 K/uL\n 9.2 g/dL\n 195 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 5.0 mEq/L\n 22 mg/dL\n 101 mEq/L\n 138 mEq/L\n 28.3 %\n 12.5 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n WBC\n 12.5\n Hct\n 29\n 28.3\n Plt\n 397\n Cr\n 0.9\n TCO2\n 31\n Glucose\n 173\n 195\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:32/26, Alk Phos / T\n Bili:234/0.6, Albumin:3.2 g/dL, Ca++:9.6 mg/dL, Mg++:1.7 mg/dL, PO4:4.2\n mg/dL\n Imaging: CXR 9:00pm: Slight improvement in LLL consolidation. ET\n Tube ~ 2cm from carina\n Microbiology: MRSA Screen P\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach found to have CBD stones base on CT\n from now undergoing ERCP with removal of stones and\n sphincterotomy. There is no record of fever in the accompanying notes,\n and the white count in the OSH records seems to be mildly elevated but\n stable. She does not clinically meet the criteria for cholangitis at\n this time.\n # CBD Stones\n - s/p ERCP now, will hold aspirin for now per advanced endoscopy team\n for now\n - will continue antibiotics for now per-procedurally, and discuss with\n team for duration. Likely 24-48h and trend WBC since this has been\n managed interventionally. Cipro 400mg IV q12h and metronidazole 500mg\n IV q8h.\n - trend tbili, lfts\n # Respiratory Failure/COPD\n - Patient underwent procedure under anesthesia and was intubated for\n this procedure.\n - on AC for now, will change to CPAP/PS and aim for extubation tomorrow\n after SBT\n # Diabetes\n - Noted to be type one, had\n dose glargine last night, and received\n glucagon during ERCP which could elevate BS. For now will continue the\n glargine 13 units sc at bedtime, and cover with humalog sliding scale.\n If difficult to control sugars, we can change over to nph and humalog\n coverage to allow for tighter titration.\n # Chronic Diastolic CHF\n - compensated and stable at this time. Will hold dose of lisinopril\n overnight given her lower bps requiring fluid boluses of 1 liter total,\n and restart tomorrow.\n # h/o possible but not confirmed c. diff, not recently on treatment.\n Will send c.diff if suspicion is raised by diarrhea.\n # Asthma: can try MDI if necessary\n # h/o HTN: hold HCTZ/lisinopril overnight.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:07 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2104-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573236, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:50 PM\n Continued Ventilation, small fluid requirements to maintain blood\n pressure\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 09:00 PM\n Metronidazole - 06:02 AM\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 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: 36.7\nC (98\n HR: 75 (60 - 92) bpm\n BP: 132/60(77) {95/56(67) - 132/69(83)} mmHg\n RR: 14 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,570 mL\n 442 mL\n PO:\n TF:\n IVF:\n 1,570 mL\n 442 mL\n Blood products:\n Total out:\n 582 mL\n 800 mL\n Urine:\n 282 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 988 mL\n -358 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 85\n PIP: 32 cmH2O\n Plateau: 24 cmH2O\n Compliance: 28.9 cmH2O/mL\n SpO2: 100%\n ABG: 7.47/42/91/29/6\n Ve: 5.1 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\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: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, No(t) Tender: , Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 397 K/uL\n 9.2 g/dL\n 195 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 5.0 mEq/L\n 22 mg/dL\n 101 mEq/L\n 138 mEq/L\n 28.3 %\n 12.5 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n WBC\n 12.5\n Hct\n 29\n 28.3\n Plt\n 397\n Cr\n 0.9\n TCO2\n 31\n Glucose\n 173\n 195\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:32/26, Alk Phos / T\n Bili:234/0.6, Albumin:3.2 g/dL, Ca++:9.6 mg/dL, Mg++:1.7 mg/dL, PO4:4.2\n mg/dL\n Imaging: CXR 9:00pm: Slight improvement in LLL consolidation. ET\n Tube ~ 2cm from carina\n Microbiology: MRSA Screen P\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach found to have CBD stones base on CT\n from now undergoing ERCP with removal of stones and\n sphincterotomy. There is no record of fever in the accompanying notes,\n and the white count in the OSH records seems to be mildly elevated but\n stable. She does not clinically meet the criteria for cholangitis at\n this time.\n # CBD Stones\n - s/p ERCP now, will hold aspirin for now per advanced endoscopy team\n for now\n - will continue antibiotics for now per-procedurally, and discuss with\n team for duration. Likely 24-48h and trend WBC since this has been\n managed interventionally. Cipro 400mg IV q12h and metronidazole 500mg\n IV q8h.\n - trend tbili, lfts\n # Respiratory Failure/COPD\n - Patient underwent procedure under anesthesia and was intubated for\n this procedure.\n - on AC for now, will change to CPAP/PS and aim for extubation tomorrow\n after SBT\n # Diabetes\n - Noted to be type one, had\n dose glargine last night, and received\n glucagon during ERCP which could elevate BS. For now will continue the\n glargine 13 units sc at bedtime, and cover with humalog sliding scale.\n If difficult to control sugars, we can change over to nph and humalog\n coverage to allow for tighter titration.\n # Chronic Diastolic CHF\n - compensated and stable at this time. Will hold dose of lisinopril\n overnight given her lower bps requiring fluid boluses of 1 liter total,\n and restart tomorrow.\n # h/o possible but not confirmed c. diff, not recently on treatment.\n Will send c.diff if suspicion is raised by diarrhea.\n # Asthma: can try MDI if necessary\n # h/o HTN: hold HCTZ/lisinopril overnight.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:07 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Respiratory ", "chartdate": "2104-04-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 573333, "text": "Demographics\n Day of mechanical ventilation: 2\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Blood Tinged / 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: Attempted to placed pt on PSV settings today; became\n tachycardic with decreased desaturations.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2104-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573387, "text": "Diabetes Mellitus (DM), Type I\n Assessment:\n FBS at 2200 = 199\n Action:\n Treated with lantus 26 units and humalog regular 2 units sc\n Response:\n Blood sugar in better control\n Plan:\n Continue to monitor blood sugar q 6 hrs and cover with sliding scale\n restlessness\n Assessment:\n Pt medicated on propofol at 60 mcg/kg/min and fentanyl 25 mcg /hr\n Pt denies pain\n Pt restless and attempting to pull out ETT\n Pt attempting to mouth words, but not understandable, and becoming\n agitated\n Action:\n Propofol increased to 75 mcg/kg/min\n Response:\n Pt wakes at times, but comfortably sedated, and no longer restless\n Plan:\n Wean propofol in the am to be ready for ventilator weaning and\n extubation\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Bp dropped to 80\ns systolic, HO notified\n u/o dropped to 25-30 cc/hr\n LOS fluid balance is -250 cc\n Action:\n NS bolus 500 cc over 1 hour\n Response:\n Bp returned to 110/50\n Plan:\n Monitor bp q 30 mins. Monitor u/o q 1 hr.\n ------ Protected Section ------\n Hct 23 down from 28. Blood consent not obtained from pt as she is on a\n propofol and fentanyl drip. HO unable to obtain telephone report from\n relative. transfused with 1 unit packed cells. Post transfusion hct\n pending.\n ------ Protected Section Addendum Entered By: , RN\n on: 05:53 ------\n" }, { "category": "Respiratory ", "chartdate": "2104-05-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 573390, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Tan / 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 Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Comments: Pt. remains intubated overnoc on A/C. ABG acceptable. RSBI 46\n this am, audible cuff leak this am. Wean as tolerated.\n" }, { "category": "Respiratory ", "chartdate": "2104-04-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 573210, "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:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Airway problems: leak with cuff down\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: Blood Tinged / Frothy\n Sputum source/amount: Suctioned / Moderate\n Comments/Plan\n Pt remains orally intubated, fully vent supported. Sxing copious\n secretions all shift. Periods of dysynchrony noted. RSBI=85. Starting\n MDI\ns for increasing audible wheezing. ABG\ns stable. No cuff leak\n noted w/ ETT cuff down earlier in shift. As pt was an extremely\n difficult intubation, hoping to extubate later this am, with back up\n staff available. See flowsheet for further pt data. Will follow.\n 06:48\n" }, { "category": "Physician ", "chartdate": "2104-04-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 573229, "text": "Chief Complaint: post ercp, 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 24 Hour Events:\n INVASIVE VENTILATION - START 05:50 PM\n EKG - At 11:00 PM\n remains intubated overnight\n rsbi in am 85\n with freq sx needs Q 1 hr--thick and white\n History obtained from ho\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:02 AM\n Ciprofloxacin - 08:58 AM\n Infusions:\n Other ICU medications:\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:53 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: 36.8\nC (98.3\n HR: 82 (60 - 100) bpm\n BP: 131/78(91) {95/56(67) - 156/78(91)} mmHg\n RR: 24 (14 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,570 mL\n 749 mL\n PO:\n TF:\n IVF:\n 1,570 mL\n 749 mL\n Blood products:\n Total out:\n 582 mL\n 1,020 mL\n Urine:\n 282 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n 988 mL\n -271 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 85\n PIP: 27 cmH2O\n Plateau: 14 cmH2O\n Compliance: 61.1 cmH2O/mL\n SpO2: 99%\n ABG: 7.47/42/91/29/6\n Ve: 11.4 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal 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: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 9.2 g/dL\n 397 K/uL\n 195 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 5.0 mEq/L\n 22 mg/dL\n 101 mEq/L\n 138 mEq/L\n 28.3 %\n 12.5 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n WBC\n 12.5\n Hct\n 29\n 28.3\n Plt\n 397\n Cr\n 0.9\n TCO2\n 31\n Glucose\n 173\n 195\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:32/26, Alk Phos / T\n Bili:234/0.6, Albumin:3.2 g/dL, Ca++:9.6 mg/dL, Mg++:1.7 mg/dL, PO4:4.2\n mg/dL\n Imaging: cxr--et ok, b/l haziness--prob edema with loss of r and l\n hemidiaph\n Microbiology: no data (need 0Sh records)\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n 76 yo obese F with DM, HTN, CAD, and recent hospitalization with\n pna/FTW s/p trach (now decannulated) and peg, on supp O2 at baseline\n who developed cholangitis and was transferred from OSH for ercp which\n required general anesthsia and intubation.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2104-05-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573554, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 04:15 PM\n - First repeat Hct 25, second hct 27.0\n - Blood repeated lipemic, added on Triglycerides\n - Likely extubate in AM with anesthesia present\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:07 PM\n Ciprofloxacin - 09:33 PM\n Metronidazole - 04:53 AM\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 04:53 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 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: 36.3\nC (97.3\n HR: 69 (56 - 81) bpm\n BP: 98/41(55) {93/38(53) - 130/73(84)} mmHg\n RR: 20 (12 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 2,821 mL\n 486 mL\n PO:\n TF:\n IVF:\n 2,547 mL\n 461 mL\n Blood products:\n 274 mL\n Total out:\n 2,405 mL\n 1,110 mL\n Urine:\n 2,405 mL\n 1,110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 416 mL\n -624 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 322 (322 - 522) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 92\n PIP: 10 cmH2O\n SpO2: 99%\n ABG: 7.39/54/92./29/5\n Ve: 6.4 L/min\n PaO2 / FiO2: 232\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 336 K/uL\n 8.4 g/dL\n 105 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.1 mEq/L\n 10 mg/dL\n 112 mEq/L\n 149 mEq/L\n 25.1 %\n 9.0 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n 08:27 PM\n 11:15 PM\n 04:18 AM\n 01:59 PM\n 09:53 PM\n 10:19 PM\n 04:40 AM\n WBC\n 12.5\n 9.4\n 9.0\n Hct\n 29\n 28.3\n 23.4\n 27.5\n 25.0\n 27.0\n 25.1\n Plt\n 397\n 341\n 336\n Cr\n 0.9\n 0.7\n 0.6\n TCO2\n 31\n 28\n 34\n Glucose\n 173\n 195\n 190\n 105\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:18/13, Alk Phos / T\n Bili:156/0.4, Albumin:3.2 g/dL, LDH:182 IU/L, Ca++:8.1 mg/dL, Mg++:1.5\n mg/dL, PO4:3.2 mg/dL\n Microbiology: MRSA Screen +\n Staph Aureus in Sputum\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:07 PM\n PICC Line - 06:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments: Phone call with\n Granddaughter \n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2104-05-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 573555, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 04:15 PM\n - First repeat Hct 25, second hct 27.0\n - Blood repeated lipemic, added on Triglycerides\n - Likely extubate in AM with anesthesia present\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:07 PM\n Ciprofloxacin - 09:33 PM\n Metronidazole - 04:53 AM\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 04:53 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 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: 36.3\nC (97.3\n HR: 69 (56 - 81) bpm\n BP: 98/41(55) {93/38(53) - 130/73(84)} mmHg\n RR: 20 (12 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 2,821 mL\n 486 mL\n PO:\n TF:\n IVF:\n 2,547 mL\n 461 mL\n Blood products:\n 274 mL\n Total out:\n 2,405 mL\n 1,110 mL\n Urine:\n 2,405 mL\n 1,110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 416 mL\n -624 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 322 (322 - 522) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 92\n PIP: 10 cmH2O\n SpO2: 99%\n ABG: 7.39/54/92./29/5\n Ve: 6.4 L/min\n PaO2 / FiO2: 232\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: S1 & S2 regular without murmur\n Peripheral Vascular: 1+ Distal pulses bilaterally\n Respiratory / Chest: Symmetric chest expansion, anterior exam clear\n Abdominal: Soft, nontender, obese, PEG in place.\n Extremities: Trace bilateral edema\n Skin: Not assessed\n Neurologic: Intubated & sedated, pupils reactive\n Labs / Radiology\n 336 K/uL\n 8.4 g/dL\n 105 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.1 mEq/L\n 10 mg/dL\n 112 mEq/L\n 149 mEq/L\n 25.1 %\n 9.0 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n 08:27 PM\n 11:15 PM\n 04:18 AM\n 01:59 PM\n 09:53 PM\n 10:19 PM\n 04:40 AM\n WBC\n 12.5\n 9.4\n 9.0\n Hct\n 29\n 28.3\n 23.4\n 27.5\n 25.0\n 27.0\n 25.1\n Plt\n 397\n 341\n 336\n Cr\n 0.9\n 0.7\n 0.6\n TCO2\n 31\n 28\n 34\n Glucose\n 173\n 195\n 190\n 105\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:18/13, Alk Phos / T\n Bili:156/0.4, Albumin:3.2 g/dL, LDH:182 IU/L, Ca++:8.1 mg/dL, Mg++:1.5\n mg/dL, PO4:3.2 mg/dL\n Microbiology: MRSA Screen +\n Staph Aureus in Sputum\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach s/p ERCP with removal of CBD stones\n and sphincterotomy.\n # Respiratory Failure/COPD/Asthma: The patient remains intubated after\n ERCP. Given her lack of cuff leak yesterday, she was given a short\n course of glucocorticoids and today does have a cuff leak. Of note,\n her sputum is positive for GPCs in clusters and pairs. This could be\n HCAP, HAP or VAP or tracheobronchitis given her recent hospital courses\n and relatively short stay on a ventilator. She is tolerating PSV on\n well\n - Extubation today pending Hct stability (see below)\n - Vancomycin 1g Q12 with trough after dose three pending speciation of\n her sputum flora\n - NPO for extubation\n # Blood volume instability: The patient had physiology and laboratory\n studies consistent with blood loss yesterday night, but as of yet has\n not demonstrated a bleeding source. She was transfused 1 unit of blood\n and returned to within her pre-\nbleed\n hematocrit.\n - Hematocrit at 11am and 7pm (TID), transfusing as necessary\n - Active T&S\n - Guaiac stools\n - monitor lines for bleeding\n # CBD Stones: S/P ERCP day 2, will continue antibiotics and continue\n PEG tube feeds once she is extubated\n - Appreciated ERCP recs\n # Diabetes: Type 1. Continue Home Lantus 28 units SC QHS and sliding\n scale given short steroid pulse.\n # Chronic Diastolic CHF: Holding lisinopril now, will readdress given\n blood pressure throughout the day.\n # h/o HTN: hold HCTZ/lisinopril overnight.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:07 PM\n PICC Line - 06:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments: Phone call with\n Granddaughter \n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2104-05-01 00:00:00.000", "description": "Physician Resident/attending Progress Note - MICU", "row_id": 573484, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 10:30 AM\n PICC LINE - START 06:00 PM\n - started steroids as had no cuff leak and hx difficult extubation\n - increased lantus from 26 to 36 for high sugars\n - hct drop after hypotensive tachycardic episode, gave 1 Prbc, unable\n to get consent from family/hcp (no answer on phone). vitals resolved\n prior to unit\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Metronidazole - 05:38 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 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 07:36 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: 35.6\nC (96.1\n HR: 59 (55 - 118) bpm\n BP: 122/52(68) {83/36(49) - 137/105(110)} mmHg\n RR: 12 (12 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 101.3 kg (admission): 104.8 kg\n Total In:\n 2,382 mL\n 775 mL\n PO:\n TF:\n IVF:\n 2,382 mL\n 501 mL\n Blood products:\n 274 mL\n Total out:\n 2,060 mL\n 515 mL\n Urine:\n 2,060 mL\n 515 mL\n NG:\n Stool:\n Drains:\n Balance:\n 322 mL\n 260 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 550) mL\n Vt (Spontaneous): 488 (467 - 643) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 46\n PIP: 21 cmH2O\n Plateau: 16 cmH2O\n Compliance: 45.5 cmH2O/mL\n SpO2: 98%\n ABG: 7.40/44/103/26/1\n Ve: 6.1 L/min\n PaO2 / FiO2: 258\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: S1 & S2 regular without murmur\n Peripheral Vascular: 1+ Distal pulses bilaterally\n Respiratory / Chest: Symmetric chest expansion, anterior exam clear\n Abdominal: Soft, nontender, obese, PEG in place.\n Extremities: Trace bilateral edema\n Skin: Not assessed\n Neurologic: Intubated & sedated, pupils reactive\n Labs / Radiology\n 341 K/uL\n 8.1 g/dL\n 190 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 97 mEq/L\n 132 mEq/L\n 27.5 %\n 9.4 K/uL\n [image002.jpg]\n 08:45 PM\n 02:54 AM\n 08:27 PM\n 11:15 PM\n 04:18 AM\n WBC\n 12.5\n 9.4\n Hct\n 29\n 28.3\n 23.4\n 27.5\n Plt\n 397\n 341\n Cr\n 0.9\n 0.7\n TCO2\n 31\n 28\n Glucose\n 173\n 195\n 190\n Other labs: PT / PTT / INR:13.3/25.6/1.1, ALT / AST:18/16, Alk Phos / T\n Bili:169/0.7, Albumin:3.2 g/dL, LDH:182 IU/L, Ca++:8.2 mg/dL, Mg++:1.5\n mg/dL, PO4:5.0 mg/dL\n Imaging: CXR: ET tube ~ 3.3cm from carina. R PICC in place at SVC.\n Heavily rotated, continued haziness at R base\n Microbiology: Sputum Gram stain :\n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND\n CLUSTERS.\n Assessment and Plan\n 76 y/oF with multiple medical comorbidities and recent prolonged\n hospitalization for pneumonia/trach s/p ERCP with removal of CBD stones\n and sphincterotomy.\n # Respiratory Failure/COPD/Asthma: The patient remains intubated after\n ERCP. Given her lack of cuff leak yesterday, she was given a short\n course of glucocorticoids and today does have a cuff leak. Of note,\n her sputum is positive for GPCs in clusters and pairs. This could be\n HCAP, HAP or VAP or tracheobronchitis given her recent hospital courses\n and relatively short stay on a ventilator. She is tolerating PSV on\n well\n - Extubation today pending Hct stability (see below)\n - Vancomycin 1g Q12 with trough after dose three pending speciation of\n her sputum flora\n - NPO for extubation\n # Blood volume instability: The patient had physiology and laboratory\n studies consistent with blood loss yesterday night, but as of yet has\n not demonstrated a bleeding source. She was transfused 1 unit of blood\n and returned to within her pre-\nbleed\n hematocrit.\n - Hematocrit at 11am and 7pm (TID), transfusing as necessary\n - Active T&S\n - Guaiac stools\n - monitor lines for bleeding\n # CBD Stones: S/P ERCP day 2, will continue antibiotics and continue\n PEG tube feeds once she is extubated\n - Appreciated ERCP recs\n # Diabetes: Type 1. Continue Home Lantus 28 units SC QHS and sliding\n scale given short steroid pulse.\n # Chronic Diastolic CHF: Holding lisinopril now, will readdress given\n blood pressure throughout the day.\n # h/o HTN: hold HCTZ/lisinopril overnight.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:07 PM\n PICC Line - 06:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n MICU ATTENDING PROGRESS NOTE\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. 76 yo obese F with DM,\n HTN, CAD, and recent hospitalization with pna/FTW s/p trach/peg (now\n decannulated) , on supp O2 at baseline who developed\n cholangitis s/p ercp with removal of stones. Intubated for procedure.\n Remains intubated because of need for frequent suctioning and no cuff\n leak. Overnight transiently hypotensive and tachy with hct drop with\n appropriate response post 1 unit prbc. No obvious bleeding. Cuff leak\n on PSW. Decreased secretions.\n PE: 100.1 55-118 83-1-37/36-105 ACV 500/12/5/40% rsbi 46\n sedated intubated\n coarse BS\n rr distant\n +BS soft\n warm, w/o edema\n LABS reviewed, as above\n CXR: very rotated, b/basilar atelectasis\n Micro\nsputum cx gpc pairs and clusters\n I/P:\n Barriers to extubation now include sedation/ms. Now with cuff leak and\n decreased secretions. Agree with plan to cover with vanco for\n tracheobronchitis/pna given her recent fevers, secretions, and sputum\n cx findings. F/u cx data. Continue chest pt/sx. RSBI < 100 but still\n very sedated. Lighten sedation and reassess for extubation. Regarding\n Hct drop overnight there is no obvious bleeding site but is s/p ERCP.\n Will touch base with GI, heme check, continue PPI, keep t and c, and\n follow serial h/h.\n In terms of cholangitis\nis doing well. LFTs decreasing. Continue\n current antibx.\n Wound care for decubs.\n Remainder as per housestaff note.\n Critically ill/ICU\n Time spent: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 03:31 PM ------\n" }, { "category": "Respiratory ", "chartdate": "2104-05-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 573485, "text": "Demographics\n Day of mechanical ventilation: 3\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7mm\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 weaned to PSV today with decrease in PS throughout shift;\n pt tolerating well.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated.\n Possible a.m. extubation.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2104-05-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573661, "text": "Ms. is a 76 y/oF with a history of CHF, likely COPD, HTN, DM Type\n I per report who recently underwent a prolonged hospitalization for\n pneumonia requiring intubation and ultimately trach/peg for failure to\n extubate.\n On she developed nausea and vague abdominal pain. She had a CT\n on that showed two small stones in the distal CD without\n intrahepatic biliary dilation. She was managed conservatively with\n antibiotics and transferred today for ERCP to be done under general\n anesthesia.\n ERCP had clearance of two CBD stones and sphincterotomy was\n performed. She had a difficult intubation and remained intubated on\n arrival to the medical ICU.\n Has been kept npo since midnight for ? extubation this am still with\n large amts of thick yellow sputum, ? if she will be able to be\n intubated, propofol at 75mcg/hr, she is still light and when she wakes\n up she is very agitated trying to pull at tubes\n Impaired Skin Integrity\n Assessment:\n Bilateral gluteal decubs, stage 3\n Action:\n Dsgs were changed using collaganase ointment covered with dsd and\n medipoer tape\n Response:\n Moderate amt of purulent drainage on ols dsgs.\n Plan:\n Continue with qd dsg changes which are sone @ \n" }, { "category": "Respiratory ", "chartdate": "2104-05-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 573535, "text": "Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments: mdi as ordered\n Secretions\n Sputum color / consistency: Tan / 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 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 Reason for continuing current ventilatory support: no cuff leak\n Pt remained intubated overnight on psv. ABG acceptable. No cuff leak\n detected this am.\n" } ]

[ { "category": "Radiology", "chartdate": "2131-07-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 828962, "text": " 10:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate IJ placement and infiltrate progression.\n Admitting Diagnosis: LYMPHOMA;CHEMO\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M with relapsed lymphoma, s/p laminectomy for cord compression now\n with incr O2 requirement and worsening hypoxia with acute desat to 60s. Now\n s/p RIJ placement.\n REASON FOR THIS EXAMINATION:\n Evaluate IJ placement and infiltrate progression.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, 1 VIEW, PORTABLE:\n\n INDICATION: 64 year old male patient with recurrent lymphoma, worsening\n hypoxemia.\n\n COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with\n the previous study at 4:24 P.M.\n\n There is increasing pulmonary edema. In addition, there are multifocal patchy\n opacities involving both lower lobes indicating superimposed pneumonia. There\n is continued cardiomegaly and small bilateral pleural effusion. The right\n jugular IV catheter terminates in the right atrium. No pneumothorax is\n identified.\n\n IMPRESSION: Worsening pulmonary edema with superimposed pneumonia in both\n lower lobes. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2131-07-07 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 828964, "text": " 11:20 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: pls eval lungs for evidence of lymphoma vs PCP\n Admitting Diagnosis: LYMPHOMA;CHEMO\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with NHL, now with worsening hypoxia and infiltrates , s/p\n laminectomy for lumbar mass removal\n REASON FOR THIS EXAMINATION:\n pls eval lungs for evidence of lymphoma vs PCP\n CONTRAINDICATIONS for IV CONTRAST:\n worsening renal failure\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE CHEST W/O CONTRAST:\n\n INDICATION: 64 year old man with Non-Hodgkin's lymphoma with worsening\n hypoxemia. Lymphoma vs. PCP.\n\n COMMENTS: Unenhanced CT scan of the chest was performed without the\n administration of contrast media. Spiral CT scan was performed encompassing\n both lungs. Comparison was made with the previous study dated .\n\n There are slightly increased mediastinal and hilar lymphadenopathy consistent\n with the patient's known Non-Hodgkin's lymphoma.\n\n There is new bilateral patchy ground-glass opacity predominantly upper and mid\n lung zones associated with interlobular septal thickening in upper lobes.\n These findings most likely represent a combination of pulmonary edema and\n reaction to chemotherapeutic drugs in this patient with recent chemotherapy\n for Non-Hodgkin's lymphoma. Alternatively, a portion of the diffuse patchy\n ground-glass opacity could indicate diffuse infection such as PCP.\n\n Note is made of nodular opacities in the lateral basal segments of the right\n lower lobe, which becomes more nodular compared with the previous study of . These findings indicate the patient's presumptive diagnosis of fungal\n infection such as aspergillosis or nocardia.\n\n Patchy atelectasis is seen in both lung bases. Again note is made of large\n esophageal hiatus hernia. The tip of the right-sided PICC line is identified\n in the superior vena cava. The heart is normal in size. No definite pleural\n effusion or pericardial effusion is identified.\n\n The visualized portion of the liver, spleen, and adrenal glands are within\n normal limits, though this study was performed without contrast enhancement.\n\n There is evidence of laminectomies throughout lower thoracic spine and upper\n lumbar spine.\n\n IMPRESSION:\n 1) Diffuse patchy ground-glass opacity with interlobular septal thickening\n indicating a combination of pulmonary edema and reaction to the\n chemotherapeutic drug. Alternatively, the possibility of diffuse infection\n (Over)\n\n 11:20 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: pls eval lungs for evidence of lymphoma vs PCP\n Admitting Diagnosis: LYMPHOMA;CHEMO\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n such as PCP is considered as differential diagnosis.\n\n 2) Nodular opacities in the right lower lobe indicating fungal infection.\n\n 3) Slightly increased mediastinal and hilar lymphadenopathy indicating Non-\n Hodgkin's lymphoma in this patient. Large esophageal hiatus hernia. Status\n post laminectomies of the lower thoracic and upper lumbar spine.\n\n" }, { "category": "Radiology", "chartdate": "2131-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 828882, "text": " 7:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrates, effusions, interval cahnges\n Admitting Diagnosis: LYMPHOMA;CHEMO\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M with relapsed lymphoma, s/p laminectomy for cord compression now with\n incr O2 requirement and worsening hypoxia\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrates, effusions, interval cahnges\n ______________________________________________________________________________\n FINAL REPORT\n CHEST 1 VIEW PORTABLE:\n\n INDICATION: 64 y/o male patient with ----- lymphoma with cord compression and\n hypoxemia.\n\n COMMENT: Portable AP radiograph of the chest is reviewed, and compared with\n the previous study of .\n\n There is continued elevation of the left hemidiaphragm. The previously\n identified left lower lobe opacity has been improving. The right lower lobe\n patchy opacity is also improving. There is mild pleural effusion overload.\n The heart and mediastinum are within normal limits.\n\n IMPRESSION:\n\n Improving pneumonia in both lower lobes. Continued elevation of the left\n hemidiaphragm.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-07-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 828939, "text": " 4:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for interval changes\n Admitting Diagnosis: LYMPHOMA;CHEMO\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M with relapsed lymphoma, s/p laminectomy for cord compression now\n with incr O2 requirement and worsening hypoxia with acute desat to 60s\n REASON FOR THIS EXAMINATION:\n Eval for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 64 y/o male patient with fecalent lymphoma and hypoxemia.\n\n PORTABLE AP CHEST: Comparison is made to previous films from yesterday. The\n radiograph is severely degraded due to patient motion.\n\n There is increased pulmonary edema with multiple patchy opacities in both\n lower lobes indicating supine post pneumonia. There is continued elevation of\n the left hemidiaphragm. The heart is mildly enlarged. The right sided PICC\n line remains in place.\n\n" }, { "category": "Radiology", "chartdate": "2131-07-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 829066, "text": " 12:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate infiltrates\n Admitting Diagnosis: LYMPHOMA;CHEMO\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M with relapsed lymphoma, s/p laminectomy for cord compression now\n with incr O2 requirement and worsening hypoxia with acute desat to 60s. Now\n s/p RIJ placement.\n REASON FOR THIS EXAMINATION:\n evaluate infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64 y/o with lymphoma and increase in hypoxia.\n\n PORTABLE FRONTAL RADIOGRAPH:\n\n COMPARISON: and .\n\n The cardiac and mediastinal contours are unchanged. There is persistent\n opacification of the left lower lobe and the retrocardiac region with\n obscuration of the hemidiaphragm. There is also patchy opacity in the right\n lower lobe. These are not significantly changed from the prior study.\n The pulmonary vasculature is slightly more prominent than on the prior study.\n A right IJ central venous catheter is unchanged in position. No pneumothorax\n is identified.\n\n IMPRESSION: Slightly worsened congestive heart failure. Persistent,\n unchanged multifocal lower lobe pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2131-07-06 00:00:00.000", "description": "GALLIUM SCAN", "row_id": 828749, "text": "GALLIUM SCAN Clip # \n Reason: 64 MALE W/ RELAPSED LARGE B CELL LYMPHOMA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sixty-four year old man with relapsed large B cell lymphoma.\n\n INTERPRETATION: Whole body images were obtained, and demonstrate foci of\n increased tracer uptake in the mediastinum, and right chest. There is diffuse\n bowel uptake, as well as an area of increased uptake in the epigastrium.\n\n SPECT images of the chest were performed followed by reconstructed images in the\n axial, coronal and sagittal planes. These images demonstrate a focus of\n increased uptake at the lower right chest wall, the mediastinum, and left\n supraclavicular regions.\n\n SPECT images of the abdomen were performed, and reconstructed in the axial,\n coronal and sagittal planes. Again seen is diffuse uptake of the bowel,\n however, in addition there is an abnormal focus of increased uptake in the\n region of the epigastrium, and it is difficult to fully distinguish/evaluate\n this finding secondary to the increased adjacent bowel uptake.\n\n SPECT images of the pelvis were performed, and reconstructed in the axial,\n coronal, and sagittal planes. These images again demonstrate uptake in the\n bowel, and no abnormal foci of uptake are identified in the pelvis.\n\n The above findings are consistent with recurrence of disease in the chest.\n Possible focus of disease in the epigastric area. These findings are new\n compared with the FDG study dated .\n\n IMPRESSION: Multiple foci of increased uptake in the chest and possible\n increased uptake in the epigastric area, as described above, worrisome for\n disease recurrence.\n /nkg\n\n\n , M.D.\n , M.D. Approved: MON 3:30 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": "2131-07-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 828746, "text": " 12:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check placement of new pic line\n Admitting Diagnosis: LYMPHOMA;CHEMO\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with nonHodgkin's lymphoma\n REASON FOR THIS EXAMINATION:\n check placement of new pic line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64 year old with non-Hodgkin's lymphoma.\n\n PORTABLE UPRIGHT FRONTAL RADIOGRAPH.\n\n COMPARISON: .\n\n The cardiac and mediastinal contours are unremarkable with slight widening of\n the right paratracheal and azygous contours. There has been improvement in\n patchy opacity at the left lower lung zone. Patchy opacity in the right lower\n lobe is essentially unchanged. The pulmonary vasculature is normal and there\n is no pneumothorax. There has been interval placement of a right-sided PICC\n line terminating in the mid SVC. Skin staples are seen in the mid chest.\n Note is again made of a large hiatal hernia.\n\n IMPRESSION: Improvement in left lower lobe pneumonia. Unchanged appearance\n of right lower lobe patchy opacity. PICC line in satisfactory position.\n\n" }, { "category": "Echo", "chartdate": "2131-07-09 00:00:00.000", "description": "Report", "row_id": 75020, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function.\nHeight: (in) 68\nWeight (lb): 170\nBSA (m2): 1.91 m2\nBP (mm Hg): 110/60\nHR (bpm): 102\nStatus: Inpatient\nDate/Time: at 10:10\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Due to suboptimal technical quality, a\nfocal wall motion abnormality cannot be fully excluded. There is mild global\nleft ventricular hypokinesis. There is no resting left ventricular outflow\ntract obstruction.\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. The right\nventricular cavity is dilated. There is severe global right ventricular free\nwall hypokinesis.\n\nAORTA: The aortic root is mildly dilated. There are focal calcifications in\nthe aortic root. The ascending aorta is mildly dilated. There are focal\ncalcifications in the ascending aorta.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. The mitral valve supporting structures are normal. The\nleft ventricular inflow pattern suggests impaired relaxation.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Tricuspid\nregurgitation is present but cannot be quantified. There is mild pulmonary\nartery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nThere is mild global left ventricular hypokinesis (ejection fraction 40-50\npercent). The right ventricular cavity is dilated. There is severe global\nright ventricular free wall hypokinesis. The aortic root is mildly dilated.\nThe ascending aorta is mildly dilated. The aortic valve leaflets (3) are\nmildly thickened but not stenotic. Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nThe left ventricular inflow pattern suggests impaired relaxation. Tricuspid\nregurgitation is present but cannot be quantified. There is mild pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nCompared with the findings of the prior study (tape reviewed) of ,\ncontractile function of the right ventricle is markedly reduced, and\ncontractile function of the left ventricle is mildly reduced.\n\n\n" }, { "category": "ECG", "chartdate": "2131-07-07 00:00:00.000", "description": "Report", "row_id": 167232, "text": "Sinus tachycardia\nLow QRS voltages\nSince previous tracing, T wave flattening\n\n" }, { "category": "Nursing/other", "chartdate": "2131-07-10 00:00:00.000", "description": "Report", "row_id": 1467267, "text": "1900-0700\n\nGeneral: Pt refused po meds through the night, HO made aware. Pt refused am care or back care. Started on clear liquid diet and refused to eat. Denies pain, resting quietly. Spoke with son and explained situation.\n\nNeuro: Awake, alert, oriented, follows commands well. MAE. PERLA.\n\nResp: Weaned O2 NC 5L, aresol face 70%. O2sat 95-98%, no resp distress noted. Lungs clear/diminished bilaterally. No cough noted.\n\nCV: Sinus Tachycardia on c-monitor with alarms on. HR: 100-110, BP 130-140/70-80, CVP: . + pulses to ext. Thoracic L posterior dsg intact with no drainage noted. HCT:26.3, WBC:1.2. No edema noted.\n\nGU/GI: Abd soft + BS, no BM noted. Foley catheter to BSD draining lt yellow cl urine. BUN: 84, CR: 2.7, Phos: 8.4, Uric acid: 7.7.\n\nIV: R IJ tlc intact with NSS@ 150cc/hr infusing cont.\n\nPlan: Discuss need for cooperation with medication regiment. Continue evaluate renal function.\n RN\n" }, { "category": "Nursing/other", "chartdate": "2131-07-10 00:00:00.000", "description": "Report", "row_id": 1467268, "text": "NPN 0700-1900\nGeneral: A&Ox2 earlier today, has been refusing exam and meds, states that people are trying to hurt him, 1630 became more lethargic at the same time taking off his O2, desats to 80% witout O2 and slow to recover to norm sat. Bilat. wrist restraints applied, team aware of pt MS. Renal u/s tomorrow d/t MS changes.\n\nNeuro: His current MS is inconsistent with baseline MS reported by 7F nurses who have said that he was very gentle and cooperative, able to bend knee and lift leg, able to help minimally with turning though was able to turn self yesterday. No c/o pain, at times refuses to be touched.\n\nResp: Lungs with crackles throughout, dry cough no sputum today, no c/o SOB, O2@5LNC and 70%Cool Neb face RR 10-22, O2sats 94-98%, PCP sputum cx pending.\n\nCV: T max 97.2, HR 103-122 ST no ectopy, BP's 106-143/55-87, CVP currently 9, no edema, 3+Pedal Pulses bilat. echo shows EF 40-50% (see report).\n\nGI: BS(+)x 4 quad., abd soft non distended non-tender, no BM today, took approx 40cc po flds today, D51/2 NS at 100cc/hr x 2 L infusing (see ).\n\nGU: FOley cath intact draining clear yellow urine in adequate amts.\n\nEndo: FBS 1200 was 182, tx per SSI.\n\nSkin: Pale, Drsg. to post chest laminectomy dry and intact, reinforced.\n\nSocial: Family to be in this evenining to talk to team about future plan of care.\n\nPlan: Continue to watch for new MS changes, monitor resp status- O2sats, follow eve. labs, monitor I/o's.\n\n" }, { "category": "Nursing/other", "chartdate": "2131-07-09 00:00:00.000", "description": "Report", "row_id": 1467263, "text": "MICU-NPN\nNEURO: Pt. sleepy most of noc, awakens easily to stimuli. Denies pain with movement, although visible discomfort/SOB.\nCV: afebrile, HR 101-110 ST, no ectopy noted. SBP 110-140's, CVP 8-14, SVO2 55-63. 40mg lasix given x1 with moderate effect. HCT 27.7\nRESP: Remains on 100% NRB with Sat's 86-96%. Pt. has low reserve when taking mask off, sat's down to 78%. Pt. denied any SOB at that time. Pt. tried on BIPAP but did not tolerate. MD aware. Pt. with multiple desats t/o noc into the 80's but rebounds on his own. Short periods of apnea noted. Induced sputum to be sent in am. No cough noted. Pt. also placed on 6LNC (w/ NRB).\nGI: abdomen soft and distended, +BS noted. No stool over noc.\nGU: Foley intact drng adeq. amt's of clear, yellow urine.\nSKIN: s/p laminectomy, dsg D&I.\nID: WBC 1.9, continues on voriconazole, acyclovir, cefepime, azithromycin, and vanco.\n\n" }, { "category": "Nursing/other", "chartdate": "2131-07-09 00:00:00.000", "description": "Report", "row_id": 1467264, "text": "Resp Care: Pt seen for refractory hypoxemia, spo2 88-92% on rbm/6l nc with freq desat when off for care/pills; attemted NIPPV x1 @ fio2 1.0 tol poorly, pt unable to tol , cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2131-07-09 00:00:00.000", "description": "Report", "row_id": 1467265, "text": "Respiratory Care\nSputum induction w/neb ud albuteral/atrovent given. Pt produced small amount of thick blood tinged secreations withg strong forceful cough. Sputum sent to lab.\n" }, { "category": "Nursing/other", "chartdate": "2131-07-09 00:00:00.000", "description": "Report", "row_id": 1467266, "text": "NPN 0700-1900\nGeneral: A&Ox3, no c/o pain, neutropenic precautions cont. 7mo. post BMT with last chemo. on , WBC 1.9 Neutrophils 350, Filgastrin ordered for Pancytopenia, sputum thick with bright red blood sent for PCP cx, cont vanco/cefepime, azithromycin, voriconazole for PNA, ordered for 2L NS at 150cc/hr (see ) with 20mg lasix IV given at 1530 for tumor lysis syndrome. Clear liquids as tolerated.\n\nNeuro: Hard of hearing, Able to follow commands, responds appropriately to questions, MAE, able to turn self in bed with minimal assistance.\n\nResp: Lungs coarse to lower lobes and diminished to upper lobes, RR 10-20, O2 sats 94-98% on O2 weaned to 5LNC and O2 40% face with mist, no c/o SOB, occasional episode of apnea during sleep however pt awakens self to breathe, team aware.\n\nCV: HR 99-117 ST no ectopy, no c/o CP, BP 121-141/60-70, CVP 10-17, no edema, 3+pedal pulses bilat.\n\nGI: BS (+)x 4 quad., abd softly distended, no BM today, (+)flatus.\nGU: Foley cath draining light clear yellow urine in adequate amts.\n\nFBS: FBS 214 at 1200, tx per SSI orders.\n\nSKin: Laminectomy drsg. to posterior chest dry and reinforced with silk tape.\n\nPlan: Continue to watch O2sats, wean O2 per NC as tolerated, monitor UO, tx FBS per SSI.\n" }, { "category": "Nursing/other", "chartdate": "2131-07-08 00:00:00.000", "description": "Report", "row_id": 1467261, "text": "NPN -0700\nGeneral: Pt admitted from 7 had chemo tx this am, adm to MICU d/t SOB, hypotn, febrile; sepsis protocol initiated. Arrived to MICU via stretcher A&Ox2, no c/o pain, T= 100.4, SBP 84, O2 at 10L face mask sat's 98%, arrived in MICU without resp distress and continues on face mask. Lactate levels <2 all night, lactate draws dc'd this am by intern. Given total 5L NS bolus overnight, decadron given. 3-Lumen Pre- cath inserted to R IJ, ok to use, insertion site with continous bldg. overnight even after applying 1hr. of pressure to site, pt given 3 units platlets current Plt=69, 1 u PRBC's currently infuing. Pt taken to CT Chest to look for lymphoma involvement in the lungs, no results at this time. Neutrophils 350, WBC 1.7 pt placed on neutropenic precautions.\n\nNeuro: A&Ox2, lethargic, MAE in bed, follows commands, no c/o pain, pt environment secured, SR up x 4.\n\nResp: Lungs coarse to upper airways, diminished to lower lobes, RR 12-16, O2 sat's 98% on O2 at 8L Face mask, no c/o SOB.\n\nCV: Temp max 100.4, ST 111-127 no ectopy, BP 84-114/40's-72, CVP 15-17, SVO2 60-71%, 2+Pedal Pulses Palpable bilat., compression sleeves on. PICC line intact to R Arm, site benign, 3-Lumen presep cath intact, site cont. to ooze bld. from 2200-0600, gel foam applied x 3 to site to decrease bldg. HO aware.\n\nGI: BS (+) x 4 quad., abd soft and distended, no BM, (+)flatus, currently NPO except for meds.\n\nGU: Foley cath intact draining clear light yellow urine in adequate amts. see careview for details.\n\nSkin: Drsg.Posterior chest from thoracic laminectomy dry intact no drainage noted.\n\nSocial: Sons in last night, will visit today. Need more information from sons for admission (ICU admit.-careview).\n\nPlan: Continue to monitor resp fx, monitor vs, follow labs inlcuding platlet and neutrophil ct., neutropenic precautions.\n" }, { "category": "Nursing/other", "chartdate": "2131-07-08 00:00:00.000", "description": "Report", "row_id": 1467262, "text": "Neuro a/o x3 mae fc pupils equal and reactive, able to lift both legs in air laminectomy dsg D+I\ncardiac Hct 1 hr after first unit prbc 23.9 received second unit repeat Hct 1 hr after transfusion pnding, Plt count 74, rtij stopped oozing blood HR 111-178 ST-episodes ? PAT rates as high as 178. K+ 4.0 ionized ca .97 tx with 2gm calicium gluconate mag > 2. bp 95/57-112/58. CVP 8-14 skin Warm and pale pp+\nResp 100% NRB mixed venous 42-62% lungs diminished thoughout sputum sent for culture, AFB, pneumocystis. O2 sat 90-97% with mask when removed immediately drops to 80's%\nGU u/o > 30 BUN 57 cr 1.6\nGI sm liq brown stool OB neg abd soft distended\nID mac max 97-95.5 Ax, on voriconazole, acyclovir, cefepime, azithromycin, vanco lactate 2.1\naccess rt ij triple, rt antecub picc\nendo ss insulin\na. NHL, community acq pnx, s/p laminectomy T10-11 cord compression admitted for hypoxia\nARF\np. tx hct < 27 monitor plts check s+s blding\nantibx as ordered monitor renal status closely\nawait cx reports\n" }, { "category": "Nursing/other", "chartdate": "2131-07-11 00:00:00.000", "description": "Report", "row_id": 1467269, "text": "micu/sicu nsg note:1900-0700\nneuro: pt alert, orientedx1 to person, conversing with family on the phone and able to follow commands at the beginning of the shift. perrla 3mm brisk towards the middle of the shift, pt becoming increasingly lethargic, waking up to light sternal rub. perrla 3mm brisk. by 4 am, pt unresponsive to sternal rub. perrla 3mm sluggish. dr. notified and up to evaluate pt. pt awaiting stat head ct.\n\ncv: hr ranging 108-118 st with no ectopy noted. bp ranging 96-128/58-76.\n\nresp: pt on 5l nc with 70% cool mist face tent with 02 sat ranging 83-96%. 02 sat dropping to the 80s with ? periods of apnea. 02 sat improved with repositioning and suctioning back of throat for thick white sputum via yankaeur. lungs were coarse with occasional exp wheezing in the upper airways and diminished at the bases at the beginning of the shift. rales at bases approx 1 hr after 500cc ns bolus was given per. dr. in attempt to improve pt's tachycardia-provided minimal effect. by 4am when pt unresponsive to sternal rub, pt's 02 sat in the low 90s. dr. drew an abg: 7.47/37.62, 100% nrb placed with 02 sat 92-95%. pt opened eyes with sternal rub and at one point was able to say \"what?\" - now only opens eyes to sternal rub.\n\ngi/gu: abd soft, round, +bs, no bm, took 2 sips bottled water in 90degree upright position with + slight cough. unable to take any further po liquids or pills. dr. aware and spoke with pt's family re: possible need for tpn in the near future. 2 way indwelling foley catheter draining 26-110cc light yellow urine. cr 3.9. renal team following pt and with recommendation for iv lasix.\n\nskin: back dsg removed. site cd&i and left ota. multiple bruised areas on arms, reddened area between right thigh- left ota.\n\ncomfort: pt denied pain at beginning of shift. unable to assess presently.\n\nlines: right tlcl, right arm picc\n\nId: temp 96.1-97 ax. receiving if cefipime.\n\nheme: am plt count= 20 . received 1 unit plts.\n\nplan: continue to monitor hemodynamics/resp status, monitor mental status and pt to have stat head ct this am. recheck plt count at 8:10am. monitor level of comfort, monitor skin. monitor u.o. and diurese as tolerated. consider tpn. continue abx and follow micro data. transfuse to keep plt > 50.\n\n" }, { "category": "Nursing/other", "chartdate": "2131-07-11 00:00:00.000", "description": "Report", "row_id": 1467270, "text": "M/SICU NPN for 7a-4p: DNR/CMO\n\nNeuro: Essentially unarousable on SL concentrated Morphine. Has not rec'ed a dose of SL Morphine at present. However, did receive a total of 7mg Morphine IV push throughout the day. Pupils reactive, but sluggish.\n\nResp: Placed on 4L o2 via NC with sats currently in the 70's. MD's are aware. Lung sounds Rhonchi and diminished throughout. Attempted to suction orally.\n\nCV: Remains ST with Hr 100's - 120's no ectopy. D/c'ed Central to RIJ intacted and left RAC PICC.\n\nGU: Foley in place.\n\nPlan: Transfer back to BMT unit per son when bed is available under palliative care per son's/family request.\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2144-02-15 00:00:00.000", "description": "Report", "row_id": 292963, "text": "Sinus rhythm. Left atrial abnormality. Left ventricular hypertrophy.\nBorderline prolonged Q-T interval. Compared to the previous tracing of \nthe Q-T interval is shorter, likely reflecting a change in electrolytes or\nan improvement in pulmonary hypertension.\n\n" }, { "category": "ECG", "chartdate": "2144-02-14 00:00:00.000", "description": "Report", "row_id": 292964, "text": "Baseline artifact. Left ventricular hypertroph with strain type ST segment\nsagging in leads I and aVL. Mild non-specific ST segment flattening in\nleads V5-V6. Slight prolongation of the Q-T interval. Compared to the\nprevious tracing of ectopic atrial bradycardia has resolved. The rate\nis slightly faster. Repolarization and depolarization patterns are similar.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2112-04-12 00:00:00.000", "description": "Report", "row_id": 1332842, "text": " nsg note: 7:00-19:00\nthis is a 56 y.o. man adm with rul pna to 11r with hx htn, obesity, gout, etoh use( 2-3beers/day per pt) who became increasingly agitated all day on day of adm, code purple was called and pt was given total of 8mg iv ativan, then dropped sats to the 60s, became hypertensive, very lethargic, dev. resp distress, intubated and tx'd with ivabx and at one point levophed for hypotension. pt had bronch at bedside revealing thick mucous but with no obstruction. extubated within 1 hour after bronch on and tolerated well.\n\nneuro: a&ox3, appears lethargic most of the day, napping alot (has been off all sedation since 4pm ) but easily arousable, conversing when spoken to. mae, oob to chair most of the afternoon. requiring 2 assist with transfers to get up but able to take steps with encouragement and guidance. tolerating well. following commands appropriately.\n\ncv: hr ranging 70s-80s sr with wap with occas pvcs. k=4.1, mg= 1.9, po4=2.6, mg and po4 repleted. sbp ranging 150s-160s in the am and increasing up to 190 by 11am. pt restarted on 25mg po lopressor-sbp now in the 120s-130s. +pp, +csm, trace pedal edema.\n\nresp: on 35% cool neb face tent with sats in the mid to high 90s. able to take off 02 to eat and sats stable in mid 90s. pt couging up thick yellow secretions in small to moderate amts with encouragement and remminders to cough and deep breathe and using incentive spirometer. cpt also given.\n\ngi/gu: abd obese, soft, +bs, swallowing well without difficulty. ngt pulled this am. tolerating ice chips in am, clear liquids for lunch and ordered solid diabetic diet for dinner. had 2 lg loose brown bms ob negative. foley dc/'d at 2pm and pt voided 110cc + medium amt when had a bm.\n\nendo: bld sugar in 80s 8am, 12pm, increased to 219 in pm now that he's eating.\nskin: rl leg with .5x2cm abrasion pink, ota. l thigh with small amt bruising.\n\nlines: r and l hand piv #20g , l sc tlcl - all placed and patent.\n\nsocial: lives alone. next of is sister in and nephew locally. has a friend who is his health care proxy. had no services pta.\n\nplan: transfer to floor when bed available. continue to enc. to cough and deep breathe, use of incentive spirometer, cpt, monitor hr and bp and continue lopressor. monitor bld sugars qid prn/ provide bedtime snack.\n" }, { "category": "Nursing/other", "chartdate": "2112-04-13 00:00:00.000", "description": "Report", "row_id": 1332843, "text": "MICU NPN\nUNEVENTFUL NIGHT, PT. IS ALERT AND COOPERATIVE, SLEPT, LOPRESSOR DOSE INCREASED TO START AT 8AM. CALLED OUT WAITING FOR A BED, TRANSFER NOTE IS DONE.\n" }, { "category": "Nursing/other", "chartdate": "2112-04-13 00:00:00.000", "description": "Report", "row_id": 1332844, "text": "pmicu nursing progress note\ncardiac: just got report on pt approx 1hr ago----bp 178/90 with pulse of 77 wap, frequent pacs. k+ 3.9, mag 1.8, ca 8.4. echo on . lopressor increased to 37.5.\n\nresp: extubated on and pt is presently on 35% cool neb with resp rate of 26-30 and sats of 95-96%.lung sounds are coarse. bronched on . pt has epsiodes of becoming \"bronchospastic\", intermittently coughing up thick yellow plugs being obtained with yankuar suction catheter. slightly sob with physical therapy, as well as when speaking.\n\nid: temps of 98.2po, 98.5po, 99.2po---on ceftriaxone, urine culture sent on urine cx neg, blood cultures pending and rpr is non-reactive.\n\ngi: abdomin soft, with + bowel sounds. clear liquid diet. passed a large amt of loose brown, ob neg stool.\n\ngu: uses urinal----urine is amber in color with sediment.\n\naccess: left subclavian, #20g in rt hand and #20 in left.\n\nneuro: alert and oriented.\n" }, { "category": "Nursing/other", "chartdate": "2112-04-11 00:00:00.000", "description": "Report", "row_id": 1332840, "text": " nursing note 7:00-19:00\nneuro: patient is alert and oriented X 3. responds to commands. opens eyes to voice. perrla 3mm brisk. fentanyl given until extubation for throat pain from ett.\n\ncv: hr in the 60s-80s sr- now noted to be in wap which pt known to have on past ekg. pt with pvcs in am. am k=3.4. repleted with 20meq iv kcl. sbp 110s-160s.\n\nresp: lung sounds diminished, clear to aucultation with crackles at left base in the am and coarse in the pm. pt with minimal secretions in the am and team concerned of possible tracheal obstruction. bronch done at bedside revealing no obstruction but copious amts secretions that were removed. pt extubated at 16:15 and tolerating well on 50% cool mist face mask with O2sats in the mid to upper 90s. provided chest pt, and pt coughing up moderate to lg amts thick yellow secretions. pt enc. to cough and deep breathe.\n\ngi/gu: abd soft, obese, nt/nd, +bs, tf off since 7:15am in prep for extubation. ngt remains clamped and pt remains npo for now to observe how breathing. no bm this shift. foley patent draining adequate amts clear yellow secretions.\n\nskin: bruising on l thigh and abrasion on r calf ota. heels sl red. aloe vesta cream applied.\n\ncomfort: c/o throat pain in am relieved with iv fentanyl, now appears more comfortable s/p extubation.\n\nlines: r radial aline and l sc tlcl patent.\n\nsocial: nephew called today for update and might be in to visit later this pm.\n\nendo: bld sugar in the 60s-70s requiring 1 amp d50 this am, in 70s this pm.\n\nplan: continue to enc. pt to cough and deep breathe, suction prn, cpt, enc use of incentive spirometer. monitor level of comfort. q4-6hr bld sugar checks.\n" }, { "category": "Nursing/other", "chartdate": "2112-04-12 00:00:00.000", "description": "Report", "row_id": 1332841, "text": "PT. REMAINS LETHARGIC, BUT EASILY AROUSABLE. PT. HAS REMAINED ORIENTED X3. NUEROLOGICALLY INTACT AND REMAINING AFEBRILE.\nPT. HAS CONTINUED IN A WAP RYTHM IN A CONTROLLED RATE IN THE 60-90'S WITH NO NOTED ECTOPY. B/P HAS REMAINED 140-150'S/50-60'S. TRACE EDEMA NOTED WITH PEDAL PULSES WEAK, BUT EASILY PALPABLE.\nPT. WAS EXTUBATED YESTERDAY AND REMAINS COARSE THROUGHOUT. PT. HAS BEEN ABLE TO CLEAR HIS OWN SECRETIONS WHICH REMAIN THICK TENACIOUS TAN. PT. WAS NOTED TO DROP SATS ONCE INTO THE HIGH 80'S BUT WITH DEEP BREATHING AND COUGHING. PT. WAS ABLE TO CLEAR ON HIS OWN AND SATS CLIMBED TO 100%. OTHERWISE SATS HAVE REMAINED >97%. RESP RATE IS CONTROLLED.\nPT. REMAINS NPO AT THIS TIME. BUT HAS BEEN GIVEN FEW ICE CHIPS AND TOLERATED THESE WELL WITH NO COUGHING NOTED. ABD. REMAINS BENIGN WITH BOWEL SOUNDS EASILY AUDIBLE. NO STOOL NOTED THIS SHIFT. BLOOD SUGARS HAVE REMAINED INTHE 70'S, WITH AM LABS PENDING.\nFOLEY CATHETER INTACT AND DRAINING SMALL BUT AMPLE AMT'S OF AMBER SEDIMENT URINE. RANGING 30-110CC/HR.\nSKIN REMAINS UNCHANGED WITH ABRASIONS NOTED TO TRUNK AND LOWER EXTREMITIES. ALL LINES CONTINUE TO FUNCTION WELL.\nPT. REMAINS A FULL CODE, WITH PLANS TO MONITOR AND ENCOURAGE DEEP BREATHING AND COUGHING.\n" }, { "category": "Nursing/other", "chartdate": "2112-04-10 00:00:00.000", "description": "Report", "row_id": 1332835, "text": "NPN 1900-0700\n\nNEURO: SEDATED ON PROPOFOL @ 30MCG/HR. RESPONDS TO NOXIOUS STIM . WILL CHANGE TO FENT AND VERSED WHEN AVAILABLE FROM PHARMACY.\n\nRESP: ON A/C 600X 16 50% PEEP 5 , SUCTIONED FOR LARGE AMTS FROTHY PINK SECRETIONS. MAINT SATS HIGH 90'S.LUNGS RHONCHOROUS THROUGHOUT.\n\nC/V: ST , BP MAINTAINED W/ LEVOPHED . RECIEVED 750CC NSS BOLUSES OVER NOC. CVP 10-14.\n\nF/E/N: UO ~ 100 CC HR. AM LYTES PENDING , NO STOOL OVER NOC.\n\nPLAN: CONT MECH VENT, WEAN LEVO ,MONITOR HEMODYNAMICS.\n" }, { "category": "Nursing/other", "chartdate": "2112-04-10 00:00:00.000", "description": "Report", "row_id": 1332836, "text": "Resp Care\nPt remains intubated, stable on AC. Plan to continue with current settings and monitor.\n" }, { "category": "Nursing/other", "chartdate": "2112-04-10 00:00:00.000", "description": "Report", "row_id": 1332837, "text": "micu nursing note 7a-7p\n\nNeuro pt weened of propofol this morning and changed over to versed at 2mg hr and fentenyl at 40 mcgs/hr pt opens eyes to voice and nods , hands remain in soft restraints. no signs of DT's\n\nCV pt remins on noreepi attempt to ween of lasted 20 min pt's BP dropped to the 8o's sbp. pt placed back on drip at .042 mcg/kg/min BP now 114/62-120/70 hr72 sr with occ pvc's\n\nResp pt remains on 40%600/16 with 5 of peep spont breathing over vent, sats 98-100 see flow sheet for abg, lung sounds course right side and left base, pt suctioned for small amounts of blood tinged secreations.\n\nGI abd soft non tender, no stool, bs hypoactive.\nGU foley passing pink tinged urine , cloudy, 40-80 cc/hr\nID pr afebrile, remians on iv antibiotics\nendo pt hypoglycemic 48 this ams given Iv D50 with good effect and tonight at 5 pm bs 50 , pt given second amp of D50 repeat bs 126, we are waiting to start tube feeds in hope it will keep BS^ now waiting on feeding pump.\nA/p would continue with pulm toilet as tol, iv antibiotics , follow bs as needed would recheck bs tonight , ween norepi if tol, would keep versed and fent drip to pervent dt's\n" }, { "category": "Nursing/other", "chartdate": "2112-04-11 00:00:00.000", "description": "Report", "row_id": 1332838, "text": "NPN 1900-0700\n\nNEURO : LIGHTLY SEDATED ON FENT AND VERSED. OPENS EYES TO VOICE, TRACKS AND FOLLOWS COMMANDS.NO SIGN OF DT.\n\nRESP: SWITCHED TO CPAP 10/5 @ 0500 THIS AM. TOL WELL AT THIS TIME. SUCTIONED OVER NOC FOR SMALL AMTS THICK TAN SECRETIONS.MANT SATS 96-99%.\n\nC/V: SR-ST NO ECTOPY, BP STABLE OF LEVO. 100-1TEENS.\n\nF/E/N: UO 40-50CC HR DARK AMBER URINE, AM LYTES PENDING. TOL TF @ 30CC HR. CHECK RESIDUALS @ 0800. RECIEVED 1 AMP D50 FOR BS OF 49 W/ GOOD RESPONSE .NO STOOL OVER NOC.\n\nPLAN:WEAN MECH VENT AS TOL , CONT AB TX, MONITOR HEMODYNAMICS FS BS COVERAGE AS PER SS.\n\n" }, { "category": "Nursing/other", "chartdate": "2112-04-11 00:00:00.000", "description": "Report", "row_id": 1332839, "text": "RESPIRATORY CARE NOTE:\n\nPt remain orally intubated & sedated ond receiced on vent support, + assisting. We were able to transition to spont ventilation; CPAP & PS. See Careview. RSBI done this AM ~ 71. We are sxtn for small am tof thick tan secretions from ETT. Plan: WEan as tolerated and Continue present ICU monitoring. Will follow.\n" }, { "category": "Echo", "chartdate": "2112-04-11 00:00:00.000", "description": "Report", "row_id": 81854, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension. Left ventricular function.\nHeight: (in) 70\nWeight (lb): 208\nBSA (m2): 2.12 m2\nBP (mm Hg): 129/67\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 10:15\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Mildly\ndilated aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The aortic arch is\nmildly dilated. The aortic valve leaflets (3) are mildly thickened. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial\nmitral regurgitation is seen. There is a trivial/physiologic pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2112-04-08 00:00:00.000", "description": "Report", "row_id": 197980, "text": "Probable ectopic atrial rhythm\nSupraventricular extrasystoles\nSince previous tracing, ectopic atrial rhythm and atrial premature complexes\nseen\n\n" }, { "category": "ECG", "chartdate": "2112-04-07 00:00:00.000", "description": "Report", "row_id": 197981, "text": "Sinus tachycardia\nPossible left atrial abnormality\nNo previous tracing available for comparison\n\n" }, { "category": "Radiology", "chartdate": "2112-04-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906175, "text": " 12:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out infiltrate, fluid overload\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with new onset hypoxia\n REASON FOR THIS EXAMINATION:\n rule out infiltrate, fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, , AT 12:30 A.M.\n\n COMPARISON: PA and lateral chest, .\n\n INDICATION: Hypoxia.\n\n Exam is limited by respiratory motion and low lung volumes. Even accounting\n for these factors, there has been apparent progression of extensive\n consolidation in the right upper lobe. There is a relative area of lucency\n centrally within the right upper lobe, which may be due to an area of spared\n lung parenchyma, but necrotizing pneumonia cannot be excluded on this portable\n projection.\n\n Low lung volumes and respiratory motion limiting assessment for cardiovascular\n status of the patient but there is no gross evidence of pulmonary edema\n allowing for this limitation.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-04-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906176, "text": " 1:12 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: tube placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with new onset hypoxia s/p intubation\n\n REASON FOR THIS EXAMINATION:\n tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 1:32 A.M.\n\n COMPARISON: Previous study of earlier the same date at 12:30 a.m.\n\n INDICATION: Intubation.\n\n There has been interval placement of an endotracheal tube terminating at the\n level of the superior aspect of the clavicles, about 8 cm above the carina.\n Right upper lobe consolidation has slightly progressed in the interval. There\n is otherwise no significant change since the recent chest radiograph.\n\n Please note that at the time of this dictation a separately dictated chest\n radiograph under clip shows repositioning of the endotracheal tube in\n satisfactory position.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-04-10 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 906182, "text": " 3:10 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please assess central line\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with hypotension, s/p new central line placement, requiring\n pressors\n REASON FOR THIS EXAMINATION:\n please assess central line\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, , 3:21 A.M.\n\n COMPARISON: Previous study of the same date at 1:32 a.m.\n\n INDICATION: Line placement.\n\n Since the recent radiograph, a left subclavian catheter has been placed,\n terminating in the superior vena cava. The distal tip is directed towards the\n lateral wall of this vessel. There is no evidence of pneumothorax on the\n supine radiograph, there is otherwise no change from the recent radiograph of\n approximately 2 hours earlier.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-04-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 905887, "text": " 6:22 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with high WBC, cough\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Leukocytosis and cough, evaluate for pneumonia.\n\n COMPARISON: None.\n\n PA AND LATERAL CHEST RADIOGRAPHS: There is opacification of the right upper\n lobe, involving all segments, extending inferiorly to the minor fissure. The\n right middle lobe and right lower lobe as well as the left lung appear clear.\n The cardiac and mediastinal contours appear unremarkable. No pleural\n effusions are identified. No pneumothoraces are seen.\n\n IMPRESSION: Large right upper lobe opacity consistent with pneumonia. Follow\n up PA and lateral chest radiograph is recommended after treatment to exclude a\n centrally obstructing lesions.\n\n Findings discussed with Dr. at 7:20 pm on .\n\n" }, { "category": "Radiology", "chartdate": "2112-04-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906346, "text": " 2:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for progression of PNA\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with hypotension, lobar pneumonia, ? central clearing of PNA\n on recent film\n REASON FOR THIS EXAMINATION:\n please evaluate for progression of PNA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Pneumonia.\n\n Endotracheal tube, central venous catheter unchanged in position. A\n nasogastric tube has been placed and terminates in the stomach. There remains\n consolidation in the right upper lobe, which show some interval improvement,\n particularly centrally and at the apex. No new or progressive areas of\n consolidation are evident in the remainder of the lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-04-07 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 905899, "text": " 9:04 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: r/o abscess\n Admitting Diagnosis: PNEUMONIA\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with n/v, upper abd pain, elev WBC, DM\n REASON FOR THIS EXAMINATION:\n r/o abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 9:44 PM\n No acute pathology.\n No abscess.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Nausea, vomiting and upper abdominal pain, elevated white cell\n count, diabetes, rule out abscess.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT acquired images of the abdomen and pelvis were obtained after\n the administration of IV and oral contrast. Coronal and sagittal reformatted\n images were also obtained.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The imaged portions of the lung bases are\n clear. The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys\n are unremarkable. Loops of small and large bowel are of normal caliber with\n no wall thickening. There are scattered large bowel diverticula without\n evidence of diverticulitis. No intra-abdominal free air or free fluid. No\n pathologically enlarged lymph nodes.\n\n CT OF THE PELVIS WITH IV CONTRAST: There are scattered sigmoid diverticula\n without evidence of diverticulitis. Bladder is decompressed. Prostate gland\n and seminal vesicles are grossly unremarkable. No pelvic or inguinal\n lymphadenopathy.\n\n Bone windows reveal no suspicious lytic or sclerotic lesions.\n\n IMPRESSION: No acute pathology seen to explain the patient's symptoms. No\n intraabdominal abscess is present.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2180-11-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1210420, "text": " 11:40 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: post op\n Admitting Diagnosis: PITUITARY ADENOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with transphenoidal resection of macroadenoma\n REASON FOR THIS EXAMINATION:\n post op\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:10 PM\n IMPRESSION: No evidence of hemorrhage status post resection of macroadenoma.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 54-year-old man status post transsphenoidal resection of a\n macroadenoma.\n\n STUDY: Non-contrast head CT.\n\n COMPARISON: MR of the head from and MR of the head from .\n\n FINDINGS: There is no large intracranial hemorrhage, mass effect, or shift of\n the midline structures. There is no vascular territorial infarct. The sulci\n and ventricles are normal in shape and caliber. The imaged portions of the\n mastoid air cells and paranasal sinuses are unremarkable. The visualized soft\n tissue and osseous structures are unremarkable.\n\n CT provides limited detail in regards to the sella. Air is seen in the post\n surgical bed in the sella, but there is no evidence of hemorrhage.\n\n IMPRESSION: No evidence of hemorrhage status post resection of macroadenoma.\n\n" }, { "category": "Radiology", "chartdate": "2180-11-02 00:00:00.000", "description": "MR HEAD W/ CONTRAST", "row_id": 1210361, "text": " 4:33 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: pre-surgical mapping for transphenoidal resection\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with non secreting pituitary mass\n REASON FOR THIS EXAMINATION:\n pre-surgical mapping for transphenoidal resection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old man with pituitary mass. Presurgery status.\n\n COMPARISON: MRI head dated .\n\n TECHNIQUE: Following IV administration of gadolinium, sagittal MP-RAGE with\n coronal and axial reformats as well as axial T1 spin echo sequences were\n obtained.\n\n FINDINGS: When compared to , there is no interval progress with regard to\n the sella mass, measuring 16 (AP) x 22 (TRV) x 22 (CC) mm. The mass appears\n to originate in the sella turcica and spans the bony floor as well as its\n anterior margin. It has a characteristic snowman configuration and extends\n through the diaphragma sellae into the suprasellar cistern. Significant mass\n effect is seen on the optic chiasm, the optic tract as well as the A1\n segments. The mass abuts the cavernous sinus bilaterally. However, there is\n no evidence of cavernous sinus invasion or encasement of the cavernous sinus\n ICA segments.\n\n The remainder of the exam is unremarkable. Specifically, there are no new\n contrast-enhancing lesions. The imaged paranasal sinuses and mastoid air\n cells are unremarkable on T1 images.\n\n IMPRESSION: No short interval change with regard to large sellar mass which\n most likely corresponds to a pituitary macroadenoma. Unchanged mass effect\n upon optic chiasm and A1 segments.\n\n" }, { "category": "Radiology", "chartdate": "2180-11-02 00:00:00.000", "description": "SELLA TURCICA (2 VIEWS)", "row_id": 1210399, "text": " 9:47 AM\n SELLA TURCICA (2 VIEWS); SKULL FLUORO Clip # \n Reason: TRANSPHONOIDAL,ENDOSCOPE\n Admitting Diagnosis: PITUITARY ADENOMA/SDA\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Sella turcica, .\n\n HISTORY: Transphenoidal surgery\n\n CLINICAL HISTORY: Intraoperative images have been submitted for dictation.\n These demonstrate placement of instruments in the region of sella turcica.\n The total intraservice fluoroscopic time was 9.9 seconds. Please refer to the\n operative note for additional details.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2166-08-16 00:00:00.000", "description": "Report", "row_id": 1597533, "text": "Neuro: sleeping most of day. easily aroused. oriented to self and place occasionally able to state the date. Pupils 2mm brisk, follows directions without difficutly. Pt having continued abdominal pain. med with dilaudid for every repositioning with little effect.\nCV: Tmax 99.7, HR 90's NSR with occasional tachycardia with repositioning. SBP 130's with occasional hypertension 180's with repostioning. CVP 11-14. lytes replaced today. Recieved 1u PRBC's for HCT 28 this am. followed by 40mg Lasix, with good diuresis.\nRESP: lungs clear to dim at bases. O2 at 4l via N/C with sats > 97%.\nGI: tol tube feed at goal. Colostomy draining mod amounts of loose brown neg guaiac stool. Stool spec for C-diff.\nGU: foley draining adequate amounts of clear yellow urine.\nENdocrine: blood sugars WNL.\nSKIN: Coccyx area abrasion dressing of mepilex changed today.\nLLQ I&D area open with red tissue packing placed. Colostomy red and slightly protruding. Small open area between colostomy and I&D area red with mod amount of sero-sang drg.\n" }, { "category": "Nursing/other", "chartdate": "2166-08-17 00:00:00.000", "description": "Report", "row_id": 1597534, "text": "n/sicu nursing note 7p-7a\nreview of systems\n\nneuro: aox1. pt not following commands. mae upper>lowers. pearl. episode of agitation that was rx'd with ativan 0.5mg iv with effect. dilaudid 1mg iv prn for pain.\n\ncv: hr 70-90 sr with no ecotpy. sbp 100-120. +pp with skin warm and dry. lopressor 5mg iv q6.\n\nresp: l/s clear and diminished at bases. no sob or resp distress noted. o2 4lnc with good sats.\n\ngi: abd softly distended with +bs. conts on impact with fiber at 65cc/hr via peditube. colostomy stoma red and appliance changed d/t leaking. colostomy output is loose brown. vac dsg intact to abd wound. ns w>d dsg changed to I&d site. small puncture site with aquacel.\n\ngu: u/o adequate. lytes repleted.\n\nheme: hct stable.\n\nendo: bs wnl.\n\nid: afebrile. wbc flat. conts on linezolid, meropenum and diflucan\n\nskin: dsg to coccyx intact.\n\nsocial: no contact with family this shift.\n\nplan: cont current treatment and ? move to floor today.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2166-08-17 00:00:00.000", "description": "Report", "row_id": 1597535, "text": "Neuro: Pt withdrawn most of day. arouses to voice, pupils 2mm brisk. follows all directions. oriented to person and place. having much pain during repositioning.\nCV: afebrile HR 80's NSR with no ectopy, SBP 110-130's, CVP 10-14, extremities warm with 2-3+ pitting edema. Dopplerable pulses. Lytes replaced.\nRESP: lungs clear to dim at bases. O2 increased to 4l via N/C this afternoon due to agitation when repositioning.\nGI: pt vomited approx 200cc undigested tube feed X1. tube feed on hold at this time. colostomy draining mod amounts of loose brown negative guaiac stool.\nGU: foley draining adequate amounts of clear yellow urine.\nEndocrine: blood sugars WNL.\nSKIN: colostomy red and protruding, tissue surrounding slightly red but intact. I&D site red with mod amounts of sero-sang drg, tissue surrounding with erythema. Open area between colostomy and I&D site remains with erythema, packed with soaked NS 2X2. coccyx area with Stage II small amount of sero-sang drg. mepilex changed.\n" }, { "category": "Nursing/other", "chartdate": "2166-08-15 00:00:00.000", "description": "Report", "row_id": 1597531, "text": "CONDITION UPDATE\nASSESSMENT:\nNEURO- SLEEPING MOST OF NIGHT, ORIENTED TO PERSON & PLACE. MOVES ALL EXTREMITIES BUT VERY WEAK.\nCV/GU- HEART RATE AND BLOOD PRESSURE STABLE, SEE FLOWSHEET FOR DETAILS. HOURLY URINE OUTPUT LOW MOST OF THE NIGHT, 2 FLUID BOLUSES GIVEN WITHOUT EFFECT. DR. (ICU RESIDENT) AWARE. CVP ~ 14-15 AND PT STABLE, NO FURTHER INTERVENTION.\nGI- ABDOMEN OBESE, WOUND VAC IN PLACE ON MIDLINE INCISION, NO DRAINAGE. LEFT LOWER QUADRANT, CLEANSED WITH NORMAL SALINE, PACKED, AND APPLIANCE CHANGED. LEFT LOWER QUADRANT DRAINING MOD AMOUNTS SEROUS DRAINAGE. STOMA PINK, LARGE AREA OF ERYTHEMA SURROUNDING STOMA, OUTLINED. OSTOMY APPLIANCE CHANGED BY ETRN. TOLERATING TUBE FEEDS AT GOAL RATE OF 80CC/HR.\nRESP- LUNG SOUNDS CLEAR, SP02 > 94% WITH 4 LITERS NASAL CANNULA.\nINTEG- SEE WOUND INFO. SACRAL AREA WITH PINK OPEN AREA, APPROX 6CM BY 1 CM. FOAM DRESSING PLACED OVER WOUND AS SUGGESTED BY , SKIN NURSE.\nPLAN:\nCONTINUE ON CURRENT ANTIBIOTICS. CONTINUE WITH CURRENT ICU MONITORING AND TREATMENT.\n" }, { "category": "Nursing/other", "chartdate": "2166-08-15 00:00:00.000", "description": "Report", "row_id": 1597532, "text": "Neuro: Pt alert and oriented to person and place, occasionally oriented to time. Pupils 2mm brisk, answers questions appropriately. follows all directions without difficulty despite generalized weakness. EMG done at bedside, results pending. Pt having abd/incisional pain med several times with dilaudid 2mg with minimal effect.\nCV: low grade temp 99.5, HR 80-90's NSR to Sinus tach with no noted ectopy, SBP 100-120's, episode of hypertension 170's during repositioning but quickly returned to baseline. CVP 10-14. Extremities warm with 2+ pitting edema. +PP.\nRESP: lungs clear to dim at bases. O2 at 4l via N/C. O2 sats >98%. Occasional congested non-prod cough.\nGI: tube feed at goal, colostomy draining small amount of liquid brown stool this eve. Abd obese with +BS.\nGU: foley draining just adequate amounts of clear yellow urine. 20-40cc/hr.\nEndocrine: blood sugars WNL. no coverage needed per RISS.\nSKIN: Coccyx dressing intact, to be changed QD. Colostomy red in color. LLQ ID site pink with mod amount of sero-sang drg. Packing changed several times by several teams. Tissue between ID site and colostomy boggy and red. Dr. assessed area and did ID at bedside. Area drained mod amount of pus. Packing placed and changed X1 today, drainage sent for cultures. Pt placed on Kinair bed for skin breakdown.\n" }, { "category": "Nursing/other", "chartdate": "2166-08-13 00:00:00.000", "description": "Report", "row_id": 1597528, "text": "Nursing Admission Note\n 1030->\n\nSee FHP and flowsheet for details.\n\nPt transferred from PACU to SICU s/p I&D of abdominal abcess. Pt encountering low BP and decreased u/o post op, ? d/t dehydration s/p bowel prep vs septic progression.\nPt placed on ICU monitor, given LR at 150mL/hr vai #20 PIV, given LR 500mL IVB.\nMultiple attempts to place a-line d/t very low and unreliable NIBP in BUE requring BP measurment in BLE which is painful for pt.\nAbx changed for klebsiella, MRSA, VRE coverage and soft tissue coverage -> see MARs.\nPt seen by neuromed d/t severe BLE weakness -> see neuro note. Pt to undergo EMG, head MRI, and possible LP under fluoro.\nPt had pigtail drainage tube placed into abdominal abcess under bedside ultrasound. Aspirate purulent and bloody, sent for cx.\nPt seen by infectious disease -> abx changed.\nPt seen by skin care nurse -> colcostomy bag changed; sacral decubitus extends to anus, drng purulent and bldy drng -> aquacel drsg and with DSD. Per skin care nurse, apply window of ostomy wafer when available to protect skin from frequent tape changes.\nPersitent pain at left abd flank treated with fenatnyl without results and changed to dilaudid.\nPersistent back pain treated with Toradol 15mg IM without effect.\nHypotension to SBP 70's in RUE / >85 in RLE treated with LR boluses x2 with + rise in BP.\nDecreased u/o treated with IVF with increase in urine output htis evening.\nSee CareVue flowsheet, FHP, MARs for details.\n\nA/P\n\nContinue monitoring, treating fluid balance, BP, pain, infection issues.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2166-08-14 00:00:00.000", "description": "Report", "row_id": 1597529, "text": "NSG NOTE\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT AWAKE, ORIENTED TO PERSON ONLY. PT SELDOM SPEAKING. FOLLOWS COMMANDS. MAE.\n\nCV-AFEB. HR 90-110'S. SBP 80'S. ALINE AND CVL PLACED. MULTI FLUID BOLUS GIVEN WITH + INCREASE IN SBP. SKIN W+D. +PP. PBOOTS ON. HCT STABLE. LYTES REPLETED. RULED OUT FOR MI.\n\nRESP-O2 SAT 97% ON 3L NC. LS CLEAR, DECREASED AT BASES. NARD NOTED.\n\nGI-ABD OBESE, SOFT. NPO. ABD WOUND OPEN WITH PINK GRANULATION TISSUE. WET TO DRY DSG CHANGED. ABCESS DRG SITE WITH WET TO DRY DSG WITH OSTOMY APPLIANCE OVER IT. AREA WITH SEROUSSANG DRG. STOMA BEEFY PINK WITH SCANT AMT GOLDEN STOOL. PIGTAIL DRAIN IN PLACE WITH NO DRG.\n\nGU-U/O LOW ALL NOC. SEE I+O. MULTI FLUID BOLUSES GIVEN WITH NO EFFECT. TEAM AWARE. ALBUMIN ORDERED.\n\nENDO-SSRI.\n\nCOMFORT-DILAUDID PRN.\n\nPLAN-CON'T WITH CURRENT PLAN. MONITOR FOR CHANGES. FOLLOW LABS. I+O. SKIN CARE.\n" }, { "category": "Nursing/other", "chartdate": "2166-08-14 00:00:00.000", "description": "Report", "row_id": 1597530, "text": "focus update note\nT max 99 90-110 St to 130s lopressor given with effect NSr 80-90s NSR\nCVP 4-15, colonoscopy via colostomy- test negative- no ischemia, no perferation, EKG unchanged, ECHO 55% shows slightly enlarged atrium, CXR shows dop hoff in stomach- TF started impact with fiber. wound vac applied to abd open wound for closure at 1800 by Dr . pt alert X 2 most of day answering name and place not year. answers question regarding pain will consistently follow commands MAE to command. stool via colostomy sent for cdiff culture 2 of 3, sacral wound open red scant sang drainage- aqacel dressing and miconazole power wound RN, abd muscle biopsy site drainag sero sang drainage., 500 cc LR bolus X 3 for SBP 80-90s and heart rate 120-130\n" }, { "category": "Nursing/other", "chartdate": "2166-08-18 00:00:00.000", "description": "Report", "row_id": 1597536, "text": "7p-7a; Full assesment in flow sheet.\n\nA+OX1. MAE - weakly. Follow commands. Pain per pt abd - hydromorphone ivp given - good effect. Good cough and gag reflex. Flat affect. VSS, afebrile. warm, dry, general edema +1. Clear to coarse lung sound. 4L NC - SaO2 >96%. obese abd. +BSX4. no n/v. Dobhoff - +placement, TF continue hold. Colostomy - red, brown stool, neg guiac. abd vac site d/c/i, serous drainage. Please see flow sheet for multiple skins area. AM lab done.\n\nPlan; Continue to monitor.\n" }, { "category": "Radiology", "chartdate": "2166-08-13 00:00:00.000", "description": "PARACENTESIS DIAG. OR THERAPEUTIC", "row_id": 834079, "text": " 3:56 PM\n PARACENTESIS DIAG. OR THERAPEUTIC; 79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \n GUIDANCE FOR ABSCESS ()\n Reason: percutaneous abscess drainage under ultrasound\n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p I&D of abscess yesterday. ostomy.\n REASON FOR THIS EXAMINATION:\n percutaneous abscess drainage under ultrasound\n ______________________________________________________________________________\n FINAL REPORT\n Please see clip for complete report.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 835252, "text": " 8:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? of CHF or other cause of CP\n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with c/o chest pain\n REASON FOR THIS EXAMINATION:\n ? of CHF or other cause of CP\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Chest pain of unknown cause. Evaluate for CHF or other\n abnormalities.\n\n PORTABLE AP CHEST: AP single view of chest concentrates on lower portion and\n includes upper half of abdomen. The NG tube has now advanced further and has\n passed the stomach as well as the duodenal loop, this close to the\n duodenal/jejunal junction. The right sided jugular central venous line is\n unchanged in position and terminates in the lower SVC close to the expected\n site of the entrance into the right atrium. The accessible pulmonary fields\n do not demonstrate any significant congestive pattern, but diffuse haze over\n the bases and visibility to identify the right diaphragmatic contours is again\n suggestive of bilateral pleural effusions layering posteriorly. It appears\n that the densities are more marked on the left than on the right side.\n\n In comparison with the next previous similar chest x-ray progression of the NG\n tube is noted as described. The chest findings are suggestive of bilateral\n pleural effusions, but no evidence of CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-08-21 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 834996, "text": " 9:10 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: r/o brain/spinal abscess\n Admitting Diagnosis: HEMATOCHEZIA\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with weakness s/p I&D\n REASON FOR THIS EXAMINATION:\n r/o brain/spinal abscess\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Weakness, status-post incision and drainage, rule out brain or\n spinal abscess.\n\n Comparison is made to the prior CT of the head dated .\n\n TECHNIQUE: Multiplanar pre and post-gadolinium enhanced T1 weighted images of\n the brain were performed along with axial T2, FLAIR, susceptibility and\n diffusion weighted images of the brain were performed.\n\n FINDINGS: There is no shift of normally mid-line structures, mass effect, or\n hydrocephalus. There are no abnormal areas of enhancement within the brain\n parenchyma. Note is made of a slightly enhancing 1.8 x 0.7 cm convex extra-\n axial T1 hyperintense lesion along the anterior right inner table immediately\n adjacent to the falx. This corresponds to a area of calcification on the prior\n CT scan and is consistent with a calcified meningioma. There is again\n demonstrated prominence of the ventricles and sulci consistent with atrophy.\n There are no abnormal areas of susceptibility or restricted diffusion. There\n are periventricular and subcortical white matter FLAIR signal hyperintensities\n in both cerebral hemispheres consistent with the previously seen areas of\n hypodensity on the recent CT. Mucosal thickening is again appreciated in the\n sphenoid sinus which contains T1 hypointense material likely representing\n inspissated secretions. The visualized osseous structures are otherwise\n unremarkable.\n\n IMPRESSION:\n 1) No evidence of intracranial abscess or infarction.\n 2) Chronic small vessel ischemic changes and atrophy consistent with prior CT\n scan.\n 3) Calcified meningioma along the anterior right inner table.\n 4) Unchanged chronic sphenoid sinus mucosal disease.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 835006, "text": " 12:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Is tube in stomach?\n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p Dobhoff placement\n\n REASON FOR THIS EXAMINATION:\n Is tube in stomach?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68 y/o woman s/p Dobhoff placement.\n\n COMPARISON: .\n\n CHEST AP: Dobhoff tube is coiled with the tip in the esophagus. Right IJ CVL\n tip is in unchanged position. There are bilateral pleural effusions which are\n increased from previous study. Bibasilar atelectasis is noted. Cardiac,\n mediastinal and hilar contours are difficult to examine on this radiograph.\n Osseous and soft tissue structures are unremarkable.\n\n IMPRESSION: Dobhoff tip within esophagus. Interval increase in bilateral\n pleural effusions and bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 834636, "text": " 10:12 AM\n CHEST (PA & LAT) Clip # \n Reason: visualize pleural effusions\n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with pleural effusions\n REASON FOR THIS EXAMINATION:\n visualize pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate pleural effusions.\n\n COMPARISON: .\n\n CHEST, AP & LATERAL RADIOGRAPH: This study is markedly limited by patient body\n habitus and positioning. Allowing for technique, cardiac, mediastinal and\n hilar contours are stable. There is no definite pulmonary vascular congestion.\n There is a grossly unchanged small left pleural effusion and probable small\n right pleural effusion. The osseous structures are unremarkable.\n\n A Dobhoff tube tip overlies the stomach.\n\n IMPRESSION: Limited study, with probably unchanged small left pleural effusion\n and probable small right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-13 00:00:00.000", "description": "P US ABD LIMIT, SINGLE ORGAN PORT", "row_id": 834063, "text": " 1:38 PM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: Please assess for possibility of ultrasound guided aspirat\n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with intra-abdominal fluid collection, overlying soft tissue\n abscess s/p I&D.\n REASON FOR THIS EXAMINATION:\n Please assess for possibility of ultrasound guided aspiration/drainage.\n Discussed with .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intra-abdominal fluid collection, soft tissue abscess.\n\n ABDOMINAL ULTRASOUND AND ULTRASOUND GUIDED DRAINAGE: Limited abdominal\n ultrasound was performed and a 5.8 X 1.7 X 4.6 cm, mixed echogencity\n collection was identified underlying the left anterior abdominal wall.\n\n Signed and informed consent was obtained from the health care proxy,\n the patient's son, via telephone. The patient was prepped and draped in\n standard sterile fashion. Local anesthetic (Lidocaine) was instilled. An 18\n gauge spinal needle was then inserted under continuous direct ultrasound\n guidance into the fluid collection. Approximately 3 cc of purulent material\n was withdrawn. At that point the spinal needle was removed and an 8 French\n pigtail catheter was inserted into the collection. Approximately 5 cc more of\n purulent fluid was removed. The pigtail was then curled and secured. The\n pigtail was then left to bag drainage. There were no immediate complications.\n The fluid was set aside for labs and culture per the ICU staff.\n\n The attending radiologist, Dr. , was present throughout the entire\n procedure.\n\n IMPRESSION: Successful percutaneous drainage with pigtail catheter placement\n within left anterior intraabdominal abscess.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 834173, "text": " 2:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess location of tip\n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p Dobhoff placement\n REASON FOR THIS EXAMINATION:\n assess location of tip\n ______________________________________________________________________________\n FINAL REPORT\n Clinical Indication: Dobhoff tube placement.\n\n Comparison: Compared with previous study of 1 day earlier.\n\n Portable AP Chest: A Dobhoff tube is in place and terminates within the\n stomach. A vascular catheter remains in place in the region of the junction\n of the superior vena cava and right atrium. Cardiac and mediastinal contours\n are stable. There is a persistent left retrocardiac opacity, as well as a\n probable small left pleural effusion.\n\n IMPRESSION: Dobhoff tube terminates within the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-08-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 834110, "text": " 11:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for PTX, line placement.\n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p right IJ CVL.\n REASON FOR THIS EXAMINATION:\n Please assess for PTX, line placement.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68 year old woman status post right IJ CVL placement. Assess\n pneumothorax and line placement.\n\n CHEST AP: Right IJ CVL tip terminates at the distal SVC. There is no\n pneumothorax. There has been interval removal of right-sided PICC line.\n Cardiac size is at upper limits of normal. Mediastinal and hilar contours are\n stable in appearance. Left lower lobe atelectasis and pleural effusion remain\n but are slightly improved compared to previous study. Osseous and soft-tissue\n structures are stable in appearance.\n\n IMPRESSION: No pneumothorax. Right IJ CVL tip at distal SVC. Continued left\n lower lobe atelectasis and pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-22 00:00:00.000", "description": "CT T-SPINE W/ CONTRAST", "row_id": 835091, "text": " 5:04 PM\n CT T-SPINE W/ CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: r/o spinal abscess\n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old femal s/p I&D w/ weakness\n REASON FOR THIS EXAMINATION:\n r/o spinal abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post I&D with weakness. Evaluate for spinal abscess.\n\n COMPARISON: None.\n\n TECHNIQUE: Helically-acquired contiguous axial images of the thoracic spine\n were obtained following the administration of 150 cc of IV Optiray. Nonionic\n contrast was administered secondary to the patient's debility. Coronal and\n sagittal reconstructions were performed.\n\n CT OF THE THORACIC SPINE WITH IV CONTRAST: No fracture or malalignment of the\n thoracic spine is identified. Multilevel degenerative changes are noted with\n anterior osteophyte formation and endplate sclerotic changes. The outline of\n the thecal sac appears unremarkable. No paraspinal fluid collections are\n identified suggestive of an abscess. Bilateral pleural effusions and\n bibasilar atelectasis are noted.\n\n IMPRESSION: Multilevel degenerative changes without evidence of malalignment\n or fracture. No focal fluid collections identified suggestive of an abscess.\n Spinal canal detail is limited and an epidural abscess cannot be fully\n excluded on the basis of this study. If the patient is able to tolerate it,\n an MR study with gadolinium is a more sensitive study.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2166-08-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 835437, "text": " 10:46 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: stat cxr needed to verify NGT placement\n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p I&d\n REASON FOR THIS EXAMINATION:\n stat cxr needed to verify NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement. Verify position.\n\n PORTABLE SEMI-UPRIGHT CHEST: Comparison is made to . A feeding tube\n is seen with the tip not visualized, off the inferior film edge, but below the\n diaphragm. The wire stiffener is still within the tube. The right internal\n jugular central venous line is unchanged in appearance. The heart and lungs\n are unchanged.\n\n IMPRESSION: S/P feeding tube placement. Tip not visualized, but well below\n the GE junction. Appearance of the lungs unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-22 00:00:00.000", "description": "CT L-SPINE W/ CONTRAST", "row_id": 835089, "text": " 5:03 PM\n CT L-SPINE W/ CONTRAST; CT RECONSTRUCTION Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: r/o spinal abscess\n Admitting Diagnosis: HEMATOCHEZIA\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old femal s/p I&D w/ weakness\n REASON FOR THIS EXAMINATION:\n r/o spinal abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post I&D with weakness. Evaluate for spinal abscess.\n\n TECHNIQUE: Helically-acquired contiguous axial images of the lumbosacral\n spine were obtained following the administration of 75 cc of IV Optiray.\n Nonionic contrast was administered secondary to patient's debilitation.\n Coronal and sagittal reconstructions were performed.\n\n CT OF THE LUMBOSACRAL SPINE WITH IV CONTRAST: No fracture or malalignment of\n the lumbosacral spine is identified. There are multilevel degenerative\n changes noted at the L1-2, L3-4, L4-5, and L5-S1 levels with narrowing of the\n intervertebral disc spaces, vacuum disc phenomena, anterior and posterior\n osteophyte formation, and endplate sclerosis. At the L1-2, L2-3, L3-4, and\n L5-S1 levels, there are moderate-sized disc bulges present which narrow the\n central canal but do not appear to cause compression of the thecal sac.\n Additionally, posterior to the L4 vertebral body, there is slightly hyperdense\n areajust ventral to the thecal sac, which appears to be continuity with the\n L3-4 disc and appears to be due to disc bulgebulge.\n\n No focal paraspinal fluid collections are identified. IVC filter is\n identified. Extensive aortic calcifications are seen within the distal aorta.\n\n IMPRESSION:\n 1) Multilevel degenerative disease within the lumbar spine with several disc\n bulges identified as delineated above.\n 2) Although no large intraspinal collections or compression of thecal sac is\n seen, a small intraspinal abscess cannot be fully excluded as there is lack of\n detail within the spinal canal.\n 3) No paraspinal fluid collections consistent with an abscess are identified.\n\n An MRI study with gadolinium, if the patient can tolerate, would be a more\n sensitive study in excluding the presence of an epidural abscess.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-22 00:00:00.000", "description": "CT C-SPINE W/CONTRAST", "row_id": 835090, "text": " 5:03 PM\n CT C-SPINE W/CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: r/p spinal abscess\n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old femal s/p I&D w/ weakness\n REASON FOR THIS EXAMINATION:\n r/p spinal abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post I&D with weakness. Evaluate for spinal abscess.\n\n TECHNIQUE: Helically-acquired contiguous axial images were obtained of the\n cervical spine following the administration of 150 cc of IV Optiray. Nonionic\n contrast was used secondary to the patient's debilitation. Coronal and\n sagittal reconstructions were performed.\n\n COMPARISON: None.\n\n CT OF THE CERVICAL SPINE WITH IV CONTRAST: No acute fracture is identified.\n There is mild grade I C4 on C5 and C5 on C6 anterolisthesis. Multilevel mild\n degenerative changes are noted predominantly at C4-5, C5-6, and C6-7 with\n narrowing of the intervertebral disc space, anterior and posterior osteophyte\n formation, and endplate irregularities. The visualized outline of the thecal\n sac appears unremarkable. No paraspinal fluid collections are identified\n suggestive of an abscess. No prevertebral soft tissue swelling is identified.\n There are large bilateral pleural effusions noted. Visualization of the\n spinal canal contents is limited and an epidural abscess cannot be fully\n excluded. A nasogastric tube is seen which is looped within the oropharynx.\n\n IMPRESSION:\n 1. Mild grade I C4 on C5 and C5 on C6 anterolisthesis.\n 2. Multilevel degenerative changes.\n 3. No paraspinal fluid collections identified suggestive of an abscess. The\n detail within the spinal canal is limited and, therefore, an epidural abscess\n cannot be fully excluded. An MR study with gadolinium, if the patient can\n tolerate, is a much more sensitive study to exclude epidural abscess.\n 4. Large bilateral pleural effusions.\n 5. Nasogastric tube looped within the oropharynx. The NGT tip extends\n inferiorly, off the inferior border of the study and is at least within the\n distal esophagus.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-18 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 834561, "text": " 2:41 PM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: Please attempt aspiration and drain placement. Please \n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with diverticulitis s/p sigmoid colectomy/Hartmann's\n procedure, now with abdominal fluid collection.\n REASON FOR THIS EXAMINATION:\n Please attempt aspiration and drain placement. Please send aspirate for gram\n stain and culture.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN WITHOUT CONTRAST .\n\n TECHNIQUE: CT of the abdomen was performed without intravenous contrast using\n 5 mm collimation, and compared with the examination dated .\n\n CT ABDOMEN WITHOUT CONTRAST: There are moderate to large bilateral pleural\n effusions and collapse of the left lower lobe, and to a lesser extent, the\n right lower lobe, all of which are increased since the prior examination.\n\n The liver is extensively fatty infiltrated, as before. There is a large\n amount of dense contrast within the stomach, resulting in beam hardening\n artifact in the upper abdomen.\n\n The previously noted fluid collection within the left upper quadrant of the\n abdomen, previously measuring approximately 7 cm x 3.6 cm, has decreased in\n size considerably, now measuring approximately 5 cm x 1.3 cm. There remains\n moderate subcutaneous gas within the left flank, though decreased since the\n prior examination. An ostomy is once again noted on the left. There has been\n interval incision and drainage of thh left flank, posterior to the ostomy\n site, with gauze packing within the drainage site. There is moderate\n stranding and fluid within the soft tissues diffusely, without drainable\n abscess collection or loculated fluid collection.\n\n The gallbladder is denser than on the prior examination, possible representing\n gallbladder sludge. The left adrenal gland contains an approximately 1.4 cm\n lesion as on the prior examination. The right adrenal gland is unremarkable.\n Degenerative changes are seen within the spine.\n\n IMPRESSION: 1) Marked interval reduction in size of the previously identified\n left upper quadrant fluid collection.\n\n 2) Diffuse stranding and fluid within the left flank near the site of\n incision and drainage, without focal fluid collection or drainable abscess\n collection.\n\n The above findings were discussed with the housestaff, and in light of the\n above findings, the drainage procedure was cancelled.\n\n (Over)\n\n 2:41 PM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: Please attempt aspiration and drain placement. Please \n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2166-08-21 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 834972, "text": " 3:02 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: PT WITH LONGSTANDING IMMOBILITY, ? DVT\n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p I&D; hasn't ambulated in a while\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post excision drainage, bed ridden, swelling.\n\n BILATERAL LOWER EXTREMITY ULTRASOUND: Partially occlusive thrombus is\n identified within the left common femoral vein. This is not seen extending\n into the superficial femoral vein. Otherwise, 2D, color and Doppler waveform\n imaging of the right common femoral, bilateral superficial and popliteal veins\n demonstrates normal compressibility, waveform and augmentation. No other\n intraluminal thrombus is identified.\n\n IMPRESSION: Partially occlusive thrombosis of the left common femoral vein.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-22 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 835009, "text": " 3:17 AM\n PORTABLE ABDOMEN Clip # \n Reason: Is tube in stomach?\n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p Dobhoff placement\n\n REASON FOR THIS EXAMINATION:\n Is tube in stomach?\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE FILM:\n\n HISTORY: Feeding tube placement.\n\n The distal end of the feeding tube is coiled in the fundus of the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-11 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 833880, "text": " 8:41 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: Please evaluate for ischemic colitis, diverticulitis, absces\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with recent partial colectomy/colostomy now presents with 4\n days of hematochezia in ostomy bag and abdominal pain, worse with eating.\n REASON FOR THIS EXAMINATION:\n Please evaluate for ischemic colitis, diverticulitis, abscess.\n CONTRAINDICATIONS for IV CONTRAST:\n allergy to iodine\n ______________________________________________________________________________\n WET READ: DFDdp MON 11:54 PM\n extensive subcutaneous emphysema and soft tissue stranding adjacent to osteomy\n with thickening of the bowel wall of the loop involved in the osteomy. 3.5x7.0\n cm abscess in left anterior abdominal cavity which appears to connect to this\n loop of bowel. no obstruction.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Status post colectomy with colostomy and four days of\n hematochezia and abdominal pain.\n\n COMPARISON: None.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n lung bases to the pubic symphysis following administration of oral contrast.\n IV contrast was not administered secondary to the patient's history of\n allergy. Multiplanar reconstructions were performed.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: Small bilateral pleural effusions are\n present, left greater than right. Minor bibasilar compressive atelectasis is\n also present. The noncontrast enhanced liver, pancreas, spleen, right adrenal\n gland, kidneys, stomach, and loops of small bowel all appear within normal\n limits. The gallbladder is somewhat distended, but there is no intra- or\n extrahepatic biliary duct dilatation identified. The left adrenal gland\n appears full, and likely represents an adenoma, but this is not fully\n evaluated on this noncontrast enhanced study. There is no free air or free\n fluid. Multiple small mesenteric and retroperitoneal lymph nodes are\n identified, specifically within the para- aortic region, none of which meet CT\n criteria for pathologic enlargement.\n\n A colostomy is identified within the left lower quadrant. There is an\n extensive amount of subcutaneous emphysema identified adjacent to the ostomy\n site with soft tissue stranding identified. The loop of colon within the\n ostomy demonstrates mild bowel wall thickening and pericolonic fat stranding\n within the subcutaneous tissues. There is no evidence of bowel obstruction\n and contrast is seen flowing into the ostomy bag. The remaining loops of\n large bowel otherwise appear unremarkable. Additionally within the left\n anterior abdominal wall, anterior to the spleen, there appears to be a focal\n fluid collection with an air-fluid level identified, measuring approximately\n 3.6 x 7.0 cm. This fluid collection appears to connect with the loop of colon\n (Over)\n\n 8:41 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: Please evaluate for ischemic colitis, diverticulitis, absces\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n involved in the ostomy.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: A Foley catheter is identified within\n the bladder which contains a small pocket of air. The pelvic loops of bowel\n otherwise appear unremarkable. There is no free fluid. There is no\n significant pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are present.\n\n CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were essential in\n delineating the presence of the left anterior abdominal wall abscess and\n extensive subcutaneous emphysema surrounding the ostomy site.\n\n IMPRESSION:\n 1. Extensive subcutaneous emphysema within the soft tissues adjacent to the\n ostomy site in the left lower quadrant. Surrounding soft tissue stranding is\n present as well as bowel wall thickening and pericolonic inflammation of the\n loop of bowel involved in the ostomy. No bowel obstruction seen. These\n findings are concerning for an infectious process and necrotizing fasciitis\n cannot be fully excluded.\n 2. Abscess within the abdominal cavity which contacts the left anterior\n abdominal wall and appears to connect with the loop of bowel involved in the\n ostomy.\n 3. Small bilateral pleural effusions, left greater than right.\n 4. Left adrenal lesion, likely representing an adrenal adenoma.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-08-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 835202, "text": " 1:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please check dobhoff placement\n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p Dobhoff placement\n\n REASON FOR THIS EXAMINATION:\n please check dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 1:13 A.M.:\n\n INDICATION: Dobbhoff tube placement.\n\n FINDINGS: Since the examination from two days earlier, the feeding tube has\n been advanced, with the tip projecting over the expected area of the third\n portion of the duodenum. The visualized upper bowel loops are normal in size.\n A left-sided pleural effusion is noted, as well as retrocardiac opacification,\n suggesting atelectasis and/or consolidation, not significantly changed. There\n may be a layering right-sided pleural effusion. A right internal jugular line\n is unchanged in its position, with the tip overlying the SVC/RA junction.\n\n IMPRESSION: Satisfactory position of feeding tube.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-22 00:00:00.000", "description": "O ABDOMEN, SINGLE VIEW IN O.R.", "row_id": 835079, "text": " 3:16 PM\n ABDOMEN, SINGLE VIEW IN O.R.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n ABDOMINAL FLUORO WITHOUT RADIOLOGIST IN O.R.; -59 DISTINCT PROCEDURAL SERVICE\n Reason: DOBHOFF INSERTION UNDER FLUORO\n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: History of feeding tube placement.\n\n ABDOMEN, single view: The distal end of feeding tube is in body of stomach.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-26 00:00:00.000", "description": "PICC W/O PORT", "row_id": 835401, "text": " 7:32 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC for IV Abx, HIT+ (No heparin)\n Admitting Diagnosis: HEMATOCHEZIA\n ********************************* CPT Codes ********************************\n * PICC W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * FLUOR GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p I&D, abscess, HIT+ (No heparin)\n REASON FOR THIS EXAMINATION:\n PICC for IV Abx, HIT+ (No heparin)\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: The patient is a 68-year-old woman, status post incision and\n drainage of an abscess, Heparin induced thrombocytopenia. Need for long term\n intravenous antibiotics. IV was not passable to advance the PICC line.\n\n PROCEDURE: The procedure was performed by Dr. , Dr. , and Dr.\n , with Dr. , the Attending Radiologist, being present and\n supervising.\n\n The left upper arm was prepped and draped in a sterile fashion. Since no\n suitable superficial veins were visible, ultrasound was used for localization.\n The basilic vein was patent and compressible. After local anesthesia with 2\n ml of 1% Lidocaine, the basilic vein was entered under ultrasonographic\n guidance with a #21 gauge needle. Hard copies of ultrasound images were\n obtained, documenting patent vein before and after establishing an access. A\n 0.18 guide wire was advanced under fluoroscopic guidance into the superior\n vena cava. A #4 French catheter was then placed and trimmed to a\n length of approximately 50 cm so that the tip would lie within the superior\n vena cava. The sheath was then removed. The catheter was flushed. A final\n chest x-ray was obtained. The film demonstrates the tip to be in the superior\n vena cava. The line is ready for use. A stat lock was applied.\n\n IMPRESSION: Successful placement of a 50 cm total length PICC line\n with the tip in the superior vena cava, ready for use.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-08-22 00:00:00.000", "description": "PERCU PLCT IVC FILTER S&I", "row_id": 835077, "text": " 3:00 PM\n OR VASCULAR A-GRAM Clip # \n Reason: IVC FILTER PLACEMENT\n Admitting Diagnosis: HEMATOCHEZIA\n ********************************* CPT Codes ********************************\n * PERCU PLCT IVC FILTER S&I VENOGRAPHY IVC S&I *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n For complete report please see operative note in CareWeb ClinicaL Lookup.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 834527, "text": " 10:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: reassess tip\n Admitting Diagnosis: HEMATOCHEZIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p Dobhoff placement\n\n REASON FOR THIS EXAMINATION:\n reassess tip\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post Dobbhoff tube placement.\n\n COMPARISON: .\n\n CHEST, SUPINE RADIOGRAPH: There is stable cardiac enlargement. The\n mediastinal and hilar contours are unremarkable. There is slightly increased\n pulmonary vascular redistribution and interstitial opacities. There is a\n persistent left lower lobe retrocardiac opacity and small left pleural\n effusion. The Dobbhoff tube tip overlies the gastric bubble. The right\n internal jugular central venous catheter tip is in distal SVC. The osseous\n structures are unremarkable.\n\n IMPRESSION:\n 1) Satisfactory Dobbhoff tube placement with tip overlying the gastric air\n bubble.\n 2) Persistent left lower lobe retrocardiac opacity and small pleural\n effusion, with new mild congestive heart failure.\n\n" }, { "category": "Echo", "chartdate": "2166-08-14 00:00:00.000", "description": "Report", "row_id": 94545, "text": "PATIENT/TEST INFORMATION:\nIndication: A. Fib, LV Function\nHeight: (in) 69\nWeight (lb): 220\nBSA (m2): 2.15 m2\nBP (mm Hg): 126/63\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 14:10\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is elongated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is elongated. A catheter or\npacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Regional left ventricular wall motion is\nnormal. Overall left ventricular systolic function is normal (LVEF>55%). There\nis no resting left ventricular outflow tract obstruction.\n\nRIGHT VENTRICLE: Right ventricular systolic function is normal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is\nmoderately dilated. The aortic arch is mildly dilated.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. There is no aortic valve stenosis. Trace aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. There is mild pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: The rhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is elongated. The right atrium is elongated. There is mild\nsymmetric left ventricular hypertrophy. The left ventricular cavity size is\nnormal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular systolic\nfunction is normal. The ascending aorta is moderately dilated. The aortic arch\nis mildly dilated. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion. Trace aortic regurgitation is seen. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nmild pulmonary artery systolic hypertension. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2166-08-24 00:00:00.000", "description": "Report", "row_id": 273189, "text": "Sinus rhythm\nMarked left axis deviation\nIntraventricular conduction defect\nProbable old anteroseptal infarct\nInferior ST elevation - repeat if myocardial injury is suspected\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2166-08-14 00:00:00.000", "description": "Report", "row_id": 273190, "text": "Sinus tachycardia\nBorderline first degree A-V block\nLeft bunch branch block\nQS across precordium probably old anterior myocardial infarction\nSince previous tracing, sinus tachycardia noted\n\n" }, { "category": "ECG", "chartdate": "2166-08-12 00:00:00.000", "description": "Report", "row_id": 273191, "text": "Sinus rhythm. P-R interval prolongation. Left bundle-branch block. Left atrial\nabnormality. Compared to the previous tracing of there is no significant\ndiagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2166-08-12 00:00:00.000", "description": "Report", "row_id": 273192, "text": "Sinus rhythm. Compared to tracing #2, there is no significant diagnostic\nchange.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2166-08-12 00:00:00.000", "description": "Report", "row_id": 273193, "text": "Sinus rhythm. Compared to the previous tracing of there is no\nsignificant diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2166-08-11 00:00:00.000", "description": "Report", "row_id": 273194, "text": "Baseline artifact. Sinus rhythm. Left atrial abnormality. P-R interval\nprolongation. Intraventricular conduction delay of left bundle-branch block\ntype. Cannot rule out old inferior wall myocardial infarction. Compared to the\nprevious tracing of there is no significant diagnostic change.\nTRACING #1\n\n" } ]

[ { "category": "Nursing", "chartdate": "2141-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674578, "text": "Hypoxemia\n Assessment:\n Pt remains orally Intubated on cpap 10/5, on 80%. Suctioned fore thick\n yellow secretions. Team aware. Fentanyl/Versed for sedation. Propofol\n d/c\ns due to hypotension in beginning of shift. Sbp 80\ns while on\n propofol, then 100\ns when d/c\nd. Turned and repos frequently to enc\n resp exchange.\n Action:\n Fio2 changed to 60% after post abg showed fio2 195. Mini bal done at\n bedside by resp therapy to r/o pneumonia.\n Response:\n See flowsheet for abg on 60%. See flowsheet for drug titrations for\n sedation. Vanco/Zosyn started per team Prohyl.\n Plan:\n Wean vent as tolerates.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Goal sbp <120. Pt was hypotensive at start of shift sbp 80\ns Pa\n aware. Propofol off, then Fentanyl changed to 80mcg. Sr wit\n frequent pac\ns and atrial bigeminy. Creat increased to 2.6.\n Action:\n Pt became agitated and hypertensive, fentanyl increased to 100mcg, and\n nitro started for bp control. 20mg iv lasix given per team for low\n urine output.\n Response:\n Sbp 100\ns, and pt arousable to pain. RR 20\ns, sats 98%. Urine adequate.\n Good response to lasix.\n Plan:\n Precedex to extubate, social work consult.\n" }, { "category": "Physician ", "chartdate": "2141-06-23 00:00:00.000", "description": "Intensivist Note", "row_id": 675122, "text": "SICU\n HPI:\n HD6\n \n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMH: HTN, arthritis\n : ASA\n Current medications:\n 3. Albuterol Inhaler 4. Artificial Tears Preserv. Free 5. Aspirin 6.\n Beclomethasone Dipropionate\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Fentanyl Citrate\n 11. FoLIC Acid 12. Heparin 13. Insulin 14. Ipratropium Bromide MDI 15.\n Metoprolol Tartrate 16. Midazolam\n 17. Multiple Vitamins Liq. 18. Nitroglycerin 19. Ondansetron 20.\n Oxymetazoline 21. Pantoprazole\n 22. Piperacillin-Tazobactam Na 23. Sodium Chloride Nasal 24. Sodium\n Chloride 0.9% Flush 25. Sodium Chloride 0.9% Flush\n 26. Thiamine 27. Vancomycin\n 24 Hour Events:\n MULTI LUMEN - START 09:47 AM\n SPUTUM CULTURE - At 12:57 AM\n CARDIOVERSION/DEFIBRILLATION - At 06:46 AM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:28 PM\n Metronidazole - 12:00 AM\n Vancomycin - 12:48 AM\n Piperacillin/Tazobactam (Zosyn) - 02:09 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:52 PM\n Metoprolol - 05:45 AM\n Other medications:\n Flowsheet Data as of 04:38 PM\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: 37.1\nC (98.7\n HR: 85 (72 - 154) bpm\n BP: 126/50(68) {93/49(62) - 145/73(94)} mmHg\n RR: 14 (7 - 21) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.9 kg (admission): 90 kg\n Height: 74 Inch\n CVP: 11 (10 - 27) mmHg\n Total In:\n 2,039 mL\n 1,555 mL\n PO:\n Tube feeding:\n 271 mL\n 652 mL\n IV Fluid:\n 1,708 mL\n 903 mL\n Blood products:\n Total out:\n 2,750 mL\n 1,225 mL\n Urine:\n 2,550 mL\n 1,225 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -711 mL\n 330 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 800 (550 - 800) mL\n Vt (Spontaneous): 1,211 (976 - 1,211) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: RR >35\n PIP: 28 cmH2O\n Plateau: 21 cmH2O\n SPO2: 98%\n ABG: 7.33/45/125/22/-2\n Ve: 10.2 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Rhonchi )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\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: (Responds to: Unresponsive), Sedated, on fentanyl and\n versed\n Labs / Radiology\n 216 K/uL\n 9.5 g/dL\n 126 mg/dL\n 3.5 mg/dL\n 22 mEq/L\n 5.1 mEq/L\n 74 mg/dL\n 105 mEq/L\n 138 mEq/L\n 28.7 %\n 10.2 K/uL\n [image002.jpg]\n 03:16 AM\n 06:16 AM\n 01:51 PM\n 11:18 PM\n 01:20 AM\n 02:58 AM\n 03:07 AM\n 01:04 PM\n 01:23 PM\n 02:26 PM\n WBC\n 9.7\n 10.2\n Hct\n 28.5\n 28.3\n 28.1\n 28.7\n Plt\n 202\n 216\n Creatinine\n 2.6\n 3.1\n 3.0\n 3.5\n Troponin T\n 0.01\n 0.01\n TCO2\n 24\n 24\n 23\n 23\n 29\n 25\n Glucose\n 97\n 151\n 126\n Other labs: PT / PTT / INR:13.2/34.3/1.1, CK / CK-MB / Troponin\n T:1777/17/0.01, ALT / AST:33/49, Alk-Phos / T bili:132/0.4, Amylase /\n Lipase:62/37, Lactic Acid:0.7 mmol/L, Albumin:2.6 g/dL, LDH:732 IU/L,\n Ca:8.0 mg/dL, Mg:3.3 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n CHEST PAIN, .H/O AORTIC ANEURYSM, ABDOMINAL WITH RUPTURE (AAA)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, Pain controlled, continue fentanyl\n and versed,\n Cardiovascular: all antihypertensive meds discontinued due to blood\n pressure, treat with IV nitroglycerin for sbp < 120, rapid atrial\n flutter converted with 100 joules, CK and mb and troponin as per\n vascular request EKG unchanged\n Pulmonary: Cont ETT, (Ventilator mode:CMV)\n Gastrointestinal / Abdomen: no issues\n Nutrition: Tube feeding, start nutren renal\n Renal: Foley, Adequate UO, Acute renal failure with increased\n creatinine hold diuretics, urine lytes per renal request\n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: Vancomycin and zosyn for coverage awaiting cultures\n Lines / Tubes / Drains: Foley, OGT, ETT\n Imaging: CXR today\n Consults: Vascular surgery, CT surgery, Nutrition\n Billing Diagnosis: (Respiratory distress)\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 11:00 AM 10 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:05 PM\n Multi Lumen - 09:47 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\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: 33 minutes\n" }, { "category": "Physician ", "chartdate": "2141-06-23 00:00:00.000", "description": "Intensivist Note", "row_id": 675124, "text": "SICU\n HPI:\n HD6\n \n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMH: HTN, arthritis\n : ASA\n Chief complaint:\n PMHx:\n Current medications:\n 3. Albuterol Inhaler 4. Artificial Tears Preserv. Free 5. Aspirin 6.\n Beclomethasone Dipropionate\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Fentanyl Citrate\n 11. FoLIC Acid 12. Heparin 13. Insulin 14. Ipratropium Bromide MDI 15.\n Metoprolol Tartrate 16. Midazolam\n 17. Multiple Vitamins Liq. 18. Nitroglycerin 19. Ondansetron 20.\n Oxymetazoline 21. Pantoprazole\n 22. Piperacillin-Tazobactam Na 23. Sodium Chloride Nasal 24. Sodium\n Chloride 0.9% Flush 25. Sodium Chloride 0.9% Flush\n 26. Thiamine 27. Vancomycin\n 24 Hour Events:\n MULTI LUMEN - START 09:47 AM\n SPUTUM CULTURE - At 12:57 AM\n CARDIOVERSION/DEFIBRILLATION - At 06:46 AM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:28 PM\n Metronidazole - 12:00 AM\n Vancomycin - 12:48 AM\n Piperacillin/Tazobactam (Zosyn) - 02:09 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:52 PM\n Metoprolol - 05:45 AM\n Other medications:\n Flowsheet Data as of 04:38 PM\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: 37.1\nC (98.7\n HR: 85 (72 - 154) bpm\n BP: 126/50(68) {93/49(62) - 145/73(94)} mmHg\n RR: 14 (7 - 21) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.9 kg (admission): 90 kg\n Height: 74 Inch\n CVP: 11 (10 - 27) mmHg\n Total In:\n 2,039 mL\n 1,555 mL\n PO:\n Tube feeding:\n 271 mL\n 652 mL\n IV Fluid:\n 1,708 mL\n 903 mL\n Blood products:\n Total out:\n 2,750 mL\n 1,225 mL\n Urine:\n 2,550 mL\n 1,225 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -711 mL\n 330 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 800 (550 - 800) mL\n Vt (Spontaneous): 1,211 (976 - 1,211) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: RR >35\n PIP: 28 cmH2O\n Plateau: 21 cmH2O\n SPO2: 98%\n ABG: 7.33/45/125/22/-2\n Ve: 10.2 L/min\n PaO2 / FiO2: 250\n Physical Examination\n Labs / Radiology\n 216 K/uL\n 9.5 g/dL\n 126 mg/dL\n 3.5 mg/dL\n 22 mEq/L\n 5.1 mEq/L\n 74 mg/dL\n 105 mEq/L\n 138 mEq/L\n 28.7 %\n 10.2 K/uL\n [image002.jpg]\n 03:16 AM\n 06:16 AM\n 01:51 PM\n 11:18 PM\n 01:20 AM\n 02:58 AM\n 03:07 AM\n 01:04 PM\n 01:23 PM\n 02:26 PM\n WBC\n 9.7\n 10.2\n Hct\n 28.5\n 28.3\n 28.1\n 28.7\n Plt\n 202\n 216\n Creatinine\n 2.6\n 3.1\n 3.0\n 3.5\n Troponin T\n 0.01\n 0.01\n TCO2\n 24\n 24\n 23\n 23\n 29\n 25\n Glucose\n 97\n 151\n 126\n Other labs: PT / PTT / INR:13.2/34.3/1.1, CK / CK-MB / Troponin\n T:1777/17/0.01, ALT / AST:33/49, Alk-Phos / T bili:132/0.4, Amylase /\n Lipase:62/37, Lactic Acid:0.7 mmol/L, Albumin:2.6 g/dL, LDH:732 IU/L,\n Ca:8.0 mg/dL, Mg:3.3 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n CHEST PAIN, .H/O AORTIC ANEURYSM, ABDOMINAL WITH RUPTURE (AAA)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, Pain controlled, wean fentanyl and\n versed, CT head without contrast to evaluate for bleed or ischemia due\n to posturing and non responsive\n Cardiovascular: all antihypertensive meds on hold due to hypotension,\n treat with IV nitroglycerin for sbp < 120\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding, start nutren renal\n Renal: Foley, Adequate UO, Acute renal failure with increased\n creatinine will hydrate with NS bolus recheck in am\n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: no evidence of infection, levofloxacin until\n cultures finalized\n Lines / Tubes / Drains: Foley, OGT, ETT\n Imaging: CXR today\n Consults: Vascular surgery, CT surgery, Nutrition\n Billing Diagnosis: (Respiratory distress)\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 11:00 AM 10 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:05 PM\n Multi Lumen - 09:47 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\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: 33 minutes\n" }, { "category": "Respiratory ", "chartdate": "2141-06-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 675278, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 86.2 None\n Ideal tidal volume: 344.8 / 517.2 / 689.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\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: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n Unable to complte RSBI as PT becomes agitsted'''''''''''''''''''''''\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n" }, { "category": "Nursing", "chartdate": "2141-06-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674301, "text": "Anxiety\n Assessment:\n Pt tachypneic, sitting bolt upright in bed, removed oxygen pulling at\n lines and tubes and saying\nIve got to get outta here, Im having a full\n blown panic attack!\n Action:\n Reapplied oxygen, repositioned, emotional support, directed through\n deep breathing exercises, medicated with 1 mg po Ativan.\n Response:\n Reports feeling calmer, but not completely rid of anxiety. Able to fall\n asleep.\n Plan:\n Continue to monitor for anxiety, s/s of etoh withdrawal, drug\n withdrawal. Medicate with Ativan prn as needed.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o of chronic back pain and abdominal pain like he has had since\n admission.\n Action:\n Pt medicated with Dilaudi 1 mg iv x 3.\n Response:\n Reports pain relief for approx 1 hour after dose then asks for more\n medicine to relieve back pain and put him to sleep.\n Plan:\n Assess with pain scale and medicate as appropriate.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Blood pressure goal 120-130, on nicardipine at 4 at start of shift.\n Sats <93\n Action:\n Given dilaudid for pain, hydralazine ivp for bp >130. Started atrovent\n nebs q 12 hours.\n Response\n Nicardipine weaned to off overnight while mostly sleeping, titrate back\n up as pt is more awake in am. Continue to use nicardipine iv to prevent\n return to gtt vasopressors. Monitor for s/s of a fimus infection.\n Plan:\n Monitor bp and and s/s rupture of AAA> Encourage coughing and deep\n breathing. No chest PT per team.\n" }, { "category": "Physician ", "chartdate": "2141-06-21 00:00:00.000", "description": "Intensivist Note", "row_id": 674405, "text": "CVICU\n HPI:\n HD4\n HD3\n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMH: HTN, arthritis\n : ASA\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US R>L perfusion. nl size.\n Labetolol/Nicardipine(IV),Norvasc\n Current medications:\n Albuterol 0.083% Neb Soln 5. Albuterol 0.083% Neb Soln 6. Amlodipine 7.\n Fluticasone Propionate 110mcg\n 8. HYDROmorphone (Dilaudid) 9. HYDROmorphone (Dilaudid) 10. Heparin 11.\n HydrALAzine 12. Insulin\n 13. Ipratropium Bromide Neb 14. Labetalol 15. Levofloxacin 16.\n MetRONIDAZOLE (FLagyl) 17. NiCARdipine\n 18. Ondansetron 19. Pantoprazole 20. Sodium Chloride 0.9% Flush 21.\n Sodium Chloride 0.9% Flush\n 24 Hour Events:\n BLOOD CULTURED - At 10:23 AM\n URINE CULTURE - At 10:23 AM\n ULTRASOUND - At 08:30 PM\n reanl ultrasound at bedside due to poor resp status\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:28 PM\n Metronidazole - 12:00 AM\n Infusions:\n Nicardipine - 0.4 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 08:30 AM\n Other medications:\n Flowsheet Data as of 11:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.3\n T current: 36.4\nC (97.6\n HR: 79 (70 - 84) bpm\n BP: 125/65(85) {98/51(67) - 132/72(89)} mmHg\n RR: 18 (13 - 28) insp/min\n SPO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 3,728 mL\n 1,341 mL\n PO:\n 430 mL\n 510 mL\n Tube feeding:\n IV Fluid:\n 3,298 mL\n 831 mL\n Blood products:\n Total out:\n 1,802 mL\n 700 mL\n Urine:\n 1,802 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,926 mL\n 641 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 89%\n ABG: 7.43/30/66//-2\n PaO2 / FiO2: 66\n Physical Examination\n General Appearance: Anxious\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n Expiratory Left > Right)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 195 K/uL\n 10.1 g/dL\n 130 mg/dL\n 2.1 mg/dL\n 20 mEq/L\n 4.7 mEq/L\n 65 mg/dL\n 100 mEq/L\n 132 mEq/L\n 29.2 %\n 18.5 K/uL\n [image002.jpg]\n 08:03 PM\n 01:42 AM\n 09:45 AM\n 01:09 PM\n 05:21 PM\n 04:30 AM\n 10:19 AM\n 02:56 AM\n 03:05 AM\n WBC\n 15.6\n 23.9\n 18.5\n Hct\n 35.4\n 34.4\n 34.2\n 29.2\n Plt\n \n Creatinine\n 1.8\n 2.0\n 2.1\n 2.1\n 2.1\n Troponin T\n <0.01\n TCO2\n 24\n 20\n 21\n Glucose\n 220\n 146\n 130\n Other labs: PT / PTT / INR:13.1/27.1/1.1, CK / CK-MB / Troponin\n T:149/6/<0.01, ALT / AST:53/83, Alk-Phos / T bili:85/0.4, Lactic\n Acid:1.5 mmol/L, Ca:8.6 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\n Imaging: CXR - New bilateral mid zone mainly peripheral patchy airspace\n change, most\n suggestive of pneumonia and/or CHF.\n ECHO - Pending\n Microbiology: Urine / Blood - Pending.\n Assessment and Plan\n ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT RUPTURE (AAA), HYPOXEMIA,\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), CHEST PAIN, .H/O AORTIC\n ANEURYSM, ABDOMINAL WITH RUPTURE (AAA)\n Assessment and Plan:\n Neurologic: Pain controlled, Cont dilauid PRN for pain.\n Cardiovascular: Beta-blocker, Cont Labetalol / Amlodipine / Hydralazine\n for SBP < 120 and wean Nicardipine gtt.\n Pulmonary: Hypoxemia --> likely pneumonia or CHF --> will attempt Bipap\n but may need intubation.\n Gastrointestinal / Abdomen: No active issues.\n Nutrition: Clear liquids\n Renal: Foley, Adequate UO, Although UOP is adequate at ~1800 in past 24\n hours, his BUN/Creat is continuing to rise as a result of hypoperfusion\n to right kidney --> would cautiously diurese, however, given worsening\n CXR and hypoxemia.\n Hematology: Mild anemia\n Endocrine: RISS\n Infectious Disease: Check cultures, Induce sputum for cx today.\n Lines / Tubes / Drains: Foley\n Wounds: none\n Imaging: CXR today\n Fluids: KVO, Would KVO IVF at this time.\n Consults: Vascular surgery, CT surgery\n Billing Diagnosis: Acute renal failure, Other: Hypertensive crisis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:05 PM\n 20 Gauge - 09:00 AM\n 18 Gauge - 08:00 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: 32 minutes\n Patient is critically ill\n" }, { "category": "Nutrition", "chartdate": "2141-06-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 674716, "text": "Subjective\n Intub/sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 188 cm\n 90 kg\n 25.4\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 86.2 kg\n 104\n Diagnosis: TYPE B AORTIC DISSECTION\n PMH :\n HTN, arthritis\n Pertinent medications: Heparin, Insulin SC , Amlodipine, FoLIC Acid,\n Thiamine, Pantoprazole, Fentanyl Citrate , Midazolam , Multiple\n Vitamins Liq, Labetalol , Levofloxacin, others noted\n Labs:\n Value\n Date\n Glucose\n 97 mg/dL\n 03:16 AM\n Glucose Finger Stick\n 109\n 06:00 AM\n BUN\n 66 mg/dL\n 03:16 AM\n Creatinine\n 2.6 mg/dL\n 03:16 AM\n Sodium\n 134 mEq/L\n 03:16 AM\n Potassium\n 4.0 mEq/L\n 03:16 AM\n Chloride\n 102 mEq/L\n 03:16 AM\n TCO2\n 20 mEq/L\n 03:16 AM\n PO2 (arterial)\n 148 mm Hg\n 06:16 AM\n PCO2 (arterial)\n 42 mm Hg\n 06:16 AM\n pH (arterial)\n 7.34 units\n 06:16 AM\n pH (urine)\n 5.0 units\n 09:56 AM\n CO2 (Calc) arterial\n 24 mEq/L\n 06:16 AM\n Albumin\n 3.0 g/dL\n 02:56 AM\n Calcium non-ionized\n 8.6 mg/dL\n 04:30 AM\n Phosphorus\n 3.2 mg/dL\n 04:30 AM\n Ionized Calcium\n 1.08 mmol/L\n 03:23 AM\n Magnesium\n 2.4 mg/dL\n 03:16 AM\n ALT\n 37 IU/L\n 02:56 AM\n Alkaline Phosphate\n 70 IU/L\n 02:56 AM\n AST\n 44 IU/L\n 02:56 AM\n Amylase\n 38 IU/L\n 02:56 AM\n Total Bilirubin\n 0.4 mg/dL\n 02:56 AM\n WBC\n 9.7 K/uL\n 03:16 AM\n Hgb\n 9.8 g/dL\n 03:16 AM\n Hematocrit\n 28.5 %\n 03:16 AM\n Current diet order / nutrition support: Novasource Renal Full strength;\n Starting rate: 10 ml/hr; Advance rate by 10 ml q6h Goal rate: 40 ml/hr\n Residual Check: q4h Hold feeding for residual >= : 100 ml\n Flush w/ 30 ml water q4h\n GI: soft, NBS\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to:\n Estimated Nutritional Needs\n Calories: -2250 (BEE x or / 22-25 cal/kg)\n Protein: 108-126 (1.2-1.4 g/kg)\n Fluid: per team\n Estimation of previous intake: likely adequate\n Estimation of current intake: Adequate\n Specifics:\n 62 year old male with type B aortic dissection on medical management.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations:\n Check chemistry 10 panel daily, replete prn\n Cont insulin sliding scale if serum glucose >150 mg/dL\n Other: f/u, please page if has question\n" }, { "category": "Nutrition", "chartdate": "2141-06-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 674718, "text": "Subjective\n Intub/sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 188 cm\n 90 kg\n 25.4\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 86.2 kg\n 104\n n/a\n Diagnosis: TYPE B AORTIC DISSECTION\n PMH :\n HTN, arthritis\n Pertinent medications: Heparin, Insulin SC , Amlodipine, FoLIC Acid,\n Thiamine, Pantoprazole, Fentanyl Citrate , Midazolam , Multiple\n Vitamins Liq, Labetalol , Levofloxacin, others noted\n Labs:\n Value\n Date\n Glucose\n 97 mg/dL\n 03:16 AM\n Glucose Finger Stick\n 109\n 06:00 AM\n BUN\n 66 mg/dL\n 03:16 AM\n Creatinine\n 2.6 mg/dL\n 03:16 AM\n Sodium\n 134 mEq/L\n 03:16 AM\n Potassium\n 4.0 mEq/L\n 03:16 AM\n Chloride\n 102 mEq/L\n 03:16 AM\n TCO2\n 20 mEq/L\n 03:16 AM\n PO2 (arterial)\n 148 mm Hg\n 06:16 AM\n PCO2 (arterial)\n 42 mm Hg\n 06:16 AM\n pH (arterial)\n 7.34 units\n 06:16 AM\n pH (urine)\n 5.0 units\n 09:56 AM\n CO2 (Calc) arterial\n 24 mEq/L\n 06:16 AM\n Albumin\n 3.0 g/dL\n 02:56 AM\n Calcium non-ionized\n 8.6 mg/dL\n 04:30 AM\n Phosphorus\n 3.2 mg/dL\n 04:30 AM\n Ionized Calcium\n 1.08 mmol/L\n 03:23 AM\n Magnesium\n 2.4 mg/dL\n 03:16 AM\n ALT\n 37 IU/L\n 02:56 AM\n Alkaline Phosphate\n 70 IU/L\n 02:56 AM\n AST\n 44 IU/L\n 02:56 AM\n Amylase\n 38 IU/L\n 02:56 AM\n Total Bilirubin\n 0.4 mg/dL\n 02:56 AM\n WBC\n 9.7 K/uL\n 03:16 AM\n Hgb\n 9.8 g/dL\n 03:16 AM\n Hematocrit\n 28.5 %\n 03:16 AM\n Current diet order / nutrition support: Novasource Renal Full strength;\n Starting rate: 10 ml/hr; Advance rate by 10 ml q6h Goal rate: 40 ml/hr\n Residual Check: q4h Hold feeding for residual >= : 100 ml\n Flush w/ 30 ml water q4h\n GI: soft, NBS\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: current clinical presentation\n Estimated Nutritional Needs\n Calories: -2250 (BEE x or / 22-25 cal/kg)\n Protein: 99-117 (1.1-1.3 g/kg)\n Fluid: per team\n Estimation of previous intake: likely adequate\n Estimation of current intake: inadequate\n Specifics:\n 62 year old male admitted with type B aortic dissection, nota surgical\n candidate per chart. Patient became restless and uncooperative with\n Mask ventilation, intubated by anesthesia yesterday, tube feed ordered\n to start, patient currently tolerating tube feed at 10ml/hr, current\n regimen not meeting patient\ns estimated need, recommend change tube\n feed if patient remained intub.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: change tube feed to Nutren Plum goal\n 65ml/hr (2340kcal/106g protein)\n Check chemistry 10 panel daily, replete prn\n Cont insulin sliding scale if serum glucose >150 mg/dL\n Other: f/u, please page if has question\n" }, { "category": "Physician ", "chartdate": "2141-06-23 00:00:00.000", "description": "ICU Event Note", "row_id": 675127, "text": "Clinician: Attending\n Pt in Atrial Flutter. Cardioverted to 100 WS NSR without complications\n at 0645 AM\n Patient is critically ill.\n" }, { "category": "Respiratory ", "chartdate": "2141-06-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 675465, "text": "Demographics\n Day of intubation: 4\n Day of mechanical ventilation: 4\n Ideal body weight: 86.2 None\n Ideal tidal volume: 344.8 / 517.2 / 689.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 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: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\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: Hemodynimic\n instability, Underlying illness 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 Pt remains on mech ventilation on PSV5/8peep, secretions are minimal\n today.\n, RRT 18:31\n" }, { "category": "Nursing", "chartdate": "2141-06-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675462, "text": "Altered mental status (not Delirium)\n Assessment:\n Daily wake up this am, patient opened his eyes and moved everything\n purposefully, except his left arm, but not to command.\n Action:\n Sedation (fentanyl) turned down significantly (100mg\n25mg), nail bed\n pressure to left hand\n Response:\n Still no response to commands and with nail bed pressure localized by\n facial grimace but no movement from left hand\n Plan:\n Continue to monitor and try to wake to ween\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 76, Cr 3.9, HUO 30-100cc/hr\n Action:\n U/S collected by renal and right renal US obtained\n Response:\n Casts found on UA, good flow NP in kidney from US\n Plan:\n Patient founds to have ATN per renal team, continue to monitor renal\n enzymes and HUO\n" }, { "category": "Nursing", "chartdate": "2141-06-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674263, "text": "Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Sbp 120\ns most of day. c/o pain every 3-4 hours. Pedal pulses palp.\n Nicadipine increased to 4mcg/kg, po med increased.\n Action:\n Med with iv dilaudid in am with good effect, switched to po with poor\n effect.\n Response:\n Improved pain relief with iv dilaudid. Bp within range.\n Plan:\n Iv dilaudid.\n Keep sbp 120-130\n Hypoxemia\n Assessment:\n O2 sats 85-90%, lungs clear. Abg poor, team notified.\n Action:\n Facemask applied. Cxr done\n Response:\n O2 sat improved with facemask.\n Plan:\n Cont. eval pulm status.\n" }, { "category": "Respiratory ", "chartdate": "2141-06-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 674786, "text": "Demographics\n Day of intubation: 2\n Day of mechanical ventilation: 2\n Ideal body weight: 86.2 None\n Ideal tidal volume: 344.8 / 517.2 / 689.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation; Comments: impending Resp. Fail.\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: 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: Continuous invasive ventilation\n Visual assessment of breathing pattern:\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:\n Comments: Large TV's W/low RR's\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1000hrs\n Bedside Procedures:\n Comments:\n Remains on ventilator W/hi TV\ns and RR = . Reduced Fio2 to 50%\n, RRT 17:51\n" }, { "category": "Nursing", "chartdate": "2141-06-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675179, "text": "Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n No further episodes of afib/flutter. Freq atrial ectopy. No\n hypertension. Hypotensive towards end of shift.\n Action:\n Lytes repleted this am. Checked in afternoon. IVF bolus admin in\n afternoon. Hct sent. Type and screen sent. Cardiac enzymes sent, EKG\n obtained.\n Response:\n Remains in SR w/pacs/atrial bigem. BP improved w/fluid bolus. Hct\n <30. EKG unchanged.\n Plan:\n Recheck lytes at . Transfuse w/prbcs until hct >30. Obtain order\n for transfusion. Goal sbp 90-120. Cont to cycle cardiac enzymes- next\n set due 2200.\n Pneumonia, other\n Assessment:\n RML pneumonia noted on CXR per team. Antibiotics started on previous\n shift.\n Action:\n Antibiotics cont, but changed to renal dosing. Attempted cpap while\n still on sedation. No wake up done d/t compromised hemodynamics/vent\n status during am wake up done on earlier shift.\n Response:\n Hypoventilated on cpap, resp acidosis. Required increased rate on CMV.\n Plan:\n Keep sedated overnight. Wean as tolerates for wake up tomorrow am.\n Vanco trough to be sent prior to dose tonight.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat elevated & still rising.\n Action:\n Renal re-consulted. Pt in ATN per renal. Urine lytes sent. Serum\n lytes, bun/creat sent.\n Response:\n Creat/bun still rising.\n Plan:\n Keep sbp >90 for renal perfusion using prbcs then IVF if necessary\n overnight. Recheck lytes at . Accepting HUO 20cc or greater.\n" }, { "category": "Respiratory ", "chartdate": "2141-06-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 674556, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 86.2 None\n Ideal tidal volume: 344.8 / 517.2 / 689.6 mL/kg\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: 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 / Moderate\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: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Bedside Procedures: mini-bal\n Comments: Remains intubated and ventilated on cpap. Mini-bal\n performed, results pending.\n" }, { "category": "Nursing", "chartdate": "2141-06-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675180, "text": " admit to CCU for chest/back pain. CT scan showed lg type B\n dissection.\n transferred to cvicu for management. Team decided pt not surgical\n candidate, plan to medically manage.\n intub for severe hypoxia\n head ct for ?posturing/neuro changes- head ct was neg\n rapid afib/flutter required cardioversion at change of shift\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n No further episodes of afib/flutter. Freq atrial ectopy. No\n hypertension. Hypotensive towards end of shift.\n Action:\n Lytes repleted this am. Checked in afternoon. IVF bolus admin in\n afternoon. Hct sent. Type and screen sent. Cardiac enzymes sent, EKG\n obtained.\n Response:\n Remains in SR w/pacs/atrial bigem. BP improved w/fluid bolus. Hct\n <30. EKG unchanged.\n Plan:\n Recheck lytes at . Transfuse w/prbcs until hct >30. Obtain order\n for transfusion. Goal sbp 90-120. Cont to cycle cardiac enzymes- next\n set due 2200.\n Pneumonia, other\n Assessment:\n RML pneumonia noted on CXR per team. Antibiotics started on previous\n shift.\n Action:\n Antibiotics cont, but changed to renal dosing. Attempted cpap while\n still on sedation. No wake up done d/t compromised hemodynamics/vent\n status during am wake up done on earlier shift.\n Response:\n Hypoventilated on cpap, resp acidosis. Required increased rate on\n CMV-abg wnl on cmv.\n Plan:\n Keep sedated overnight. Wean as tolerates for wake up tomorrow am.\n Vanco trough to be sent prior to dose tonight. Cont zosyn.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat elevated & still rising.\n Action:\n Renal re-consulted. Pt in ATN per renal. Urine lytes sent. Serum\n lytes, bun/creat sent.\n Response:\n Creat/bun still rising.\n Plan:\n Keep sbp >90 for renal perfusion using prbcs then IVF if necessary\n overnight. Recheck lytes at . Accepting HUO 20cc or greater.\n" }, { "category": "Nursing", "chartdate": "2141-06-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674474, "text": "Hypoxemia\n Assessment:\n Sats high 80s-low 90s on 100% fio2 and add\nl NC. Wheezing. Unable to\n raise sputum. Hallucinogenic. Restless.\n Action:\n Am cxr obtained, reviewed by team members. Maintenance IVF stopped. Ivp\n lasix admin. Mask ventilation started. Restraints needed for treatment\n interference.\n Response:\n Pao2 increased remarkable on bipap. Restlessness/hallucinations\n decreased. No need for haldol. Unable to tolerate mask ventilation for\n long periods of time.\n Plan:\n Alternating between hi- closed mask and mask ventilation as needed.\n diuresis. ?intubation.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Hypertensive. Peripheral infusion of nicardipine causing phlebotic\n veins.\n Action:\n Titrating nicardipine gtt to maintain sbp <130. PO meds increased.\n NPO while mask ventilation on though. Rotating piv sites for\n nicardipine infusion. Cardiac echo to r/o failure.\n Response:\n Still requiring nicardipine gtt for bp control. Pt switched to nitro\n gtt to avoid more phlebitis.\n Plan:\n Transition to PO or IVP meds for bp control when able to take POs more\n regularly. Assess PIV sites frequently. ?need for central access if\n prolonged time needed on gtts. Pt not a surgical candidate per team.\n Son aware of pt\ns status and possibility of needing breathing\n tube. Son at bedside, spoke to social work this afternoon. SW\n following and will help pt apply for disability.\n" }, { "category": "Nursing", "chartdate": "2141-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674600, "text": "Hypoxemia\n Assessment:\n Pt remains orally Intubated on cpap 10/5, on 80%. Suctioned fore thick\n yellow secretions. Team aware. Fentanyl/Versed for sedation. Propofol\n d/c\ns due to hypotension in beginning of shift. Sbp 80\ns while on\n propofol, then 100\ns when d/c\nd. Turned and repos frequently to enc\n resp exchange. Family at bedside last evening very anxious, questions\n answered support provided.\n Action:\n Fio2 changed to 60% after post abg showed fio2 195. Mini bal done at\n bedside by resp therapy to r/o pneumonia.\n Response:\n See flowsheet for abg on 60%. See flowsheet for drug titrations for\n sedation. Vanco/Zosyn started per team Prohyl.\n Plan:\n Wean vent as tolerates.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Goal sbp <120. Pt was hypotensive at start of shift sbp 80\ns Pa\n aware. Propofol off, then Fentanyl changed to 80mcg. Sr wit\n frequent pac\ns and atrial bigeminy. Creat increased to 2.6.\n Action:\n Pt became agitated and hypertensive, fentanyl increased to 100mcg, and\n nitro started for bp control. 20mg iv lasix given per team for low\n urine output.\n Response:\n Sbp 100\ns, and pt arousable to pain. RR 20\ns, sats 98%. Urine adequate.\n Good response to lasix.\n Plan:\n Precedex to extubate, social work consult.\n" }, { "category": "Nursing", "chartdate": "2141-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674782, "text": "62M w/ type B aortic dissection/medical management.\n CTA torso: large type B aortic dissection, true lumen in upper abd near\n completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US R>L perfusion. nl size. Labetolol/Nicardipine(IV),Norvasc\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Intubated on CPAP, sedated on fentanyl and versed gtts. Does not follow\n commands, PERRL. Grimaces to sternal rub only. Appears to posture with\n painful stimulation. HR NSR with PAC\ns sbp 90\ns-100\ns. pulses easily\n palpable bowel sounds present, skin intact. No central access, 3\n peripheral IV\ns running well. UOP ~100cc/h creat 2.5\n Action:\n Central line placed in Left subclavian\n Pt received vecuronium for Line placement, due to pt\n posturing during insertion\n Put on CMV due to paralysis\n CT scan of head to rule out bleed or ischemia due to\n posturing and non responsive\n Ultrasound to determine if pt dissected up into carotids\n Turning every 2 hours to maintain skin integrity\n Weaning sedation as tolerated to assess neuro status\n Fluid bolus given for rise in creat to 3.1\n Neuro assessments every 2 hours\n All blood pressure medications held per team due to sbp 90\n Response:\n Central line OK for use per post placement CXR\n Pt back to CPAP with 4/4 twitches TOF and responding to\n verbal stimuli\n CT scan negative\n Ultrasound negative for carotid dissection\n CVP transduced for fluid volume assessment\n Pt slow to wake related to renal involvement of dissection\n Pt opens eyes to verbal stimuli, does not track. Postures to\n painful stimuli and to care.\n Arms extend outward, lower extremities do not respond to\n babinski assessment. Extend down and inward unrelated to pain or\n movement\n Plan:\n Alteration in Nutrition\n Assessment:\n Pt has not received nutrition in a number of days. Is intubated and\n sedated\n Action:\n Tube feedings started for enteral nutrition\n Response:\n Pt tolerating tube feeds, with no residual\n Plan:\n Continue to advance tube feeds every 4 hours, as tolerated for a goal\n rate of 40. treat per care plan\n Hypoxemia\n Assessment:\n Intubated on CPAP, PEEP 10. sats 94%, lungs clear\n Action:\n ABG this AM within normal limits, FIO2 down to 50%\n Paralyzed related to line placement- see above documentation, put back\n on a rate for duration of paralytic effect\n Response:\n Once pt responding to painful stimuli, over breathing set rate and TOF\n assessed for twitches put back on CPAP 50%\n Plan:\n Wean vent as tolerated,? Extubate pending neuro status to neuro status\n Sons in to visit. Stayed briefly, stated that sitting with him for that\n long was\nenough\n. Made comments that they found seeing him in this\n state was very emotionally difficult for them. Social work is\n following, was not here when family visited.\n" }, { "category": "Nursing", "chartdate": "2141-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674603, "text": "Hypoxemia\n Assessment:\n Pt remains orally Intubated on cpap 10/5, on 80%. Suctioned fore thick\n yellow secretions. Team aware. Fentanyl/Versed for sedation. Propofol\n d/c\ns due to hypotension in beginning of shift. Sbp 80\ns while on\n propofol, then 100\ns when d/c\nd. Turned and repos frequently to enc\n resp exchange. Family at bedside last evening very anxious, questions\n answered support provided.\n Action:\n Fio2 changed to 60% after post abg showed fio2 195. Mini bal done at\n bedside by resp therapy to r/o pneumonia.\n Response:\n See flowsheet for abg on 60%. See flowsheet for drug titrations for\n sedation. Vanco/Zosyn started per team Prophylactic.\n Plan:\n Wean vent as tolerates.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Goal sbp <120. Pt was hypotensive at start of shift sbp 80\ns Pa\n aware. Propofol off, then Fentanyl changed to 80mcg. Sr wit\n frequent pac\ns and atrial bigeminy. Creat increased to 2.6.\n Action:\n Pt became agitated and hypertensive, fentanyl increased to 100mcg, and\n nitro started for bp control. 20mg iv lasix given per team for low\n urine output.\n Response:\n Sbp 100\ns, and pt arousable to pain. RR 20\ns, sats 98%. Urine adequate.\n Good response to lasix.\n Plan:\n Precedex to extubate, social work consult.\n" }, { "category": "Physician ", "chartdate": "2141-06-24 00:00:00.000", "description": "ICU Note - CVI", "row_id": 675449, "text": "CVICU\n HPI:\n HD7\n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMH: HTN, arthritis\n : ASA\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US R>L perfusion. nl size.\n Labetolol/Nicardipine(IV),Norvasc\n :Intubated 2'resp.failure/P edema\n Chief complaint:\n PMHx:\n Current medications:\n Albuterol Inhaler 3. Artificial Tears Preserv. Free 4. Aspirin 5.\n Beclomethasone Dipropionate\n 6. Bisacodyl 7. Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral\n Rinse 9. Fentanyl Citrate\n 10. FoLIC Acid 11. Heparin 12. HydrALAzine 13. Insulin 14. Ipratropium\n Bromide MDI 15. Labetalol\n 16. Metoprolol Tartrate 17. Midazolam 18. Multiple Vitamins Liq. 19.\n Nitroglycerin 20. Ondansetron\n 21. Oxymetazoline 22. Pantoprazole 23. Piperacillin-Tazobactam Na 24.\n Sodium Chloride Nasal 25. Sodium Chloride 0.9% Flush\n 26. Sodium Chloride 0.9% Flush 27. Sodium Chloride 0.9% Flush 28.\n Thiamine 29. Vancomycin\n 24 Hour Events:\n Post operative day:\n HD7\n 62M w/ type B aortic dissection/medical management.\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 11:38 AM\n Infusions:\n Midazolam (Versed) - 0.5 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Hydralazine - 08:26 AM\n Pantoprazole (Protonix) - 11:31 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Flowsheet Data as of 05:19 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 37.7\nC (99.9\n HR: 84 (64 - 87) bpm\n BP: 114/56(73) {84/44(56) - 152/70(93)} mmHg\n RR: 12 (11 - 22) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.5 kg (admission): 90 kg\n Height: 74 Inch\n CVP: 19 (7 - 26) mmHg\n Total In:\n 3,579 mL\n 2,006 mL\n PO:\n Tube feeding:\n 950 mL\n 682 mL\n IV Fluid:\n 2,254 mL\n 949 mL\n Blood products:\n 375 mL\n 375 mL\n Total out:\n 1,655 mL\n 1,185 mL\n Urine:\n 1,655 mL\n 1,185 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,924 mL\n 821 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 800 (800 - 800) mL\n Vt (Spontaneous): 1,137 (944 - 1,137) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 14\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: Agitated\n PIP: 13 cmH2O\n Plateau: 23 cmH2O\n Compliance: 39.3 cmH2O/mL\n SPO2: 95%\n ABG: 7.32/43/94./22/-3\n Ve: 8.3 L/min\n PaO2 / FiO2: 235\n Physical Examination\n Labs / Radiology\n 229 K/uL\n 9.4 g/dL\n 192\n 3.9 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 76 mg/dL\n 107 mEq/L\n 139 mEq/L\n 30.3 %\n 9.4 K/uL\n [image002.jpg]\n 06:09 PM\n 09:30 PM\n 09:47 PM\n 01:50 AM\n 01:59 AM\n 06:00 AM\n 07:54 AM\n 10:40 AM\n 12:00 PM\n 01:06 PM\n WBC\n 9.4\n Hct\n 26.3\n 25.6\n 27.7\n 30.3\n Plt\n 229\n Creatinine\n 3.9\n Troponin T\n 0.02\n TCO2\n 23\n 24\n 23\n Glucose\n 107\n 153\n 149\n 128\n 192\n Other labs: PT / PTT / INR:13.4/34.0/1.2, CK / CK-MB / Troponin\n T:1384/11/0.02, ALT / AST:33/49, Alk-Phos / T bili:132/0.4, Amylase /\n Lipase:62/37, Lactic Acid:0.8 mmol/L, Albumin:2.6 g/dL, LDH:732 IU/L,\n Ca:8.6 mg/dL, Mg:3.2 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE,\n ARF), PNEUMONIA, OTHER\n Assessment and Plan: HD7\n 62M w/ type B aortic dissection/medical management. eintubated5/13 2'\n resp. failure. Hemodynamically stable. postop complicated with acute\n renal failure\n Neurologic: Neuro checks Q: 4 hr, Cont Thiamine/Folate. Versed/Fentanyl\n prn pain.\n Cardiovascular: Aspirin, Beta-blocker, Statins, Maintain BP<140 as\n discussed with Vasc. team. Hydralazine/NTG/Labetalol prn\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), PSV today. wean as\n tol.\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, ARF:Renal US today. Renal following->possible need for HD\n Hematology: Stable anemia. Plan to Tx for HCT <28 per Vasc team\n Endocrine: RISS\n Infectious Disease: Check cultures, Mini Bal prelim=no growth. CXs PND.\n Cont Vanco/Zosyn\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging: CXR today\n Fluids:\n Consults: Vascular surgery, CT surgery, Nephrology\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:05 PM\n Multi Lumen - 09:47 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\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 ------ Protected Section ------\n PE:\n General: Sedation weaning off. Does not follow commands. Moves Extr.\n Spont.\n CVS:RRR\n Lungs: CTA\n Abd: hypoactive BS, benign\n Extr: DP2+, warm\n ------ Protected Section Addendum Entered By: , \n on: 18:01 ------\n" }, { "category": "Nursing", "chartdate": "2141-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674738, "text": "62M w/ type B aortic dissection/medical management.\n CTA torso: large type B aortic dissection, true lumen in upper abd near\n completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US R>L perfusion. nl size. Labetolol/Nicardipine(IV),Norvasc\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Intubated on CPAP, sedated on fentanyl and versed gtts. Does not follow\n commands, PERRLA. Grimaces to sternal rub only. Appears to posture with\n painful stimulation. HR NSR with PAC\ns sbp 90\ns-100\ns. pulses easily\n palpable bowel sounds present, skin intact. No central access, 3\n peripheral IV\ns running well. UOP ~100cc/h\n Action:\n Central line placed in Left subclavian\n Pt received vecuronium for Line placement, due to pt\n posturing during insertion\n Put on CMV due to paralysis\n CT scan of head to rule out neuro issue for posturing\n Ultrasound to determine if pt dissected up into carotids\n Turning every 2 hours to maintain skin integrity\n Weaning sedation as tolerated to assess neuro status\n Response:\n Central line OK for use per post placement CXR\n Pt back to CPAP with 4/4 twitches TOF and responding to\n verbal stimuli\n CT scan negative\n Ultrasound negative for carotid dissection\n CVP transduced for fluid volume assessment\n Pt slow to wake related to renal involvement of dissection\n Plan:\n Alteration in Nutrition\n Assessment:\n Pt has not received nutrition in a number of days. Is intubated and\n sedated\n Action:\n Tube feedings started for enteral nutrition\n Response:\n Pt tolerating tube feeds, with no residual\n Plan:\n Continue to advance tube feeds every 4 hours, as tolerated for a goal\n rate of 40\n Hypoxemia\n Assessment:\n Intubated on CPAP, PEEP 10. sats 94%, lungs clear\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-06-22 00:00:00.000", "description": "Intensivist Note", "row_id": 674747, "text": "CVICU\n HD5\n \n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMH: HTN, arthritis\n : ASA\n Current medications:\n Albuterol Inhaler, Amlodipine, Beclomethasone Dipropionate, Bisacodyl,\n Fentanyl Citrate, FoLIC Acid, Heparin, HydrALAzine, Insulin,\n Ipratropium Bromide MDI, Labetalol, Levofloxacin, Midazolam, Multiple\n Vitamins Liq, Oxymetazoline, Pantoprazole, Thiamine\n 24 Hour Events:\n Remains in ICU intubated\n Hypoxia, unable to tolerate BIPAP mask requiring intubation\n NON-INVASIVE VENTILATION - START 10:40 AM\n TRANSTHORACIC ECHO - At 11:00 AM\n NON-INVASIVE VENTILATION - STOP 03:42 PM\n INVASIVE VENTILATION - START 04:10 PM\n INTUBATION - At 04:11 PM\n BAL FLUID CULTURE - At 01:48 AM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:28 PM\n Metronidazole - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 11:21 PM\n Vancomycin - 12:22 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Propofol - 04:30 PM\n Midazolam (Versed) - 04:50 PM\n Fentanyl - 01:48 AM\n Furosemide (Lasix) - 06:16 AM\n Heparin Sodium (Prophylaxis) - 07:53 AM\n Vecuronium - 09:45 AM\n Flowsheet Data as of 03:31 PM\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: 37.7\nC (99.9\n HR: 75 (68 - 83) bpm\n BP: 99/50(64) {87/44(60) - 137/116(118)} mmHg\n RR: 7 (6 - 19) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n CVP: 12 (11 - 13) mmHg\n Total In:\n 2,571 mL\n 649 mL\n PO:\n 660 mL\n Tube feeding:\n 43 mL\n IV Fluid:\n 1,911 mL\n 546 mL\n Blood products:\n Total out:\n 2,210 mL\n 1,810 mL\n Urine:\n 2,060 mL\n 1,610 mL\n NG:\n 150 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 361 mL\n -1,161 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 1,429 (756 - 1,429) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 11 cmH2O\n SPO2: 95%\n ABG: 7.34/42/148/20/-2\n Ve: 11.3 L/min\n PaO2 / FiO2: 296\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\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: (Responds to: Unresponsive), Sedated, on fentanyl and\n versed\n Labs / Radiology\n 202 K/uL\n 9.8 g/dL\n 97 mg/dL\n 3.1 mg/dL\n 20 mEq/L\n 4.5 mEq/L\n 73 mg/dL\n 102 mEq/L\n 134 mEq/L\n 28.3 %\n 9.7 K/uL\n [image002.jpg]\n 02:35 PM\n 03:25 PM\n 05:19 PM\n 05:30 PM\n 10:40 PM\n 10:52 PM\n 01:14 AM\n 03:16 AM\n 06:16 AM\n 01:51 PM\n WBC\n 9.7\n Hct\n 28.2\n 27.5\n 28.5\n 28.3\n Plt\n 202\n Creatinine\n 2.6\n 3.1\n TCO2\n 21\n 21\n 23\n 22\n 22\n 24\n Glucose\n 97\n Other labs: PT / PTT / INR:13.2/34.3/1.1, CK / CK-MB / Troponin\n T:149/6/<0.01, ALT / AST:37/44, Alk-Phos / T bili:70/0.4, Amylase /\n Lipase:38/16, Lactic Acid:0.9 mmol/L, Albumin:3.0 g/dL, LDH:819 IU/L,\n Ca:8.6 mg/dL, Mg:2.5 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n CHEST PAIN, .H/O AORTIC ANEURYSM, ABDOMINAL WITH RUPTURE (AAA)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, Pain controlled, wean fentanyl and\n versed, CT head without contrast to evaluate for bleed or ischemia due\n to posturing and non responsive\n Cardiovascular: all antihypertensive meds on hold due to hypotension,\n treat with IV nitroglycerin for sbp < 120\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding, start nutren renal\n Renal: Foley, Adequate UO, Acute renal failure with increased\n creatinine will hydrate with NS bolus recheck in am\n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: no evidence of infection, levofloxacin until\n cultures finalized\n Lines / Tubes / Drains: Foley, OGT, ETT\n Imaging: CXR today\n Consults: Vascular surgery, CT surgery, Nutrition\n Billing Diagnosis: (Respiratory distress)\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 11:00 AM 10 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:05 PM\n Multi Lumen - 09:47 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\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: 33 minutes\n" }, { "category": "Physician ", "chartdate": "2141-06-22 00:00:00.000", "description": "Intensivist Note", "row_id": 674749, "text": "HD5\n \n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMH: HTN, arthritis\n : ASA\n Current medications:\n Albuterol Inhaler, Amlodipine, Beclomethasone Dipropionate, Bisacodyl,\n Fentanyl Citrate, FoLIC Acid, Heparin, HydrALAzine, Insulin,\n Ipratropium Bromide MDI, Labetalol, Levofloxacin, Midazolam, Multiple\n Vitamins Liq, Oxymetazoline, Pantoprazole, Thiamine\n 24 Hour Events:\n Remains in ICU intubated\n Hypoxia, unable to tolerate BIPAP mask requiring intubation\n NON-INVASIVE VENTILATION - START 10:40 AM\n TRANSTHORACIC ECHO - At 11:00 AM\n NON-INVASIVE VENTILATION - STOP 03:42 PM\n INVASIVE VENTILATION - START 04:10 PM\n INTUBATION - At 04:11 PM\n BAL FLUID CULTURE - At 01:48 AM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:28 PM\n Metronidazole - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 11:21 PM\n Vancomycin - 12:22 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Propofol - 04:30 PM\n Midazolam (Versed) - 04:50 PM\n Fentanyl - 01:48 AM\n Furosemide (Lasix) - 06:16 AM\n Heparin Sodium (Prophylaxis) - 07:53 AM\n Vecuronium - 09:45 AM\n Flowsheet Data as of 03:31 PM\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: 37.7\nC (99.9\n HR: 75 (68 - 83) bpm\n BP: 99/50(64) {87/44(60) - 137/116(118)} mmHg\n RR: 7 (6 - 19) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n CVP: 12 (11 - 13) mmHg\n Total In:\n 2,571 mL\n 649 mL\n PO:\n 660 mL\n Tube feeding:\n 43 mL\n IV Fluid:\n 1,911 mL\n 546 mL\n Blood products:\n Total out:\n 2,210 mL\n 1,810 mL\n Urine:\n 2,060 mL\n 1,610 mL\n NG:\n 150 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 361 mL\n -1,161 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 1,429 (756 - 1,429) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 11 cmH2O\n SPO2: 95%\n ABG: 7.34/42/148/20/-2\n Ve: 11.3 L/min\n PaO2 / FiO2: 296\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\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: (Responds to: Unresponsive), Sedated, on fentanyl and\n versed\n Labs / Radiology\n 202 K/uL\n 9.8 g/dL\n 97 mg/dL\n 3.1 mg/dL\n 20 mEq/L\n 4.5 mEq/L\n 73 mg/dL\n 102 mEq/L\n 134 mEq/L\n 28.3 %\n 9.7 K/uL\n [image002.jpg]\n 02:35 PM\n 03:25 PM\n 05:19 PM\n 05:30 PM\n 10:40 PM\n 10:52 PM\n 01:14 AM\n 03:16 AM\n 06:16 AM\n 01:51 PM\n WBC\n 9.7\n Hct\n 28.2\n 27.5\n 28.5\n 28.3\n Plt\n 202\n Creatinine\n 2.6\n 3.1\n TCO2\n 21\n 21\n 23\n 22\n 22\n 24\n Glucose\n 97\n Other labs: PT / PTT / INR:13.2/34.3/1.1, CK / CK-MB / Troponin\n T:149/6/<0.01, ALT / AST:37/44, Alk-Phos / T bili:70/0.4, Amylase /\n Lipase:38/16, Lactic Acid:0.9 mmol/L, Albumin:3.0 g/dL, LDH:819 IU/L,\n Ca:8.6 mg/dL, Mg:2.5 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n CHEST PAIN, .H/O AORTIC ANEURYSM, ABDOMINAL WITH RUPTURE (AAA)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, Pain controlled, wean fentanyl and\n versed, CT head without contrast to evaluate for bleed or ischemia due\n to posturing and non responsive\n Cardiovascular: all antihypertensive meds on hold due to hypotension,\n treat with IV nitroglycerin for sbp < 120\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding, start nutren renal\n Renal: Foley, Adequate UO, Acute renal failure with increased\n creatinine will hydrate with NS bolus recheck in am\n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: no evidence of infection, levofloxacin until\n cultures finalized\n Lines / Tubes / Drains: Foley, OGT, ETT\n Imaging: CXR today\n Consults: Vascular surgery, CT surgery, Nutrition\n Billing Diagnosis: (Respiratory distress)\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 11:00 AM 10 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:05 PM\n Multi Lumen - 09:47 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\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: 33 minutes\n" }, { "category": "Social Work", "chartdate": "2141-06-22 00:00:00.000", "description": "Social Work Admission Note", "row_id": 674757, "text": "Family Information\n Next of : son \n Health Care Proxy appointed:\n Family Spokesperson designated:\n Communication or visitation restriction:\n Patient Information:\n Previous living situation:\n Previous level of functioning: Independent\n Previous or other hospital admissions:\n Past psychiatric history:\n Past addictions history: 1- 1/2 packs cigarettes per day, no ETOH or\n recreational drugs\n Employment status: Manager of produce market , \n Legal involvement:\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment: Pt is 62 year old man divorced Caucasian\n man, admitted for dissecting aneurysm. SW meets at length with pt's\n older son, , who gives following information:\n Pt. has been very independent, has not seen a doctor .\n Therefore, son believes pt. has never been on blood pressure\n medication. Pt. is a heavy smoker , child of alcoholic parents but not\n a drinker himself. Pt\ns ex-wife has severe mental health issues and is\n not part of his support network. Pt. has 2 sons, both of whom live\n locally. Pt. has been living with a roommate until now but pt\ns younger\n son is prepared to take pt. into his home at discharge.\n Pt. works as manager of produce market in . Son is aware that\n pt. will not be able to return to work and asks for assistance in\n obtaining application for SSI. Pt\ns son is of opinion that pt. will\n not be distressed by prospect of quitting work; son believes pt. has\n been looking for a way out for the last 2 years. Pt\ns son is, however,\n concerned that pt. may have to give up weekend job as Little League\n Umpire which is the activity he loves the most .\n Clergy Contact: Offered by SW but rejected by pt\ns son. Pt. is\n atheist.\n Communication with Team: Discussed with RN.\n Plan / Follow up: SW will continue to follow for support. Please page\n #\n" }, { "category": "Nursing", "chartdate": "2141-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674758, "text": "62M w/ type B aortic dissection/medical management.\n CTA torso: large type B aortic dissection, true lumen in upper abd near\n completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US R>L perfusion. nl size. Labetolol/Nicardipine(IV),Norvasc\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Intubated on CPAP, sedated on fentanyl and versed gtts. Does not follow\n commands, PERRLA. Grimaces to sternal rub only. Appears to posture with\n painful stimulation. HR NSR with PAC\ns sbp 90\ns-100\ns. pulses easily\n palpable bowel sounds present, skin intact. No central access, 3\n peripheral IV\ns running well. UOP ~100cc/h\n Action:\n Central line placed in Left subclavian\n Pt received vecuronium for Line placement, due to pt\n posturing during insertion\n Put on CMV due to paralysis\n CT scan of head to rule out bleed or ischemia due to\n posturing and non responsive\n Ultrasound to determine if pt dissected up into carotids\n Turning every 2 hours to maintain skin integrity\n Weaning sedation as tolerated to assess neuro status\n Fluid bolus given\n Response:\n Central line OK for use per post placement CXR\n Pt back to CPAP with 4/4 twitches TOF and responding to\n verbal stimuli\n CT scan negative\n Ultrasound negative for carotid dissection\n CVP transduced for fluid volume assessment\n Pt slow to wake related to renal involvement of dissection\n Plan:\n Alteration in Nutrition\n Assessment:\n Pt has not received nutrition in a number of days. Is intubated and\n sedated\n Action:\n Tube feedings started for enteral nutrition\n Response:\n Pt tolerating tube feeds, with no residual\n Plan:\n Continue to advance tube feeds every 4 hours, as tolerated for a goal\n rate of 40\n Hypoxemia\n Assessment:\n Intubated on CPAP, PEEP 10. sats 94%, lungs clear\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2141-06-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 675098, "text": "Demographics\n Day of intubation: 3\n Day of mechanical ventilation: 3\n Ideal body weight: 86.2 None\n Ideal tidal volume: 344.8 / 517.2 / 689.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: 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 / Plug\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: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning\n Reason for continuing current ventilatory support: 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 Pt tried on PSV but just was NOT maintaining a good MV. Returned to\n CMV. Sx\nd for a rather large plug at 1600.\n, RRT 16:11\n" }, { "category": "Social Work", "chartdate": "2141-06-21 00:00:00.000", "description": "Social Work Admission Note", "row_id": 674532, "text": "Family Information\n Next of : son \n Health Care Proxy appointed:\n Family Spokesperson designated:\n Communication or visitation restriction:\n Patient Information:\n Previous living situation:\n Previous level of functioning: Independent\n Previous or other hospital admissions:\n Past psychiatric history:\n Past addictions history: 1- 1/2 packs cigarettes per day, no ETOH or\n recreational drugs\n Employment status: Manager of produce market , \n Legal involvement:\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment: Pt is 62 year old man divorced Caucasian\n man, admitted for dissecting aneurysm. SW meets at length with pt's\n older son, , who gives following information:\n Pt. has been very independent, has not seen a doctor .\n Therefore, son believes pt. has never been on blood pressure\n medication. Pt. is a heavy smoker , child of alcoholic parents but not\n a drinker himself. Pt\ns ex-wife has severe mental health issues and is\n not part of his support network. Pt. has 2 sons, both of whom live\n locally. Pt. has been living with a roommate until now but pt\ns younger\n son is prepared to take pt. into his home at discharge.\n Pt. works as manager of produce market in . Son is aware that\n pt. will not be able to return to work and asks for assistance in\n obtaining application for SSI. Pt\ns son is of opinion that pt. will\n not be distressed by prospect of quitting work, believes he has been\n looking for a way out for the last 2 years. Pt\ns son is, however,\n concerned that pt. may have to give up weekend job as Little League\n Umpire which is the activity he loves the most .\n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n" }, { "category": "Nursing", "chartdate": "2141-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674736, "text": "Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Intubated on CPAP, sedated on fentanyl and versed gtts. Does not follow\n commands, PERRLA. Grimaces to sternal rub only. Appears to posture with\n painful stimulation. HR NSR with PAC\ns sbp 90\ns-100\ns. pulses easily\n palpable bowel sounds present, skin intact. No central access, 3\n peripheral IV\ns running well. UOP ~100cc/h\n Action:\n Central line placed in Left subclavian\n Pt received vecuronium for Line placement, due to pt\n posturing during insertion\n Put on CMV due to paralysis\n CT scan of head to rule out neuro issue for posturing\n Ultrasound to determine if pt dissected up into carotids\n Turning every 2 hours to maintain skin integrity\n Weaning sedation as tolerated to assess neuro status\n Response:\n Central line OK for use per post placement CXR\n Pt back to CPAP with 4/4 twitches TOF and responding to\n verbal stimuli\n CT scan negative\n Ultrasound negative for carotid dissection\n CVP transduced for fluid volume assessment\n Pt slow to wake related to renal involvement of dissection\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Hypoxemia\n Assessment:\n Intubated on CPAP, PEEP 10. sats 94%, lungs clear\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674762, "text": "62M w/ type B aortic dissection/medical management.\n CTA torso: large type B aortic dissection, true lumen in upper abd near\n completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US R>L perfusion. nl size. Labetolol/Nicardipine(IV),Norvasc\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Intubated on CPAP, sedated on fentanyl and versed gtts. Does not follow\n commands, PERRL. Grimaces to sternal rub only. Appears to posture with\n painful stimulation. HR NSR with PAC\ns sbp 90\ns-100\ns. pulses easily\n palpable bowel sounds present, skin intact. No central access, 3\n peripheral IV\ns running well. UOP ~100cc/h creat 2.5\n Action:\n Central line placed in Left subclavian\n Pt received vecuronium for Line placement, due to pt\n posturing during insertion\n Put on CMV due to paralysis\n CT scan of head to rule out bleed or ischemia due to\n posturing and non responsive\n Ultrasound to determine if pt dissected up into carotids\n Turning every 2 hours to maintain skin integrity\n Weaning sedation as tolerated to assess neuro status\n Fluid bolus given for rise in creat to 3.1\n Neuro assessments every 2 hours\n Response:\n Central line OK for use per post placement CXR\n Pt back to CPAP with 4/4 twitches TOF and responding to\n verbal stimuli\n CT scan negative\n Ultrasound negative for carotid dissection\n CVP transduced for fluid volume assessment\n Pt slow to wake related to renal involvement of dissection\n Pt opens eyes to verbal stimuli, does not track. Postures to\n painful stimuli and to care.\n Arms extend outward, lower extremities do not respond to\n babinski assessment. Extend down and inward unrelated to pain or\n movement\n Plan:\n Alteration in Nutrition\n Assessment:\n Pt has not received nutrition in a number of days. Is intubated and\n sedated\n Action:\n Tube feedings started for enteral nutrition\n Response:\n Pt tolerating tube feeds, with no residual\n Plan:\n Continue to advance tube feeds every 4 hours, as tolerated for a goal\n rate of 40. treat per care plan\n Hypoxemia\n Assessment:\n Intubated on CPAP, PEEP 10. sats 94%, lungs clear\n Action:\n ABG this AM within normal limits, FIO2 down to 50%\n Paralyzed related to line placement- see above documentation, put back\n on a rate for duration of paralytic effect\n Response:\n Once pt responding to painful stimuli, over breathing set rate and TOF\n assessed for twitches put back on CPAP 50%\n Plan:\n Wean vent as tolerated,? Extubate pending neuro status to neuro status\n" }, { "category": "Nursing", "chartdate": "2141-06-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674937, "text": "62M w/ type B aortic dissection/medical management\n Hypoxia, unable to tolerate BIPAP mask requiring intubation \n Hypoxemia\n Assessment:\n Pt turned to left side became agitated droping Sats to 90. Suctioned\n for thick blood tinged secretions. ABG on CPAP 5/5 7.27 51 76 24 -3\n Chest xray shows Right middle lobe pneumonia NP\n Action:\n Pt placed on SIMV with increased PEEP and FIO2 up to 100%\n Vancomuycin 1gm and Pipercillin 4.5gms given\n Sputum culture sent to lab\n Response:\n PO2 up to 160\ns so FIO2 weaned down to 50%.\n Plan:\n Continue antibiotic monitor cultures\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n PO antihypertensives held during day shift for hypotension pt became\n intermittently agitated at times with turning and stimulation SBP\n increasing to 150\ns and HR up to 150\ns then went into afib/flutter rate\n up to 150\n Action:\n Nitro drip restarted and titrated up to 3mcg\n Lopressor 5mgx4or a total of 20mg IV given\n Versed bolus 0.5mg x2 and drip increased to 2\n Fentanyl bolus of 25mcg and drip increased to 150mcg\n Response:\n SBP more controlled with lopressor nitro drip weaned off. Pt sedated\n but still becomes agitated with suctioning and movement but SBP does\n not increase as high and agitation only lasts briefly. Pt remains in\n aflutter rate around 100-120. Lopressor repeated x1\n Plan:\n Continue sedation, Plan for cardioversion today\n Alteration in Nutrition\n Assessment:\n Abdomen soft positive bowel sounds, no stool or flatus\n Action:\n Tube feeds increased to goal level of 40cc/hr residuals checked every\n 4hours HOB elevated 30-45degrees\n Response:\n Pt tolerating tube feeds well\n Plan:\n Monitor residuals and bowel function\n" }, { "category": "Nursing", "chartdate": "2141-06-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674938, "text": "62M w/ type B aortic dissection/medical management\n Hypoxia, unable to tolerate BIPAP mask requiring intubation \n Hypoxemia\n Assessment:\n Pt turned to left side became agitated droping Sats to 90. Suctioned\n for thick blood tinged secretions. ABG on CPAP 5/5 7.27 51 76 24 -3\n Chest xray shows Right middle lobe pneumonia NP\n Action:\n Pt placed on SIMV with increased PEEP and FIO2 up to 100%\n Vancomuycin 1gm and Pipercillin 4.5gms given\n Sputum culture sent to lab\n Response:\n PO2 up to 160\ns so FIO2 weaned down to 50%.\n Plan:\n Continue antibiotic monitor cultures\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n PO antihypertensives held during day shift for hypotension pt became\n intermittently agitated at times with turning and stimulation SBP\n increasing to 150\ns and HR up to 150\ns then went into afib/flutter rate\n up to 150\n Action:\n Nitro drip restarted and titrated up to 3mcg , Hydralazine 20mg IVP\n Lopressor 5mgx4or a total of 20mg IV given\n Versed bolus 0.5mg x2 and drip increased to 2\n Fentanyl bolus of 25mcg and drip increased to 150mcg\n Response:\n SBP more controlled with lopressor nitro drip weaned off. Pt sedated\n but still becomes agitated with suctioning and movement but SBP does\n not increase as high and agitation only lasts briefly. Pt remains in\n aflutter rate around 100-120. Lopressor repeated x1 HR remained in the\n 110-120 a flutter pt cardioverted with 100 joules at 0645 into a sinus\n rhythm with PAC\ns, Mag 2gms and potassium 10meq ordered\n Plan:\n Continue sedation, Titrated nitro to maintain SBP ,120\n Alteration in Nutrition\n Assessment:\n Abdomen soft positive bowel sounds, no stool or flatus\n Action:\n Tube feeds increased to goal level of 40cc/hr residuals checked every\n 4hours HOB elevated 30-45degrees\n Response:\n Pt tolerating tube feeds well\n Plan:\n Monitor residuals and bowel function\n" }, { "category": "Nursing", "chartdate": "2141-06-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674936, "text": "62M w/ type B aortic dissection/medical management\n Hypoxemia\n Assessment:\n Pt turned to left side became agitated droping Sats to 90. Suctioned\n for thick blood tinged secretions. ABG on CPAP 5/5 7.27 51 76 24 -3\n Chest xray shows Right middle lobe pneumonia NP\n Action:\n Pt placed on SIMV with increased PEEP and FIO2 up to 100%\n Vancomuycin 1gm and Pipercillin 4.5gms given\n Sputum culture sent to lab\n Response:\n PO2 up to 160\ns so FIO2 weaned down to 50%.\n Plan:\n Continue antibiotic monitor cultures\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n PO antihypertensives held during day shift for hypotension pt became\n intermittently agitated at times with turning and stimulation SBP\n increasing to 150\ns and HR up to 150\ns then went into afib/flutter rate\n up to 150\n Action:\n Nitro drip restarted and titrated up to 3mcg\n Lopressor 5mgx4or a total of 20mg IV given\n Versed bolus 0.5mg x2 and drip increased to 2\n Fentanyl bolus of 25mcg and drip increased to 150mcg\n Response:\n SBP more controlled with lopressor nitro drip weaned off. Pt sedated\n but still becomes agitated with suctioning and movement but SBP does\n not increase as high and agitation only lasts briefly. Pt remains in\n aflutter rate around 100-120. Lopressor repeated x1\n Plan:\n Continue sedation, Plan for cardioversion today\n Alteration in Nutrition\n Assessment:\n Abdomen soft positive bowel sounds, no stool or flatus\n Action:\n Tube feeds increased to goal level of 40cc/hr residuals checked every\n 4hours HOB elevated 30-45degrees\n Response:\n Pt tolerating tube feeds well\n Plan:\n Monitor residuals and bowel function\n" }, { "category": "Nursing", "chartdate": "2141-06-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675228, "text": "Type B dissection found on CT, pt is not a surgical candidate and is\n being medically managed.\n Allergy to sulfa\n Pneumonia\n Assessment:\n Pt intubated and ventilated. Lungs clear in upper lobes, very dim at\n bilateral bases. Productive congested cough with thick yellow sputum\n via ETT and orally suctioned.\n Action:\n Suctioned as needed, mdi\ns by RT, vent control by RT.\n Response:\n ABG 7.35-40-161\\-, lower lobes slightly less dim with\n suctioning.\n Plan:\n Continue vent overnight, wake and wean as tolerated on day shift.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Goal SBP 90-120.\n Action:\n Monitoring\n Response:\n SBP remains within parameters without additional drugs or\n interventions.\n Plan:\n Continue to monitor and treat to maintain parameters as necessary.\n Alteration in Nutrition\n Assessment:\n Intubated and sedated, unable to take po intake\n Action:\n Novasource renal via ogt\n Response:\n Tolerated with no residuals\n Plan:\n Continue at current rate (goal)\n Pain control (acute pain, chronic pain)\n Assessment:\n Grimacing with turns and care and suctioning. Back and arms sensitive\n to touch.\n Action:\n Fentanyl gtt increased from 75 mcg/hour to 100 mcg/hour\n Response:\n Bp normalized, able to wake slightly, no command following. Vitals show\n higher level of comfort.\n Plan:\n Continue iv gtt for pain control until prepared to wean sedation for\n extubation, follow up with team for new orders at that time.\n" }, { "category": "Physician ", "chartdate": "2141-06-24 00:00:00.000", "description": "ICU Note - CVI", "row_id": 675430, "text": "CVICU\n HPI:\n HD7\n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMH: HTN, arthritis\n : ASA\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US R>L perfusion. nl size.\n Labetolol/Nicardipine(IV),Norvasc\n :Intubated 2'resp.failure/P edema\n Chief complaint:\n PMHx:\n Current medications:\n Albuterol Inhaler 3. Artificial Tears Preserv. Free 4. Aspirin 5.\n Beclomethasone Dipropionate\n 6. Bisacodyl 7. Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral\n Rinse 9. Fentanyl Citrate\n 10. FoLIC Acid 11. Heparin 12. HydrALAzine 13. Insulin 14. Ipratropium\n Bromide MDI 15. Labetalol\n 16. Metoprolol Tartrate 17. Midazolam 18. Multiple Vitamins Liq. 19.\n Nitroglycerin 20. Ondansetron\n 21. Oxymetazoline 22. Pantoprazole 23. Piperacillin-Tazobactam Na 24.\n Sodium Chloride Nasal 25. Sodium Chloride 0.9% Flush\n 26. Sodium Chloride 0.9% Flush 27. Sodium Chloride 0.9% Flush 28.\n Thiamine 29. Vancomycin\n 24 Hour Events:\n Post operative day:\n HD7\n 62M w/ type B aortic dissection/medical management.\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 11:38 AM\n Infusions:\n Midazolam (Versed) - 0.5 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Hydralazine - 08:26 AM\n Pantoprazole (Protonix) - 11:31 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Flowsheet Data as of 05:19 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 37.7\nC (99.9\n HR: 84 (64 - 87) bpm\n BP: 114/56(73) {84/44(56) - 152/70(93)} mmHg\n RR: 12 (11 - 22) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.5 kg (admission): 90 kg\n Height: 74 Inch\n CVP: 19 (7 - 26) mmHg\n Total In:\n 3,579 mL\n 2,006 mL\n PO:\n Tube feeding:\n 950 mL\n 682 mL\n IV Fluid:\n 2,254 mL\n 949 mL\n Blood products:\n 375 mL\n 375 mL\n Total out:\n 1,655 mL\n 1,185 mL\n Urine:\n 1,655 mL\n 1,185 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,924 mL\n 821 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 800 (800 - 800) mL\n Vt (Spontaneous): 1,137 (944 - 1,137) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 14\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: Agitated\n PIP: 13 cmH2O\n Plateau: 23 cmH2O\n Compliance: 39.3 cmH2O/mL\n SPO2: 95%\n ABG: 7.32/43/94./22/-3\n Ve: 8.3 L/min\n PaO2 / FiO2: 235\n Physical Examination\n Labs / Radiology\n 229 K/uL\n 9.4 g/dL\n 192\n 3.9 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 76 mg/dL\n 107 mEq/L\n 139 mEq/L\n 30.3 %\n 9.4 K/uL\n [image002.jpg]\n 06:09 PM\n 09:30 PM\n 09:47 PM\n 01:50 AM\n 01:59 AM\n 06:00 AM\n 07:54 AM\n 10:40 AM\n 12:00 PM\n 01:06 PM\n WBC\n 9.4\n Hct\n 26.3\n 25.6\n 27.7\n 30.3\n Plt\n 229\n Creatinine\n 3.9\n Troponin T\n 0.02\n TCO2\n 23\n 24\n 23\n Glucose\n 107\n 153\n 149\n 128\n 192\n Other labs: PT / PTT / INR:13.4/34.0/1.2, CK / CK-MB / Troponin\n T:1384/11/0.02, ALT / AST:33/49, Alk-Phos / T bili:132/0.4, Amylase /\n Lipase:62/37, Lactic Acid:0.8 mmol/L, Albumin:2.6 g/dL, LDH:732 IU/L,\n Ca:8.6 mg/dL, Mg:3.2 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE,\n ARF), PNEUMONIA, OTHER\n Assessment and Plan: HD7\n 62M w/ type B aortic dissection/medical management. eintubated5/13 2'\n resp. failure. Hemodynamically stable. postop complicated with acute\n renal failure\n Neurologic: Neuro checks Q: 4 hr, Cont Thiamine/Folate. Versed/Fentanyl\n prn pain.\n Cardiovascular: Aspirin, Beta-blocker, Statins, Maintain BP<140 as\n discussed with Vasc. team. Hydralazine/NTG/Labetalol prn\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), PSV today. wean as\n tol.\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, ARF:Renal US today. Renal following->possible need for HD\n Hematology: Stable anemia. Plan to Tx for HCT <28 per Vasc team\n Endocrine: RISS\n Infectious Disease: Check cultures, Mini Bal prelim=no growth. CXs PND.\n Cont Vanco/Zosyn\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging: CXR today\n Fluids:\n Consults: Vascular surgery, CT surgery, Nephrology\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:05 PM\n Multi Lumen - 09:47 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\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" }, { "category": "Nursing", "chartdate": "2141-06-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674448, "text": "Hypoxemia\n Assessment:\n Sats high 80s-low 90s on 100% fio2 and add\nl NC. Wheezing. Unable to\n raise sputum. Hallucinogenic. Restless.\n Action:\n Mask ventilation started. Restraints needed for treatment interference.\n Ivp lasix admin.\n Response:\n Pao2 increased remarkable on bipap. Restlessness/hallucinations\n decreased. No need for haldol. Unable to tolerate mask ventilation for\n long periods of time.\n Plan:\n Alternating between hi- closed mask and mask ventilation as needed.\n diuresis.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Hypertensive. Peripheral infusion of nicardipine causing phlebotic\n veins.\n Action:\n Titrating nicardipine gtt to maintain sbp <130. PO meds increased.\n NPO while mask ventilation on though. Rotating piv sites for\n nicardipine infusion.\n Response:\n Still requiring nicardipine gtt for bp control.\n Plan:\n Transition to PO or IVP meds for bp control when able to take POs more\n regularily. Pt not a surgical candidate per team.\n" }, { "category": "Nursing", "chartdate": "2141-06-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674449, "text": "Hypoxemia\n Assessment:\n Sats high 80s-low 90s on 100% fio2 and add\nl NC. Wheezing. Unable to\n raise sputum. Hallucinogenic. Restless.\n Action:\n Am cxr obtained, reviewed by team members. Maintenance IVF stopped. Ivp\n lasix admin. Mask ventilation started. Restraints needed for treatment\n interference.\n Response:\n Pao2 increased remarkable on bipap. Restlessness/hallucinations\n decreased. No need for haldol. Unable to tolerate mask ventilation for\n long periods of time.\n Plan:\n Alternating between hi- closed mask and mask ventilation as needed.\n diuresis.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Hypertensive. Peripheral infusion of nicardipine causing phlebotic\n veins.\n Action:\n Titrating nicardipine gtt to maintain sbp <130. PO meds increased.\n NPO while mask ventilation on though. Rotating piv sites for\n nicardipine infusion.\n Response:\n Still requiring nicardipine gtt for bp control.\n Plan:\n Transition to PO or IVP meds for bp control when able to take POs more\n regularily. Assess PIV sites frequently. ?need for central access if\n prolonged time needed on gtt. Pt not a surgical candidate per team.\n" }, { "category": "Nursing", "chartdate": "2141-06-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674519, "text": "Hypoxemia\n Assessment:\n Sats high 80s-low 90s on 100% fio2 and add\nl NC. Wheezing. Unable to\n raise sputum. Hallucinogenic. Restless.\n Action:\n Am cxr obtained, reviewed by team members. Maintenance IVF stopped. Ivp\n lasix admin. Mask ventilation started. Restraints needed for treatment\n interference.\n Response:\n Pao2 increased remarkable on bipap. Restlessness/hallucinations\n decreased. No need for haldol. Unable to tolerate mask ventilation for\n long periods of time.\n Plan:\n Alternating between hi- closed mask and mask ventilation as needed.\n diuresis. ?intubation.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Hypertensive. Peripheral infusion of nicardipine causing phlebotic\n veins.\n Action:\n Titrating nicardipine gtt to maintain sbp <130. PO meds increased.\n NPO while mask ventilation on though. Rotating piv sites for\n nicardipine infusion. Cardiac echo to r/o failure.\n Response:\n Still requiring nicardipine gtt for bp control. Pt switched to nitro\n gtt to avoid more phlebitis.\n Plan:\n Transition to PO or IVP meds for bp control when able to take POs more\n regularly. Assess PIV sites frequently. ?need for central access if\n prolonged time needed on gtts. Pt not a surgical candidate per team.\n Son aware of pt\ns status and possibility of needing breathing\n tube. Son at bedside, spoke to social work this afternoon. SW\n following and will help pt apply for disability.\n ------ Protected Section ------\n Pt continued to be restless and uncooperative with Mask ventilation.\n Hypoxic with sats 87-88%. Pt intubated by anesthesia Dr .\n Etomidate and succ given. Propofol for sedation/hypertension. Started\n on midazalam and fentanyl gtt with continued severe agitation\n requiring doubling doses. Propofol gtt started. OGT inserted. Post\n intubation CXR done. Frothy white secretions from mouth and ET tube.\n Sputum obtained by RT. Family at bedside off and on asking some\n appropriate questions.. Requesting to speak with NP/MD. Son spoke with\n social worker .\n Requiring high doses of fentanyl, midazalam and propofol to sedate.\n NTG gtt off. Attempting to keep SBP>90, MAP>60 with sedation\n balancing.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:25 ------\n" }, { "category": "Physician ", "chartdate": "2141-06-26 00:00:00.000", "description": "ICU Note - CVI", "row_id": 676029, "text": "CVICU\n HPI:\n HD9\n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMH: HTN, arthritis\n : ASA\n - CTA torso:type B aortic dissection, true lumen in upper abd near\n completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -renal US R>L perfusion. nl size.\n Labetolol/Nicardipine(IV),Norvasc\n :Intubated 2'resp.failure/P edema\n :Extubated. restless, agitated at times.Labetalol GTT for BP\n control\n -PP DHT, TF begun. fenanyl for pain, calmer.Cr:3.6\n Chief complaint:\n PMHx:\n Current medications:\n Albuterol 0.083% Neb Soln 3. Artificial Tears Preserv. Free 4. Aspirin\n 5. Beclomethasone Dipropionate\n 6. Bisacodyl 7. Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral\n Rinse 9. Fentanyl Citrate\n 10. FoLIC Acid 11. Heparin 12. Insulin 13. Ipratropium Bromide Neb 14.\n Labetalol 15. Lorazepam\n 16. Lorazepam 17. Metoprolol Tartrate 18. Multiple Vitamins Liq. 19.\n Nitroglycerin 20. Ondansetron\n 21. Pantoprazole 22. Piperacillin-Tazobactam Na 23. Sodium Chloride\n Nasal 24. Sodium Chloride 0.9% Flush\n 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush 27.\n Thiamine\n 24 Hour Events:\n EKG - At 09:40 PM\n NASAL SWAB - At 02:30 AM\n MRSA screening\n Post operative day:\n Type B dissection\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Piperacillin/Tazobactam (Zosyn) - 12:00 PM\n Infusions:\n Nitroglycerin - 2 mcg/Kg/min\n Labetalol - 0.5 mg/min\n Other ICU medications:\n Haloperidol (Haldol) - 09:00 PM\n Heparin Sodium (Prophylaxis) - 12:36 AM\n Lorazepam (Ativan) - 04:20 PM\n Other medications:\n Flowsheet Data as of 04:32 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.7\nC (98\n HR: 70 (59 - 75) bpm\n BP: 146/74(96) {102/52(67) - 165/98(116)} mmHg\n RR: 18 (13 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.6 kg (admission): 90 kg\n Height: 74 Inch\n CVP: 17 (6 - 22) mmHg\n Total In:\n 2,325 mL\n 1,366 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,325 mL\n 1,366 mL\n Blood products:\n Total out:\n 2,403 mL\n 1,020 mL\n Urine:\n 2,403 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -78 mL\n 346 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SPO2: 100%\n ABG: 7.42/28/82./21/-4\n PaO2 / FiO2: 207\n Physical Examination\n General Appearance: Anxious, restless with interaction. Moaning, \n awake\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, loose\n stool\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Awake / Alert / Oriented: No(t) x 2, x 1), Follows simple\n commands, (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli, No(t) Unresponsive), Moves all extremities\n Labs / Radiology\n 263 K/uL\n 9.4 g/dL\n 108 mg/dL\n 3.6 mg/dL\n 21 mEq/L\n 4.5 mEq/L\n 76 mg/dL\n 113 mEq/L\n 144 mEq/L\n 28.1 %\n 11.9 K/uL\n [image002.jpg]\n 02:12 AM\n 05:33 AM\n 09:37 AM\n 06:20 PM\n 09:45 PM\n 10:02 PM\n 02:27 AM\n 06:55 AM\n 07:04 AM\n 12:58 PM\n WBC\n 11.9\n Hct\n 26.9\n 27.8\n 28.1\n Plt\n 263\n Creatinine\n 3.6\n TCO2\n 24\n 23\n 24\n 22\n 23\n 24\n 19\n Glucose\n 153\n 108\n Other labs: PT / PTT / INR:13.2/29.6/1.1, CK / CK-MB / Troponin\n T:1384/11/0.02, ALT / AST:44/52, Alk-Phos / T bili:288/0.8, Amylase /\n Lipase:55/68, Lactic Acid:0.9 mmol/L, Albumin:2.6 g/dL, LDH:598 IU/L,\n Ca:8.7 mg/dL, Mg:2.7 mg/dL, PO4:3.4 mg/dL\n Imaging: CXR-wet, otherwise unremarkable. DHT pp on repeat films.\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, ALTERED MENTAL STATUS (NOT DELIRIUM), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), PNEUMONIA, OTHER\n Assessment and Plan: CV stable when calm. more awake now, but not\n cooperative/oriented. Oxygenation okay/.\n Neurologic:\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker\n Pulmonary: IS\n Gastrointestinal / Abdomen: Place NGT, DHT\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS, Lantus (R)\n Infectious Disease: Check cultures\n Lines / Tubes / Drains: Foley, Dobhoff\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: Other\n Consults: O.T.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:05 PM\n Multi Lumen - 09:47 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\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" }, { "category": "Physician ", "chartdate": "2141-06-26 00:00:00.000", "description": "Generic Note", "row_id": 676030, "text": "TITLE: Intensivist Daily Note\n CVICU\n HPI:\n HD9\n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMH: HTN, arthritis\n : ASA\n - CTA torso: type B aortic dissection, true lumen in upper abdomen\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -renal US R>L perfusion. nl size. Labetolol\n /Nicardipine(IV),Norvasc\n :Intubated 2' resp. failure/P edema\n :Extubated. restless, agitated at times. Labetalol GTT for BP\n control\n -PP DHT, TF begun. fentanyl for pain, calmer.Cr:3.6\n Current medications:\n Albuterol 0.083% Neb Soln 3. Artificial Tears Preserv. Free 4. Aspirin\n 5. Beclomethasone Dipropionate 6. Bisacodyl 7. Calcium Gluconate 8.\n Chlorhexidine Gluconate 0.12% Oral Rinse 9. Fentanyl Citrate 10. FoLIC\n Acid 11. Heparin 12. Insulin 13. Ipratropium Bromide Neb 14. Labetalol\n 15. Lorazepam 17. Metoprolol Tartrate 18. Multiple Vitamins Liq. 19.\n Nitroglycerin 20. Ondansetron 21. Pantoprazole 22.\n Piperacillin-Tazobactam Na 27. Thiamine\n 24 Hour Events:\n EKG - At 09:40 PM\n NASAL SWAB - At 02:30 AM\n MRSA screening\n Post operative day:\n Type B dissection\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Piperacillin/Tazobactam (Zosyn) - 12:00 PM\n Infusions:\n Nitroglycerin - 2 mcg/Kg/min\n Labetalol - 0.5 mg/min\n Other ICU medications:\n Haloperidol (Haldol) - 09:00 PM\n Heparin Sodium (Prophylaxis) - 12:36 AM\n Lorazepam (Ativan) - 04:20 PM\n Other medications:\n Flowsheet Data as of 04:32 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.7\nC (98\n HR: 70 (59 - 75) bpm\n BP: 146/74(96) {102/52(67) - 165/98(116)} mmHg\n RR: 18 (13 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.6 kg (admission): 90 kg\n Height: 74 Inch\n CVP: 17 (6 - 22) mmHg\n Total In:\n 2,325 mL\n 1,366 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,325 mL\n 1,366 mL\n Blood products:\n Total out:\n 2,403 mL\n 1,020 mL\n Urine:\n 2,403 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -78 mL\n 346 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SPO2: 100%\n ABG: 7.42/28/82./21/-4\n PaO2 / FiO2: 207\n Physical Examination\n General Appearance: Anxious, restless with interaction. Moaning, \n awake\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, loose\n stool\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Awake / Alert / Oriented: No(t) x 2, x 1), Follows simple\n commands, (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli, No(t) Unresponsive), Moves all extremities\n Labs / Radiology\n 263 K/uL\n 9.4 g/dL\n 108 mg/dL\n 3.6 mg/dL\n 21 mEq/L\n 4.5 mEq/L\n 76 mg/dL\n 113 mEq/L\n 144 mEq/L\n 28.1 %\n 11.9 K/uL\n [image002.jpg]\n 02:12 AM\n 05:33 AM\n 09:37 AM\n 06:20 PM\n 09:45 PM\n 10:02 PM\n 02:27 AM\n 06:55 AM\n 07:04 AM\n 12:58 PM\n WBC\n 11.9\n Hct\n 26.9\n 27.8\n 28.1\n Plt\n 263\n Creatinine\n 3.6\n TCO2\n 24\n 23\n 24\n 22\n 23\n 24\n 19\n Glucose\n 153\n 108\n Other labs: PT / PTT / INR:13.2/29.6/1.1, CK / CK-MB / Troponin\n T:1384/11/0.02, ALT / AST:44/52, Alk-Phos / T bili:288/0.8, Amylase /\n Lipase:55/68, Lactic Acid:0.9 mmol/L, Albumin:2.6 g/dL, LDH:598 IU/L,\n Ca:8.7 mg/dL, Mg:2.7 mg/dL, PO4:3.4 mg/dL\n Imaging: CXR-wet, otherwise unremarkable. DHT pp on repeat films.\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, ALTERED MENTAL STATUS (NOT DELIRIUM), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), PNEUMONIA, OTHER\n Assessment and Plan: CV stable when calm. more awake now, but not\n cooperative/oriented. Oxygenation okay/.\n Neurologic: Confused. Agitated\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker\n Pulmonary: IS\n Gastrointestinal / Abdomen: Place NGT, DHT\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Endocrine: RISS, Lantus (R)\n Infectious Disease: Check cultures\n Lines / Tubes / Drains: Foley, Dobhoff\n Wounds: Dry dressings\n Imaging: CXR today\n Consults: O.T.\n Billing dignosis- Hypertension. Aortic dissection\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Arterial Line - 04:05 PM\n Multi Lumen - 09:47 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Time spent- 32 minutes\n" }, { "category": "Nursing", "chartdate": "2141-06-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676117, "text": "Pt is 62 year old male with h/o of htn, arthritis who presented to ED\n on with complaints of chest pain. Pt was riding the T to a\n ballgame today when he had a sudden urge to have a bowel movement. Pt\n went to restroom and was unable to have a bowel movement, but hen\n developed severe knife-life chest pain which radiated to back. He felt\n lightheaded, dizzy, nausea and short of breath. Pt had a CT scan with\n large type B dissection of aorta. Plan for medical management\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US no normal arterial waveforms seen in the right kidney or\n right main renal artery.\n :Intubated 2'resp.failure/P edema\n head ct for ?posturing/neuro changes- head ct was neg\n rapid afib/flutter required cardioversion x1\n Extubated\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Received pt on labetalol & nitro gtt\n SBP 100-120s at beginning of shift\n Lopressor 50mg ordered\n Norvasc 10mg daily ordered\n Action:\n Gtts weaned to off d/t SBP 100s for 2 hours\n Lopressor & Norvasc started PO\n Response:\n Pt became agitated and required gtts to be restarted SBP >150\n Plan:\n Wean gtts as tol to keep SBP <150\n Cont PO meds as ordered\n Altered mental status (not Delirium)\n Assessment:\n Received pt calm, restrained in bed with soft limb d/t interference\n with medical tx\n Pt began to get extremely agitated yelling out, raising legs,\n attempting to pull at lines and tubes\n Restless in bed moving throughout\n Pt not cooperating, confused\n Pt stating he is at church, yelling out to let him go\n Pt more understandable than following night, stating yes to pain,\n unable to describe or explain however\n Pt has visible tremors at times\n Action:\n 0.5mg IV ativan Q6 standing order\n 0.5mg IV prn breakthrough Q4\n 25-100mcg fentanyl ordered for pain\n Response:\n Pt not responding to ativan, remained restless requiring an extra of\n 0.5mg 1 hour following standing dose\n Fentanyl given for pain, with minimal relief\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-06-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676375, "text": "Altered mental status (not Delirium)\n Assessment:\n More coherent today. Able to hold conversations. Confused. Oriented to\n self. Attempting to get out of bed. Pulling out dophoff, attempting to\n pull all other lines/tubes. Pt and pt\ns family deny any drinking/drug\n abuse. Significant family history for alcoholism.\n Action:\n Psych consult. Meds changed. Ativan changed to PO and decreased d/t\n confusion, cont to give for ?withdrawing. IM haldol added. Dophoff\n reinserted for nutrition/hydration as pt too confused to feed.\n Response:\n Pt more calm in morning. Sleeping in periods. Agitation worsened as day\n progressed. Pt is easily redirected but requires freq & firm\n directing.\n Plan:\n Continue standing haldol & Ativan. ?need for increased prn haldol as\n agitation worsens at night. Reorient freq to place/time.\n Pneumonia, other\n Assessment:\n Known RML pneumonia. Previously hypoxic needing intub.\n Action:\n Pulm toilet. Pt listens to cues to cough, dose not always spit out\n sputum. No wheezes heard today, nebs held.\n Response:\n Pt clearing secretions. Able to wean to RA. Sats >96%.\n Plan:\n Cont to encourage pulm toilet.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Hypertensive when awake and with increased agitation.\n Action:\n Nitro and labetalol gtts cont to maintain sbp <150. PO\n antihypertensives increased.\n Response:\n Still requiring gtts when agitated.\n Plan:\n Increase po meds. ?adding po labetalol to transition off gtt.\n" }, { "category": "Nursing", "chartdate": "2141-06-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676170, "text": "Pt is 62 year old male with h/o of htn, arthritis who presented to ED\n on with complaints of chest pain. Pt was riding the T to a\n ballgame today when he had a sudden urge to have a bowel movement. Pt\n went to restroom and was unable to have a bowel movement, but hen\n developed severe knife-life chest pain which radiated to back. He felt\n lightheaded, dizzy, nausea and short of breath. Pt had a CT scan with\n large type B dissection of aorta. Plan for medical management\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US no normal arterial waveforms seen in the right kidney or\n right main renal artery.\n :Intubated 2'resp.failure/P edema\n head ct for ?posturing/neuro changes- head ct was neg\n rapid afib/flutter required cardioversion x1\n Extubated\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Received pt on labetalol & nitro gtt\n SBP 100-120s at beginning of shift\n Lopressor 50mg ordered\n Norvasc 10mg daily ordered\n Action:\n Gtts weaned to off d/t SBP 100s for 2 hours\n Lopressor & Norvasc started PO\n Response:\n Pt became agitated and required gtts to be restarted SBP >150\n Plan:\n Wean gtts as tol to keep SBP <150\n Cont PO meds as ordered\n ? need for ^ dose of PO meds vs pt not absorbing POs\n Altered mental status (not Delirium)\n Assessment:\n Received pt calm, restrained in bed with soft limb d/t interference\n with medical tx\n Pt began to get extremely agitated yelling out, raising legs,\n attempting to pull at lines and tubes\n Restless in bed moving throughout\n Pt not cooperating, confused\n Pt stating he is at church, yelling out to let him go\n Pt more understandable than following night, stating yes to pain,\n unable to describe or explain however\n Pt has visible tremors at times\n Action:\n Pt re-oriented prn\n 0.5mg IV ativan Q6 standing order\n 0.5mg IV prn breakthrough Q4\n 25-100mcg fentanyl ordered for pain\n Response:\n Pt not responding to ativan\n Remained restless requiring an extra of 0.5mg in between standing/prn\n dose\n Fentanyl given for pain, with minimal relief\n Haldol 5mg IV given x 1\n Pt able to speak a little clearer\n Oriented to self only\n Pt stated his name and birth date when asked\n Remains inappropriate, combative at times\n Following commands inconsistently\n Plan:\n Re-orient PRN\n Ativan/Fentanyl as needed IV\n Monitor respiratory status with pt for worry of pt tiring out\n" }, { "category": "Nursing", "chartdate": "2141-06-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676175, "text": "Pt is 62 year old male with h/o of htn, arthritis who presented to ED\n on with complaints of chest pain. Pt was riding the T to a\n ballgame today when he had a sudden urge to have a bowel movement. Pt\n went to restroom and was unable to have a bowel movement, but hen\n developed severe knife-life chest pain which radiated to back. He felt\n lightheaded, dizzy, nausea and short of breath. Pt had a CT scan with\n large type B dissection of aorta. Plan for medical management\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US no normal arterial waveforms seen in the right kidney or\n right main renal artery.\n :Intubated 2'resp.failure/P edema\n head ct for ?posturing/neuro changes- head ct was neg\n rapid afib/flutter required cardioversion x1\n Extubated\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Received pt on labetalol & nitro gtt\n SBP 100-120s at beginning of shift\n Lopressor 50mg ordered\n Norvasc 10mg daily ordered\n Action:\n Gtts weaned to off d/t SBP 100s for 2 hours\n Lopressor & Norvasc started PO\n Response:\n Pt became agitated and required gtts to be restarted SBP >150\n Plan:\n Wean gtts as tol to keep SBP <150\n Cont PO meds as ordered\n ? need for ^ dose of PO meds vs pt not absorbing POs\n Altered mental status (not Delirium)\n Assessment:\n Received pt calm, restrained in bed with soft limb d/t interference\n with medical tx\n Pt began to get extremely agitated yelling out, raising legs,\n attempting to pull at lines and tubes\n Restless in bed moving throughout\n Pt not cooperating, confused\n Pt stating he is at church, yelling out to let him go\n Pt more understandable than following night, stating yes to pain,\n unable to describe or explain however\n Pt has visible tremors at times\n Action:\n Pt re-oriented prn\n 0.5mg IV ativan Q6 standing order\n 0.5mg IV prn breakthrough Q4\n 25-100mcg fentanyl ordered for pain\n Response:\n Pt not responding to ativan\n Remained restless requiring an extra of 0.5mg in between standing/prn\n dose\n Fentanyl IV given for pain, with minimal relief\n Haldol 5mg IV given x 1\n Pt able to speak a little clearer\n Oriented to self only\n Pt stated his name and birth date when asked\n Remains inappropriate, combative at times\n Following commands inconsistently\n Plan:\n Re-orient PRN\n Ativan/Fentanyl as needed IV\n Monitor respiratory status\n worry of pt tiring out & protection of\n airway\n" }, { "category": "Nursing", "chartdate": "2141-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676773, "text": " 0700-1500\n Altered mental status, delirious at times\n Assessment:\n Pt oriented x 1 (self) throughout shift. Disoriented, wanting to get\n out of bed, making inappropriate statements. Pt unaware that he\ns in\n hospital. Sitter at bedside.\n Action:\n Required high doses of Haldol and Fentanyl to try and keep pt calm.\n Soft wrist restraints in place to avoid disruption in treatment.\n Reoriented patient frequently, emotional support provided. Also, NP\n increased haldol to 5mg po 4x/day per psych recommendation.\n EKG performed\n Response:\n Pt had periods of sleep with periods of restlessness and attempts to\n get out of bed. No improvement in mental status noted. QTc-0.44.\n Plan:\n Continue to monitor mental status closely. Administer Haldol and\n Fentanyl as ordered. Measure QTc q shift. I\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Hypertension that increases with agitation. NTG gtt continued to keep\n SBP 120-150. Drip increased to 3mcg/kg/hr. Lopressor also increased\n to 37.5mg 3x/ by NP Coutney.\n False lumen perfusing L kidney, ATN improving. Creat/bun decreasing but\n still elevated.?mesenteric ischemia d/t dissection, loose stool cont.\n Cdiff neg x2.\n Action:\n Nitro gtt weaned keeping sbp <150. Unable to wean off. Clonidine patch\n and po load started on previous shift.\n Renal following.\n Response:\n Continues to be hypertensive at times requiring nitro gtt despite po\n meds. Good HUO. Loose stools cont with flexiseal in place.\n Plan:\n Wean nitro gtt keeping sbp <150. Cont po clonidine load, pt wearing\n patch. Vascular want to re-image dissection when pt neurologically\n appropriate. ?stenting renal artery. Renal will cont to follow until\n creat improves. Third cdiff to be sent.\n" }, { "category": "Nursing", "chartdate": "2141-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676766, "text": "Altered mental status (not Delirium)\n Assessment:\n Patient received clonidine and haldol via NGT. More cooperative, more\n easily redirected. Patient restless briefly, trying to get out of\n chair.\n Action:\n Patient redirected. Ginger ale offered.\n Response:\n Patient calmer after drinking\n Plan:\n Continue pgt haldol with prn for breakthrough. Continue to redirect.\n" }, { "category": "Nursing", "chartdate": "2141-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675790, "text": "Pt is 62 year old male with h/o of htn, arthritis who presented to ED\n on with complaints of chest pain. Pt was riding the T to a\n ballgame today when he had a sudden urge to have a bowel movement. Pt\n went to restroom and was unable to have a bowel movement, but hen\n developed severe knife-life chest pain which radiated to back. He felt\n lightheaded, dizzy, nausea and short of breath. Pt had a CT scan with\n large type B dissection of aorta. Plan for medical management\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US no normal arterial waveforms seen in the right kidney or\n right main renal artery.\n :Intubated 2'resp.failure/P edema\n head ct for ?posturing/neuro changes- head ct was neg\n rapid afib/flutter required cardioversion at change of shift\n Extubated\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675787, "text": "Pt is 62 year old male with h/o of htn, arthritis who presented to ED\n on with complaints of chest pain. Pt was riding the T to a\n ballgame today when he had a sudden urge to have a bowel movement. Pt\n went to restroom and was unable to have a bowel movement, but hen\n developed severe knife-life chest pain which radiated to back. He felt\n lightheaded, dizzy, nausea and short of breath. Pt had a CT scan with\n large type B dissection of aorta. Plan for medical management\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US R>L perfusion. nl size.\n :Intubated 2'resp.failure/P edema\n head ct for ?posturing/neuro changes- head ct was neg\n rapid afib/flutter required cardioversion at change of shift\n Extubated\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675784, "text": "Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675785, "text": "62M w/ type B aortic dissection/medical management.\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US R>L perfusion. nl size.\n Labetolol/Nicardipine(IV),Norvasc\n :Intubated 2'resp.failure/P edema\n : Extubated\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675786, "text": "Pt is 62 year old male with h/o of htn, arthritis who presented to ED\n on with complaints of chest pain. Pt was riding the T to a\n ballgame today when he had a sudden urge to have a bowel movement. Pt\n went to restroom and was unable to have a bowel movement, but hen\n developed severe knife-life chest pain which radiated to back. He felt\n lightheaded, dizzy, nausea and short of breath. Pt had a CT scan with\n large type B dissection of aorta. Plan for medical management\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US R>L perfusion. nl size.\n :Intubated 2'resp.failure/P edema\n : Extubated\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2141-06-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 674871, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 86.2 None\n Ideal tidal volume: 344.8 / 517.2 / 689.6 mL/kg\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Accessory muscle use\n Assessment of breathing comfort:\n :\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Pt remains intubated (now at 25cm at incisor), and required AC mode on\n vent due to ^RR and WOB. Multiple vent changes made, see flowsheet.\n Received MDI\ns, secretions thick blood tinged/ tan , culture sent. CXR\n shows L sided pneumonia.\n" }, { "category": "Nursing", "chartdate": "2141-06-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674924, "text": "Hypoxemia\n Assessment:\n Pt turned to left side became agitated droping Sats to 90. Suctioned\n for thick blood tinged secretions. ABG on CPAP 5/5 7.27 51 76 24 -3\n Chest xray shows Right middle lobe pneumonia NP\n Action:\n Pt placed on SIMV with increased PEEP and FIO2 up to 100%\n Vancomuycin 1gm and Pipercillin 4.5gms given\n Sputum culture sent to lab\n Response:\n PO2 up to 160\ns so FIO2 weaned down to 50%.\n Plan:\n Continue antibiotic monitor cultures\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n PO antihypertensives held during day shift for hypotension pt became\n intermittently agitated at times with turning and stimulation SBP\n increasing to 150\ns and HR up to 150\ns then went into afib/flutter rate\n up to 150\n Action:\n Nitro drip restarted and titrated up to 3mcg\n Lopressor 5mgx4or a total of 20mg IV given\n Versed bolus 0.5mg x2 and drip increased to 2\n Fentanyl bolus of 25mcg and drip increased to 150mcg\n Response:\n SBP more controlled with lopressor nitro drip weaned off. Pt sedated\n but still becomes agitated with suctioning and movement but SBP does\n not increase as high and agitation only lasts briefly. Pt remains in\n aflutter rate around 100-120. Lopressor repeated x1\n Plan:\n Continue sedation, Plan for cardioversion today\n Alteration in Nutrition\n Assessment:\n Abdomen soft positive bowel sounds, no stool or flatus\n Action:\n Tube feeds increased to goal level of 40cc/hr residuals checked every\n 4hours HOB elevated 30-45degrees\n Response:\n Pt tolerating tube feeds well\n Plan:\n Monitor residuals and bowel function\n" }, { "category": "Nursing", "chartdate": "2141-06-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674040, "text": ".H/O aortic aneurysm, abdominal with rupture (AAA)\n Assessment:\n Patient remains on nicardipine with BP <130 goal. Labetalol po given.\n Action:\n BP remains 120-130 on nicardipine. Labetaolo dose increased, norvasc to\n be added.\n Response:\n Patient remains with BP 120\ns, increase to 130\ns with activity.\n Plan:\n Continue to monitor BP, titrate meds per vascular, ICU team to keep\n <130.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient with c/o pain in chest, lower back radiating to LE.\n Action:\n PRN hydromorphone. Patient with c/o generalized malaise.\n Response:\n Patient sleeping with adequate pain relief.\n Plan:\n Patient to receive prn hydromorphone. Swabs, cool clothes and other\n comfort measures offered.\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-06-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674043, "text": ".H/O aortic aneurysm, abdominal with rupture (AAA)\n Assessment:\n Patient remains on nicardipine with BP <130 goal. Labetalol po given.\n Action:\n BP remains 120-130 on nicardipine. Labetaolo dose increased, norvasc to\n be added.\n Response:\n Patient remains with BP 120\ns, increase to 130\ns with activity.\n Plan:\n Continue to monitor BP, titrate meds per vascular, ICU team to keep\n <130.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient with c/o pain in chest, lower back radiating to LE.\n Action:\n PRN hydromorphone. Patient with c/o generalized malaise.\n Response:\n Patient sleeping with adequate pain relief.\n Plan:\n Patient to receive prn hydromorphone. Swabs, cool clothes and other\n comfort measures offered.\n Hypoxemia\n Assessment:\n Patient with clear BS, intermittent non-productive cough. NC O2 with\n SAT in low 90\n Action:\n Oxygen continued. Lower sat tolerated due to smoking history.\n Response:\n Patient with stable SAT. Encourage cough and deep breathe.\n Plan:\n Continue pulmonary toilet.\n" }, { "category": "Nursing", "chartdate": "2141-06-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 673851, "text": "Pt is 62 year old male with h/o of htn, arthritis who presented to ED\n with complaints of chest pain. Pt was riding the T to a ballgame today\n when he had a sudden urge to have a bowel movement. Pt went to\n restroom and was unable to have a bowel movement, but hen developed\n severe knife-life chest pain which radiated to back. He felt\n lightheaded, dizzy, nausea and short of breath. Pt had a CT scan with\n large type B dissection of aorta. Right kidney is asymmetrically\n hypoperfused indicating vascular comprise.\n Chest pain and back pain\n Assessment:\n Pt c/o chestpain that radiated to back\n Pt rated pain a\n on a scale of \n Action:\n Pt received .5mg iv hydromorphone x2\n Response:\n Pain level went from a 7 to a\n which pt states is an\n acceptable level of pain\n Plan:\n Continue to monitor\n Medicate for pain as ordered\n See nursing care plan\n .H/O aortic aneurysm, abdominal with rupture (AAA)\n Assessment:\n Pt alert and oriented x3\n Pt follows commands\n Pt with palable radial, pedal pulses bilaterally\n Sbp less than 140\n Pt c/o nausea\n Urine output greater than 30cc/hr\n Action:\n Pt received zofran\n Nipride gtt at 2.5mcg/kg/min\n Labetatol at 1mg/min\n Response:\n Sbp remains less than 140 per dr. . \n Denies any further c/o nausea\n Plan:\n Continue to monitor\n Titrate labetatol and nipride to keep sbp less than 140\n Check and replete electroyles as ordered\n Monitor urine output\n Check radial and pedal pulses, assess circulation to\n extremties\n Assess mentation\n" }, { "category": "Nursing", "chartdate": "2141-06-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674093, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n At last eve,pt c/o sharp pain # in lower substernal area into\n back (same as he\ns had since adm).\n Action:\n IV dilaudid 1mg given. Bed alarm on.\n Response:\n Pain subsided to #7 initially. Required Q2-4 hr dosing of pain med\n during night. Pain tolerable for pt @ #. Slept after doses.\n Self positioned in bed throughout night. Attempted to get OOB x 1\n during night after waking thinking that\nit was Sunday and I had to do\n my laundry\n. Got as far as edge of bed.\n Plan:\n Continue dilaudid prn but try to decrease frequency if possible. Keep\n bed alarm on and reorient as needed.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n A&O w/ 1 episode confusion on waking during night(see above). UE & LE\n pulses all easily palpable. Feet w/ gd csm. Pain as above. SBP\n high 120\ns-132 range early in shift. When asked if he took\n antihypertensive meds @ home , pt answered no and said that he\nkind of\n gave up on the high blood pressure thing\n Action:\n Norvasc started and additional Hydralazine given. Pt enc to move\n carefully in bed and allowed to sleep most of night.\n Response:\n SBP remained slightly above 130 after above meds so Nicardipine drip\n increased slightly\n SBP 100-120 range rest of night. Pt slept well in\n between pain med doses.\n Plan:\n Continue BP management for goal SBP </= 130. Allowed up to chair w/\n assist. Reviewed w/ pt nature of his disease and discussed need for\n careful BP management even once pt is d/c\nd to home. Pt seemed to\n understand but did not indicate if he could follow regimen.\n" }, { "category": "Physician ", "chartdate": "2141-06-19 00:00:00.000", "description": "Intensivist Note", "row_id": 673935, "text": "SICU\n HPI:\n 62M w/ type B aortic dissection.\n Chief complaint:\n chest/back pain\n PMHx:\n PMH: HTN, arthritis\n : ASA\n Current medications:\n 1. 1000 mL 1/2NS Continuous at 100 ml/hr Order date: @ 1455\n 2. NiCARdipine 1-5 mcg/kg/min IV DRIP TITRATE TO SBP<130 Order date:\n @ 0039\n 3. HYDROmorphone (Dilaudid) 0.25-1 mg IV Q2H:PRN pain Order date:\n @ \n 4. Nitroprusside Sodium 5-8 mcg/kg/min IV DRIP TITRATE TO SBP<130 Order\n date: @ 0137\n 5. Heparin 5000 UNIT SC TID Order date: @ 1455\n 6. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1734\n 7. Insulin SC (per Insulin Flowsheet) Sliding Scale Order date:\n @ 0242\n 8. Labetalol 0.5-2 mg/min IV DRIP TITRATE TO SBP<130 Order date: \n @ 0031\n 24 Hour Events:\n Admitted to SICU on labetalol & Nipride gtts. Added nicardipine, then\n weaned off. Cardiac enzymes negative x 3.\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Labetalol - 1 mg/min\n Nitroprusside - 4 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 03:57 AM\n Hydromorphone (Dilaudid) - 04:46 AM\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: 35.8\nC (96.5\n T current: 35.6\nC (96\n HR: 64 (55 - 65) bpm\n BP: 106/57(72) {106/50(68) - 169/86(113)} mmHg\n RR: 12 (8 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 1,297 mL\n 1,525 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,297 mL\n 1,525 mL\n Blood products:\n Total out:\n 495 mL\n 210 mL\n Urine:\n 495 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 802 mL\n 1,315 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (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 (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 215 K/uL\n 12.0 g/dL\n 220 mg/dL\n 1.8 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 32 mg/dL\n 102 mEq/L\n 135 mEq/L\n 35.4 %\n 15.6 K/uL\n [image002.jpg]\n 08:03 PM\n 01:42 AM\n WBC\n 15.6\n Hct\n 35.4\n Plt\n 215\n Creatinine\n 1.8\n Troponin T\n <0.01\n Glucose\n 220\n Other labs: PT / PTT / INR:13.1/27.1/1.1, CK / CK-MB / Troponin\n T:149/6/<0.01, Ca:8.7 mg/dL, Mg:1.9 mg/dL, PO4:4.2 mg/dL\n Imaging: CTA torso: large type B aortic dissection, true lumen in\n upper abd near completely occluded, false lumen supplies celiac, SMA, L\n renal, R kidney asymmetrically hypoperfused\n Assessment and Plan\n CHEST PAIN, .H/O AORTIC ANEURYSM, ABDOMINAL WITH RUPTURE (AAA)\n Assessment and Plan: 62M w/ type B aortic dissection.\n Neurologic: Pain controlled, Dilaudid prn.\n Cardiovascular: Beta-blocker, HD stable on labetalol & Nipride gtts.\n Wean Nipride and add Nicardipine Goal SBP<130.\n Pulmonary: IS, Supplemental O2 as needed.\n Gastrointestinal / Abdomen: NPO for possible procedure.\n Nutrition: NPO\n Renal: Foley, Adequate UO, R kidney hypoperfused. Cr rising 1.4 ->\n 1.8.\n Hematology: Hct 44.2 -> 35.4, likely dilutional. Recheck in AM.\n Endocrine: RISS, Goal FS<150.\n Infectious Disease: No issues. WBC 15.6, likely reactive.\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: Other, 1/2NS@100.\n Consults: Vascular surgery, CT surgery\n Billing Diagnosis: Acute renal failure, Other: aortic dissection\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 05:24 PM\n 20 Gauge - 05:24 PM\n 18 Gauge - 05:25 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n" }, { "category": "Physician ", "chartdate": "2141-06-19 00:00:00.000", "description": "Intensivist Note", "row_id": 673943, "text": "SICU\n HPI:\n 62M w/ type B aortic dissection.\n Chief complaint:\n chest/back pain\n PMHx:\n PMH: HTN, arthritis\n : ASA\n Current medications:\n 1. 1000 mL 1/2NS Continuous at 100 ml/hr Order date: @ 1455\n 2. NiCARdipine 1-5 mcg/kg/min IV DRIP TITRATE TO SBP<130 Order date:\n @ 0039\n 3. HYDROmorphone (Dilaudid) 0.25-1 mg IV Q2H:PRN pain Order date:\n @ \n 4. Nitroprusside Sodium 5-8 mcg/kg/min IV DRIP TITRATE TO SBP<130 Order\n date: @ 0137\n 5. Heparin 5000 UNIT SC TID Order date: @ 1455\n 6. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1734\n 7. Insulin SC (per Insulin Flowsheet) Sliding Scale Order date:\n @ 0242\n 8. Labetalol 0.5-2 mg/min IV DRIP TITRATE TO SBP<130 Order date: \n @ 0031\n 24 Hour Events:\n Admitted to SICU on labetalol & Nipride gtts. Added nicardipine, then\n weaned off. Cardiac enzymes negative x 3.\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Labetalol - 1 mg/min\n Nitroprusside - 4 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 03:57 AM\n Hydromorphone (Dilaudid) - 04:46 AM\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: 35.8\nC (96.5\n T current: 35.6\nC (96\n HR: 64 (55 - 65) bpm\n BP: 106/57(72) {106/50(68) - 169/86(113)} mmHg\n RR: 12 (8 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 1,297 mL\n 1,525 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,297 mL\n 1,525 mL\n Blood products:\n Total out:\n 495 mL\n 210 mL\n Urine:\n 495 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 802 mL\n 1,315 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Mild tenderness, 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 (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 215 K/uL\n 12.0 g/dL\n 220 mg/dL\n 1.8 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 32 mg/dL\n 102 mEq/L\n 135 mEq/L\n 35.4 %\n 15.6 K/uL\n [image002.jpg]\n 08:03 PM\n 01:42 AM\n WBC\n 15.6\n Hct\n 35.4\n Plt\n 215\n Creatinine\n 1.8\n Troponin T\n <0.01\n Glucose\n 220\n Other labs: PT / PTT / INR:13.1/27.1/1.1, CK / CK-MB / Troponin\n T:149/6/<0.01, Ca:8.7 mg/dL, Mg:1.9 mg/dL, PO4:4.2 mg/dL\n Imaging: CTA torso: large type B aortic dissection, true lumen in\n upper abd near completely occluded, false lumen supplies celiac, SMA, L\n renal, R kidney asymmetrically hypoperfused\n Assessment and Plan\n CHEST PAIN, .H/O AORTIC ANEURYSM, ABDOMINAL WITH RUPTURE (AAA)\n Assessment and Plan: 62M w/ type B aortic dissection.\n Neurologic: Pain controlled, Dilaudid prn.\n Cardiovascular: Beta-blocker, HD < 130 on labetalol & Nipride gtts.\n Wean Nipride and restart Nicardipine for Goal SBP<130 and start\n Hydralazine PRN and Labetalol PO.\n Pulmonary: IS, Supplemental O2 as needed.\n Gastrointestinal / Abdomen: Advance to clears.\n Nutrition: Clears\n Renal: Foley, oliguria this AM, R kidney hypoperfused and Cr rising 1.4\n ->1.8\n change IVF to LR to improve intra-vascular volume.\n Hematology: Hct 44.2 -> 35.4, likely dilutional. Repeat later today.\n Endocrine: RISS, Goal FS<150.\n Infectious Disease: No issues. WBC 15.6, likely reactive.\n Lines / Tubes / Drains: Foley\n Wounds: none\n Imaging: none\n Fluids: Other, 1/2NS@100\n change to LR as above.\n Consults: Vascular surgery, CT surgery\n Billing Diagnosis: Acute renal failure, Other: aortic dissection\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 05:24 PM\n 20 Gauge - 05:24 PM\n 18 Gauge - 05:25 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n" }, { "category": "Physician ", "chartdate": "2141-06-23 00:00:00.000", "description": "Intensivist Note", "row_id": 675114, "text": "SICU\n HPI:\n HD6\n \n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMH: HTN, arthritis\n : ASA\n Chief complaint:\n PMHx:\n Current medications:\n 3. Albuterol Inhaler 4. Artificial Tears Preserv. Free 5. Aspirin 6.\n Beclomethasone Dipropionate\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Fentanyl Citrate\n 11. FoLIC Acid 12. Heparin 13. Insulin 14. Ipratropium Bromide MDI 15.\n Metoprolol Tartrate 16. Midazolam\n 17. Multiple Vitamins Liq. 18. Nitroglycerin 19. Ondansetron 20.\n Oxymetazoline 21. Pantoprazole\n 22. Piperacillin-Tazobactam Na 23. Sodium Chloride Nasal 24. Sodium\n Chloride 0.9% Flush 25. Sodium Chloride 0.9% Flush\n 26. Thiamine 27. Vancomycin\n 24 Hour Events:\n MULTI LUMEN - START 09:47 AM\n SPUTUM CULTURE - At 12:57 AM\n CARDIOVERSION/DEFIBRILLATION - At 06:46 AM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:28 PM\n Metronidazole - 12:00 AM\n Vancomycin - 12:48 AM\n Piperacillin/Tazobactam (Zosyn) - 02:09 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:52 PM\n Metoprolol - 05:45 AM\n Other medications:\n Flowsheet Data as of 04:38 PM\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: 37.1\nC (98.7\n HR: 85 (72 - 154) bpm\n BP: 126/50(68) {93/49(62) - 145/73(94)} mmHg\n RR: 14 (7 - 21) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.9 kg (admission): 90 kg\n Height: 74 Inch\n CVP: 11 (10 - 27) mmHg\n Total In:\n 2,039 mL\n 1,555 mL\n PO:\n Tube feeding:\n 271 mL\n 652 mL\n IV Fluid:\n 1,708 mL\n 903 mL\n Blood products:\n Total out:\n 2,750 mL\n 1,225 mL\n Urine:\n 2,550 mL\n 1,225 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -711 mL\n 330 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 800 (550 - 800) mL\n Vt (Spontaneous): 1,211 (976 - 1,211) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: RR >35\n PIP: 28 cmH2O\n Plateau: 21 cmH2O\n SPO2: 98%\n ABG: 7.33/45/125/22/-2\n Ve: 10.2 L/min\n PaO2 / FiO2: 250\n Physical Examination\n Labs / Radiology\n 216 K/uL\n 9.5 g/dL\n 126 mg/dL\n 3.5 mg/dL\n 22 mEq/L\n 5.1 mEq/L\n 74 mg/dL\n 105 mEq/L\n 138 mEq/L\n 28.7 %\n 10.2 K/uL\n [image002.jpg]\n 03:16 AM\n 06:16 AM\n 01:51 PM\n 11:18 PM\n 01:20 AM\n 02:58 AM\n 03:07 AM\n 01:04 PM\n 01:23 PM\n 02:26 PM\n WBC\n 9.7\n 10.2\n Hct\n 28.5\n 28.3\n 28.1\n 28.7\n Plt\n 202\n 216\n Creatinine\n 2.6\n 3.1\n 3.0\n 3.5\n Troponin T\n 0.01\n 0.01\n TCO2\n 24\n 24\n 23\n 23\n 29\n 25\n Glucose\n 97\n 151\n 126\n Other labs: PT / PTT / INR:13.2/34.3/1.1, CK / CK-MB / Troponin\n T:1777/17/0.01, ALT / AST:33/49, Alk-Phos / T bili:132/0.4, Amylase /\n Lipase:62/37, Lactic Acid:0.7 mmol/L, Albumin:2.6 g/dL, LDH:732 IU/L,\n Ca:8.0 mg/dL, Mg:3.3 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n CHEST PAIN, .H/O AORTIC ANEURYSM, ABDOMINAL WITH RUPTURE (AAA)\n Assessment and Plan:\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 Nutren Renal (Full) - 11:16 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:05 PM\n Multi Lumen - 09:47 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2141-06-23 00:00:00.000", "description": "Intensivist Note", "row_id": 675115, "text": "SICU\n HPI:\n HD6\n \n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMH: HTN, arthritis\n : ASA\n Chief complaint:\n PMHx:\n Current medications:\n 3. Albuterol Inhaler 4. Artificial Tears Preserv. Free 5. Aspirin 6.\n Beclomethasone Dipropionate\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Fentanyl Citrate\n 11. FoLIC Acid 12. Heparin 13. Insulin 14. Ipratropium Bromide MDI 15.\n Metoprolol Tartrate 16. Midazolam\n 17. Multiple Vitamins Liq. 18. Nitroglycerin 19. Ondansetron 20.\n Oxymetazoline 21. Pantoprazole\n 22. Piperacillin-Tazobactam Na 23. Sodium Chloride Nasal 24. Sodium\n Chloride 0.9% Flush 25. Sodium Chloride 0.9% Flush\n 26. Thiamine 27. Vancomycin\n 24 Hour Events:\n MULTI LUMEN - START 09:47 AM\n SPUTUM CULTURE - At 12:57 AM\n CARDIOVERSION/DEFIBRILLATION - At 06:46 AM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:28 PM\n Metronidazole - 12:00 AM\n Vancomycin - 12:48 AM\n Piperacillin/Tazobactam (Zosyn) - 02:09 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:52 PM\n Metoprolol - 05:45 AM\n Other medications:\n Flowsheet Data as of 04:38 PM\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: 37.1\nC (98.7\n HR: 85 (72 - 154) bpm\n BP: 126/50(68) {93/49(62) - 145/73(94)} mmHg\n RR: 14 (7 - 21) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.9 kg (admission): 90 kg\n Height: 74 Inch\n CVP: 11 (10 - 27) mmHg\n Total In:\n 2,039 mL\n 1,555 mL\n PO:\n Tube feeding:\n 271 mL\n 652 mL\n IV Fluid:\n 1,708 mL\n 903 mL\n Blood products:\n Total out:\n 2,750 mL\n 1,225 mL\n Urine:\n 2,550 mL\n 1,225 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -711 mL\n 330 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 800 (550 - 800) mL\n Vt (Spontaneous): 1,211 (976 - 1,211) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: RR >35\n PIP: 28 cmH2O\n Plateau: 21 cmH2O\n SPO2: 98%\n ABG: 7.33/45/125/22/-2\n Ve: 10.2 L/min\n PaO2 / FiO2: 250\n Physical Examination\n Labs / Radiology\n 216 K/uL\n 9.5 g/dL\n 126 mg/dL\n 3.5 mg/dL\n 22 mEq/L\n 5.1 mEq/L\n 74 mg/dL\n 105 mEq/L\n 138 mEq/L\n 28.7 %\n 10.2 K/uL\n [image002.jpg]\n 03:16 AM\n 06:16 AM\n 01:51 PM\n 11:18 PM\n 01:20 AM\n 02:58 AM\n 03:07 AM\n 01:04 PM\n 01:23 PM\n 02:26 PM\n WBC\n 9.7\n 10.2\n Hct\n 28.5\n 28.3\n 28.1\n 28.7\n Plt\n 202\n 216\n Creatinine\n 2.6\n 3.1\n 3.0\n 3.5\n Troponin T\n 0.01\n 0.01\n TCO2\n 24\n 24\n 23\n 23\n 29\n 25\n Glucose\n 97\n 151\n 126\n Other labs: PT / PTT / INR:13.2/34.3/1.1, CK / CK-MB / Troponin\n T:1777/17/0.01, ALT / AST:33/49, Alk-Phos / T bili:132/0.4, Amylase /\n Lipase:62/37, Lactic Acid:0.7 mmol/L, Albumin:2.6 g/dL, LDH:732 IU/L,\n Ca:8.0 mg/dL, Mg:3.3 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n CHEST PAIN, .H/O AORTIC ANEURYSM, ABDOMINAL WITH RUPTURE (AAA)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, Pain controlled, wean fentanyl and\n versed, CT head without contrast to evaluate for bleed or ischemia due\n to posturing and non responsive\n Cardiovascular: all antihypertensive meds on hold due to hypotension,\n treat with IV nitroglycerin for sbp < 120\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding, start nutren renal\n Renal: Foley, Adequate UO, Acute renal failure with increased\n creatinine will hydrate with NS bolus recheck in am\n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: no evidence of infection, levofloxacin until\n cultures finalized\n Lines / Tubes / Drains: Foley, OGT, ETT\n Imaging: CXR today\n Consults: Vascular surgery, CT surgery, Nutrition\n Billing Diagnosis: (Respiratory distress)\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 11:00 AM 10 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:05 PM\n Multi Lumen - 09:47 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\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: 33 minutes\n" }, { "category": "Physician ", "chartdate": "2141-06-19 00:00:00.000", "description": "Intensivist Note", "row_id": 673911, "text": "SICU\n HPI:\n 62M w/ type B aortic dissection.\n Chief complaint:\n chest/back pain\n PMHx:\n PMH: HTN, arthritis\n : ASA\n Current medications:\n 1. 1000 mL 1/2NS Continuous at 100 ml/hr Order date: @ 1455\n 2. NiCARdipine 1-5 mcg/kg/min IV DRIP TITRATE TO SBP<130 Order date:\n @ 0039\n 3. HYDROmorphone (Dilaudid) 0.25-1 mg IV Q2H:PRN pain Order date:\n @ \n 4. Nitroprusside Sodium 5-8 mcg/kg/min IV DRIP TITRATE TO SBP<130 Order\n date: @ 0137\n 5. Heparin 5000 UNIT SC TID Order date: @ 1455\n 6. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1734\n 7. Insulin SC (per Insulin Flowsheet) Sliding Scale Order date:\n @ 0242\n 8. Labetalol 0.5-2 mg/min IV DRIP TITRATE TO SBP<130 Order date: \n @ 0031\n 24 Hour Events:\n Admitted to SICU on labetalol & Nipride gtts. Added nicardipine, then\n weaned off. Cardiac enzymes negative x 3.\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Labetalol - 1 mg/min\n Nitroprusside - 4 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 03:57 AM\n Hydromorphone (Dilaudid) - 04:46 AM\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: 35.8\nC (96.5\n T current: 35.6\nC (96\n HR: 64 (55 - 65) bpm\n BP: 106/57(72) {106/50(68) - 169/86(113)} mmHg\n RR: 12 (8 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 1,297 mL\n 1,525 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,297 mL\n 1,525 mL\n Blood products:\n Total out:\n 495 mL\n 210 mL\n Urine:\n 495 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 802 mL\n 1,315 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (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 (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 215 K/uL\n 12.0 g/dL\n 220 mg/dL\n 1.8 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 32 mg/dL\n 102 mEq/L\n 135 mEq/L\n 35.4 %\n 15.6 K/uL\n [image002.jpg]\n 08:03 PM\n 01:42 AM\n WBC\n 15.6\n Hct\n 35.4\n Plt\n 215\n Creatinine\n 1.8\n Troponin T\n <0.01\n Glucose\n 220\n Other labs: PT / PTT / INR:13.1/27.1/1.1, CK / CK-MB / Troponin\n T:149/6/<0.01, Ca:8.7 mg/dL, Mg:1.9 mg/dL, PO4:4.2 mg/dL\n Imaging: CTA torso: large type B aortic dissection, true lumen in\n upper abd near completely occluded, false lumen supplies celiac, SMA, L\n renal, R kidney asymmetrically hypoperfused\n Assessment and Plan\n CHEST PAIN, .H/O AORTIC ANEURYSM, ABDOMINAL WITH RUPTURE (AAA)\n Assessment and Plan: 62M w/ type B aortic dissection.\n Neurologic: Pain controlled, Dilaudid prn.\n Cardiovascular: Beta-blocker, HD stable on labetalol & Nipride gtts.\n Goal SBP<130.\n Pulmonary: IS, Supplemental O2 as needed.\n Gastrointestinal / Abdomen: NPO for possible procedure.\n Nutrition: NPO\n Renal: Foley, Adequate UO, R kidney hypoperfused. Cr rising 1.4 ->\n 1.8. ?enalapril if need another antihypertensive.\n Hematology: Hct 44.2 -> 35.4, likely dilutional. Recheck in AM.\n Endocrine: RISS, Goal FS<150.\n Infectious Disease: No issues. WBC 15.6, likely reactive.\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: Other, 1/2NS@100.\n Consults: Vascular surgery, CT surgery\n Billing Diagnosis: Acute renal failure, Other: aortic dissection\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 05:24 PM\n 20 Gauge - 05:24 PM\n 18 Gauge - 05:25 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n" }, { "category": "Physician ", "chartdate": "2141-06-20 00:00:00.000", "description": "ICU Note - CVI", "row_id": 674166, "text": "CVICU\n HPI:\n HD3\n HD2\n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n : ASA\n PMHx:\n PMH: HTN, arthritis\n Current medications:\n Amlodipine 5. HYDROmorphone (Dilaudid) Heparin 8. HydrALAzine 9.\n Insulin 10. Labetalol 11. NiCARdipine 12. Ondansetron\n 24 Hour Events:\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n Post operative day:\n HD3\n HD2\n 62M w/ type B aortic dissection/medical management.\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Infusions:\n Nicardipine - 3.5 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 11:21 AM\n Hydromorphone (Dilaudid) - 03:23 PM\n Flowsheet Data as of 11:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 36.8\nC (98.2\n HR: 86 (61 - 86) bpm\n BP: 137/69(91) {102/50(69) - 137/70(91)} mmHg\n RR: 20 (10 - 24) insp/min\n SPO2: 85%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 4,632 mL\n 1,620 mL\n PO:\n 160 mL\n 130 mL\n Tube feeding:\n IV Fluid:\n 4,472 mL\n 1,490 mL\n Blood products:\n Total out:\n 746 mL\n 667 mL\n Urine:\n 746 mL\n 667 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,886 mL\n 953 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 85%\n ABG: 7.44/28/59/20/-3\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, poor dental hygiene\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n bilat)\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 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 225 K/uL\n 11.5 g/dL\n 130 mg/dL\n 2.1 mg/dL\n 20 mEq/L\n 4.5 mEq/L\n 56 mg/dL\n 100 mEq/L\n 132 mEq/L\n 34.2 %\n 23.9 K/uL\n [image002.jpg]\n 08:03 PM\n 01:42 AM\n 09:45 AM\n 01:09 PM\n 05:21 PM\n 04:30 AM\n 10:19 AM\n WBC\n 15.6\n 23.9\n Hct\n 35.4\n 34.4\n 34.2\n Plt\n 215\n 225\n Creatinine\n 1.8\n 2.0\n 2.1\n 2.1\n Troponin T\n <0.01\n TCO2\n 24\n 20\n Glucose\n 220\n 146\n 130\n Other labs: PT / PTT / INR:13.1/27.1/1.1, CK / CK-MB / Troponin\n T:149/6/<0.01, ALT / AST:53/83, Alk-Phos / T bili:85/0.4, Lactic\n Acid:1.5 mmol/L, Ca:8.6 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n AORTIC ANEURYSM, ABDOMINAL WITHOUT RUPTURE (AAA), HYPOXEMIA, PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), CHEST PAIN, .H/O AORTIC ANEURYSM,\n ABDOMINAL WITH RUPTURE (AAA)\n Assessment and Plan: 62yo man w/type B dissection currently on\n Nicardipine drip to control BP\n Neurologic: Pain controlled, dilaudid PRN\n Cardiovascular: Beta-blocker, Norvasc, nicardipine, labetolol\n Pulmonary: IS, extensive smoking history >80 pack years\n Gastrointestinal / Abdomen:\n Nutrition: start full liquid diet today\n Renal: Foley, Adequate UO, Creat elevated, right kidney asymetrically\n perfused-will continue to monitor\n Hematology: stable hct\n Endocrine: RISS\n Infectious Disease: check sputum and urine culture. WBC elevated to 23K\n Afebrile\n Lines / Tubes / Drains: Foley, Aline\n Wounds: none\n Imaging: CXR today\n Consults: Vascular surgery, CT surgery\n ICU Care\n Nutrition: start full liquid diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:05 PM\n 20 Gauge - 09:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2141-06-20 00:00:00.000", "description": "ICU Note", "row_id": 674167, "text": "TITLE: Intensivist\n HPI:\n HD3\n HD2\n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n : ASA\n PMHx:\n PMH: HTN, arthritis\n Current medications:\n Amlodipine 5. HYDROmorphone (Dilaudid) Heparin 8. HydrALAzine 9.\n Insulin 10. Labetalol 11. NiCARdipine 12. Ondansetron\n 24 Hour Events:\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n Post operative day:\n HD3\n HD2\n 62M w/ type B aortic dissection/medical management.\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Infusions:\n Nicardipine - 3.5 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 11:21 AM\n Hydromorphone (Dilaudid) - 03:23 PM\n Flowsheet Data as of 11:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 36.8\nC (98.2\n HR: 86 (61 - 86) bpm\n BP: 137/69(91) {102/50(69) - 137/70(91)} mmHg\n RR: 20 (10 - 24) insp/min\n SPO2: 85%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 4,632 mL\n 1,620 mL\n PO:\n 160 mL\n 130 mL\n Tube feeding:\n IV Fluid:\n 4,472 mL\n 1,490 mL\n Blood products:\n Total out:\n 746 mL\n 667 mL\n Urine:\n 746 mL\n 667 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,886 mL\n 953 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 85%\n ABG: 7.44/28/59/20/-3\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, poor dental hygiene\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n bilat)\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 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 225 K/uL\n 11.5 g/dL\n 130 mg/dL\n 2.1 mg/dL\n 20 mEq/L\n 4.5 mEq/L\n 56 mg/dL\n 100 mEq/L\n 132 mEq/L\n 34.2 %\n 23.9 K/uL\n [image002.jpg]\n 08:03 PM\n 01:42 AM\n 09:45 AM\n 01:09 PM\n 05:21 PM\n 04:30 AM\n 10:19 AM\n WBC\n 15.6\n 23.9\n Hct\n 35.4\n 34.4\n 34.2\n Plt\n 215\n 225\n Creatinine\n 1.8\n 2.0\n 2.1\n 2.1\n Troponin T\n <0.01\n TCO2\n 24\n 20\n Glucose\n 220\n 146\n 130\n Other labs: PT / PTT / INR:13.1/27.1/1.1, CK / CK-MB / Troponin\n T:149/6/<0.01, ALT / AST:53/83, Alk-Phos / T bili:85/0.4, Lactic\n Acid:1.5 mmol/L, Ca:8.6 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n AORTIC ANEURYSM, ABDOMINAL WITHOUT RUPTURE (AAA), HYPOXEMIA, PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), CHEST PAIN, .H/O AORTIC ANEURYSM,\n ABDOMINAL WITH RUPTURE (AAA)\n Assessment and Plan: 62yo man w/type B dissection currently on\n Nicardipine drip to control BP\n Neurologic: Pain controlled, dilaudid PRN\n Cardiovascular: Beta-blocker, Norvasc, nicardipine, labetolol\n Pulmonary: IS, extensive smoking history >80 pack years\n Gastrointestinal / Abdomen:\n Nutrition: start full liquid diet today\n Renal: Foley, Adequate UO, Creat elevated, right kidney asymetrically\n perfused-will continue to monitor\n Hematology: stable hct\n Endocrine: RISS\n Infectious Disease: check sputum and urine culture. WBC elevated to 23K\n Afebrile\n Lines / Tubes / Drains: Foley, Aline\n Wounds: none\n Imaging: CXR today\n Consults: Vascular surgery, CT surgery\n ICU Care\n Nutrition: start full liquid diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:05 PM\n 20 Gauge - 09:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code Time spent 32 min\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2141-06-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 673888, "text": "Pt is a 62 year old male with h/o htn, arthritis who presents to ED\n with c/o chest pain. Was riding the T to a ball game today when he had\n a sudden urge to have a bowel movement. Went to the bathroom and was\n unable to have a bowel movement. He then developed knife-like chest\n pain which radiated to his back. He felt lightheaded, dizzy, nauseous\n and SOB. Had CT scan done that showed large type B dissection of aorta.\n Right kidney is hypoperfused, indicating vascular compromise. CR 1.4.\n u/o adq.\n Chest pain- related to aortic dissection\n Assessment:\n SR/SB 50-60s. SBP 130s.\n c/o lower back pain and mid chest pain ranging from .\n Goal SBP <140. On Nipride and labetalol to maintain SBP\n parameters.\n At 0100 pt had severe pain and SBP 160s.\n Easily palpable pulses in all four extremities, warm and\n normal in color.\n BUN/Cr bump with a.m. labs.\n Action:\n Dilaudid 0.5 mg IV given q2 for pain mgmt and ativan given\n at 0100 for\nfidgety-ness\n Attempted to switch Nipride to Nicardipine for SBP control\n d/t high doses pt was receiving, compromised renal function and\n possible concern for toxicity. RN talked with Dr. and Dr. and\n expressed concerns about high doses and possible toxicity. Titrated\n Nipride to 5-6 mcg/kg/min during severe chest pain and hypertension and\n was maxed on Nicardipine. After discussion with Dr. & pain and SBP\n well managed, titrated Nicardipine to off and continue with Nipride and\n labetalol.\n Dr. and Dr. notified of BUN/Cr bump.\n Ice packs to lower back.\n Response:\n Dilaudid & ice packs with good effect.\n When hypertensive, pain increases to and\n vice-a-versa.\n Ativan with min effect.\n After attempt to transition to Nicardipine unsuccessfully\n (maxed on Nicardipine and still requiring Nipride and labetalol to keep\n within SBP parameters), per Dr. , continue with Nipride and monitor\n BUN/Cr.\n Plan:\n Discuss with team weaning of Nipride to another blood\n pressure mgmt today or tomorrow.\n Closely follow renal fn (BUN/Cr)\n Follow nursing care plan- pain.\n Closely monitor extremities and assess pulses frequently.\n Provide comfort and support.\n" }, { "category": "Nursing", "chartdate": "2141-06-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674005, "text": "Nursing (1400-1500)\n Pt. transferred to CVICU/vascular service this afternoon without\n incident, Diagnosis\n Type B Aortic Dissection. Pt. is presently\n restful, vitals stable. Skin warm and dry with easily palpable distal\n pulses. Pt. received on 3mcg/kg/min nicardipine and started on PO\n labetolol this afternoon. Goal SBP <130 per vascular service to\n medically manage dissection. Pt. with intermittent complaints of chest\n and left hip/flank pain that\nsettles\n and becomes tolerable with\n rest. Continue to follow BP closely.\n" }, { "category": "Nursing", "chartdate": "2141-06-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674006, "text": "Nursing (1400-1500)\n Pt. transferred to CVICU/vascular service this afternoon without\n incident, Diagnosis\n Type B Aortic Dissection. Pt. is presently\n restful, vitals stable. Skin warm and dry with easily palpable distal\n pulses. Pt. received on 3mcg/kg/min nicardipine and started on PO\n labetolol this afternoon. Goal SBP <130 per vascular service to\n medically manage dissection. Pt. with intermittent complaints of chest\n and left hip/flank pain that\nsettles\n and becomes tolerable with\n rest. Continue to follow BP closely.\n ------ Protected Section ------\n Addendum: Pt. had a series of 3 hiccups shortly after arrival and was\n noted to drop HR to 45 very briefly. Pt. denies symptoms at this time.\n ------ Protected Section Addendum Entered By: , RN\n on: 15:02 ------\n" }, { "category": "Respiratory ", "chartdate": "2141-06-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 674525, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 86.2 None\n Ideal tidal volume: 344.8 / 517.2 / 689.6 mL/kg\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 / Moderate\n Comments:\n Pt with increased O2 requirements regardless of applied O2 system. Very\n wet but can only withstand gentle diuresis due to fragile renal status.\n Intubated for hypoxic failure.\n" }, { "category": "Nursing", "chartdate": "2141-06-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 673980, "text": "Pt is a 62 year old male with h/o htn, arthritis who presents to ED\n with c/o chest pain. Was riding the T to a ball game today when he had\n a sudden urge to have a bowel movement. Went to the bathroom and was\n unable to have a bowel movement. He then developed knife-like chest\n pain which radiated to his back. He felt lightheaded, dizzy, nauseous\n and SOB. Had CT scan done that showed large type B dissection of aorta.\n Right kidney is hypoperfused, indicating vascular compromise. CR 1.4.\n u/o adq.\n Chest pain- related to aortic dissection\n Assessment:\n SR/SB 50-60s\n SBP 90-130s\n Pt having episodes of chest pain with hiccupping where pt\n appears to vagal stimulate and brady down to 40s, rebounding quickly to\n HR ~60s\n c/o abd pain and chest pain ranging from \n Goal SBP <130\n Pt received on Nipride and labetalol gtts\n Easily palpable pulses in all four extremities, warm and\n pale/normal in color.\n BUN/Cr bump with a.m. labs\n UO marginal 16-35 cc/hr\n Action:\n Dilaudid 0.5 mg IV given q2 PRN for pain mgmt\n Nipride weaned off d/t high risk for toxicity/renal function\n worsening\n Pt restarted on nicardipine gtt\n Labetalol gtt weaned off and PO labetalol started\n Hydral PRN started and given 10mg x1 with good effect\n D/t marginal UO, afternoon labs sent to monitor BUN/Cr\n status\n PP/BLE warmth/color monitored closely\n Response:\n Dilaudid with good effect\n When hypertensive/having hiccupping painful episodes, pain\n increases to \n Plan:\n Closely follow renal fn (BUN/Cr)\n Follow nursing care plan- pain.\n Closely monitor extremities and assess pulses frequently.\n Provide comfort and support.\n" }, { "category": "Physician ", "chartdate": "2141-06-30 00:00:00.000", "description": "ICU Note - CVI", "row_id": 676879, "text": "CVICU\n HPI:\n HD13\n 62M w/ type B aortic dissection/medical management.\n EF 75 Cr 1.4 WT 185lbs HgbA1c\n PMH: HTN, arthritis\n : ASA\n - CTA torso:type B aortic dissection, true lumen in upper abd near\n completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -renal US R>L perfusion. nl size.\n Labetolol/Nicardipine(IV),Norvasc\n :Intubated 2'resp.failure/P edema\n :Extubated. restless, agitated.Labetalol GTT for BP control\n -PP DHT, TF begun. fenanyl for pain, calmer.Cr:3.6\n -more awake. Ativan/haldol scheduled, Haldol for breakthru. Psych\n saw.Pulled DHT out. Back to stomach,feeds resumed.\n - episodes of agitation. Ativan stopped-cont haldol/Fentanyl\n Current medications:\n Albuterol 0.083% Neb Soln . Amlodipine . Artificial Tears Preserv. Free\n . Aspirin . Atorvastatin. Beclomethasone Dipropionate . Bisacodyl .\n Calcium Gluconate . CloniDINE . Famotidine . Fentanyl Citrate .\n Haloperidol\n Heparin Insulin . Ipratropium Bromide Neb . . Metoprolol Tartrate .\n Metoclopramide Metoprolol Tartrate . Multiple Vitamins Liq. .\n Nitroglycerin . Piperacillin-Tazobactam Na Sodium Chloride Nasal\n 24 Hour Events:\n STOOL CULTURE - At 05:13 PM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:32 PM\n Infusions:\n Nitroglycerin - 2.5 mcg/Kg/min\n Other ICU medications:\n Haloperidol (Haldol) - 10:45 AM\n Heparin Sodium (Prophylaxis) - 11:51 PM\n Other medications:\n Flowsheet Data as of 10:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.4\nC (97.6\n HR: 55 (49 - 76) bpm\n BP: 149/80(98) {119/60(81) - 164/89(107)} mmHg\n RR: 15 (13 - 20) insp/min\n SPO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 91.6 kg (admission): 90 kg\n Height: 74 Inch\n Total In:\n 3,433 mL\n 1,230 mL\n PO:\n 200 mL\n 320 mL\n Tube feeding:\n 1,083 mL\n 461 mL\n IV Fluid:\n 1,335 mL\n 449 mL\n Blood products:\n Total out:\n 3,700 mL\n 1,280 mL\n Urine:\n 2,880 mL\n 1,280 mL\n NG:\n Stool:\n 20 mL\n Drains:\n Balance:\n -267 mL\n -50 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 95%\n ABG: ///21/\n Physical Examination\n General Appearance: No acute distress, Anxious, much calmer, knows he's\n in hosptila today.\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 346 K/uL\n 9.2 g/dL\n 90 mg/dL\n 3.0 mg/dL\n 21 mEq/L\n 3.8 mEq/L\n 51 mg/dL\n 111 mEq/L\n 143 mEq/L\n 27.2 %\n 16.8 K/uL\n [image002.jpg]\n 09:45 PM\n 10:02 PM\n 02:27 AM\n 06:55 AM\n 07:04 AM\n 12:58 PM\n 02:47 AM\n 02:37 AM\n 03:03 AM\n 03:05 AM\n WBC\n 11.9\n 12.9\n 15.1\n 16.2\n 16.8\n Hct\n 26.9\n 27.8\n 28.1\n 27.9\n 26.5\n 27.4\n 27.2\n Plt\n 263\n 287\n 317\n 320\n 346\n Creatinine\n 3.6\n 3.4\n 3.2\n 3.1\n 3.0\n TCO2\n 23\n 24\n 19\n Glucose\n 108\n 122\n 180\n 80\n 90\n Other labs: PT / PTT / INR:14.2/28.9/1.2, CK / CK-MB / Troponin\n T:1384/11/0.02, ALT / AST:50/39, Alk-Phos / T bili:216/0.6, Amylase /\n Lipase:94/140, Lactic Acid:0.9 mmol/L, Albumin:3.2 g/dL, LDH:498 IU/L,\n Ca:8.7 mg/dL, Mg:2.3 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), ALTERED MENTAL STATUS (NOT DELIRIUM), RENAL FAILURE,\n ACUTE (ACUTE RENAL FAILURE, ARF)\n Assessment and Plan: improving neuro status, awakening, calm. NTG off\n w/o change in BP.\n Neurologic: Neuro checks Q: 8 hr, Pain controlled\n Cardiovascular: Beta-blocker, Statins\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet\n Renal: Foley, Adequate UO\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Fluids: Other\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 04:00 AM 45 mL/hour\n Comments: tf OFF\n Glycemic Control:\n Multi Lumen - 09:47 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: ICU\n" }, { "category": "Physician ", "chartdate": "2141-06-30 00:00:00.000", "description": "Generic Note", "row_id": 676882, "text": "TITLE: Intensivist Daily Note\n CVICU\n HPI:\n HD13\n 62M w/ type B aortic dissection/medical management.\n EF 75 Cr 1.4 WT 185lbs HgbA1c\n PMH: HTN, arthritis\n : ASA\n - CTA torso:type B aortic dissection, true lumen in upper abd near\n completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -renal US R>L perfusion. nl size.\n Labetolol/Nicardipine(IV),Norvasc\n :Intubated 2'resp.failure/P edema\n :Extubated. restless, agitated.Labetalol GTT for BP control\n -PP DHT, TF begun. fenanyl for pain, calmer.Cr:3.6\n -more awake. Ativan/haldol scheduled, Haldol for breakthru. Psych\n saw.Pulled DHT out. Back to stomach,feeds resumed.\n - episodes of agitation. Ativan stopped-cont haldol/Fentanyl\n Current medications:\n Albuterol 0.083% Neb Soln . Amlodipine . Artificial Tears Preserv. Free\n . Aspirin . Atorvastatin. Beclomethasone Dipropionate . Bisacodyl .\n Calcium Gluconate . CloniDINE . Famotidine . Fentanyl Citrate .\n Haloperidol\n Heparin Insulin . Ipratropium Bromide Neb . . Metoprolol Tartrate .\n Metoclopramide Metoprolol Tartrate . Multiple Vitamins Liq. .\n Nitroglycerin . Piperacillin-Tazobactam Na Sodium Chloride Nasal\n 24 Hour Events:\n STOOL CULTURE - At 05:13 PM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:32 PM\n Infusions:\n Nitroglycerin - 2.5 mcg/Kg/min\n Other ICU medications:\n Haloperidol (Haldol) - 10:45 AM\n Heparin Sodium (Prophylaxis) - 11:51 PM\n Other medications:\n Flowsheet Data as of 10:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.4\nC (97.6\n HR: 55 (49 - 76) bpm\n BP: 149/80(98) {119/60(81) - 164/89(107)} mmHg\n RR: 15 (13 - 20) insp/min\n SPO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 91.6 kg (admission): 90 kg\n Height: 74 Inch\n Total In:\n 3,433 mL\n 1,230 mL\n PO:\n 200 mL\n 320 mL\n Tube feeding:\n 1,083 mL\n 461 mL\n IV Fluid:\n 1,335 mL\n 449 mL\n Blood products:\n Total out:\n 3,700 mL\n 1,280 mL\n Urine:\n 2,880 mL\n 1,280 mL\n NG:\n Stool:\n 20 mL\n Drains:\n Balance:\n -267 mL\n -50 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 95%\n ABG: ///21/\n Physical Examination\n General Appearance: No acute distress, Anxious, much calmer, knows he's\n in hosptila today.\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 346 K/uL\n 9.2 g/dL\n 90 mg/dL\n 3.0 mg/dL\n 21 mEq/L\n 3.8 mEq/L\n 51 mg/dL\n 111 mEq/L\n 143 mEq/L\n 27.2 %\n 16.8 K/uL\n [image002.jpg]\n 09:45 PM\n 10:02 PM\n 02:27 AM\n 06:55 AM\n 07:04 AM\n 12:58 PM\n 02:47 AM\n 02:37 AM\n 03:03 AM\n 03:05 AM\n WBC\n 11.9\n 12.9\n 15.1\n 16.2\n 16.8\n Hct\n 26.9\n 27.8\n 28.1\n 27.9\n 26.5\n 27.4\n 27.2\n Plt\n 263\n 287\n 317\n 320\n 346\n Creatinine\n 3.6\n 3.4\n 3.2\n 3.1\n 3.0\n TCO2\n 23\n 24\n 19\n Glucose\n 108\n 122\n 180\n 80\n 90\n Other labs: PT / PTT / INR:14.2/28.9/1.2, CK / CK-MB / Troponin\n T:1384/11/0.02, ALT / AST:50/39, Alk-Phos / T bili:216/0.6, Amylase /\n Lipase:94/140, Lactic Acid:0.9 mmol/L, Albumin:3.2 g/dL, LDH:498 IU/L,\n Ca:8.7 mg/dL, Mg:2.3 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), ALTERED MENTAL STATUS (NOT DELIRIUM), RENAL FAILURE,\n ACUTE (ACUTE RENAL FAILURE, ARF)\n Assessment and Plan: improving neuro status, awakening, calm. NTG off\n w/o change in BP.\n Neurologic: Neuro checks Q: 8 hr, Pain controlled\n Cardiovascular: Beta-blocker, Statins\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet\n Renal: Foley, Adequate UO\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Fluids: Other\n Billing diagnosis: Aortic dissection\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 04:00 AM 45 mL/hour\n Comments: tf OFF\n Glycemic Control:\n Multi Lumen - 09:47 AM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Time spent : 32 minutes\n" }, { "category": "Nursing", "chartdate": "2141-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676997, "text": "Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Remains confused, oriented to self only. Talkative at\n times, but content not appropriate to conversation at hand. Pt\n generally calm. Attempted to get out of bed multiple times.\n Redirected and reoriented patient. Compliant with requests. No\n verbalization of pain or discomfort.\n Hypertensive with SBP ranging from 150-170s. BP higher when\n agitated and will decrease as patient falls asleep. Hydralazine IV\n given to decrease BP. Lopressor (IV or PO) not given due to\n bradycardia in 40-50s. Pulses palpable x 4 extremities.\n Lungs clear bilaterally. No cough, SOB, dyspnea noted. At\n times, pt purse-lip breathing, but when asked if he\ns having trouble\n sleeping, he states\n Abdomen soft, non-tender. BS x 4 present. Flexiseal in\n place, but little stool observed. Will continue to monitor.\n Urine output copious with output > 90 cc/hr.\n Skin intact.\n Blood glucose WNL.\n Plan:\n Monitor mental status and reorient as necessary. Monitor BP closely.\n Per CVICU team, keep SBP <= 150. Possible transfer to VICU today.\n" }, { "category": "Nursing", "chartdate": "2141-07-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 677075, "text": "Altered mental status (not Delirium)\n Assessment:\n ? withdrawal from unknown substance. Pt oriented x3 at times, mostly\n oriented just to self. Pleasant\n Action:\n Reoriented easily, non-aggressive. Haldol given every 6hours PO.\n Response:\n Responds well to staff when they take time to explain interventions and\n rationals. Concerned with fine details of actions and information,\n rambles at times, not making any sense.\n Plan:\n Continue to assess mental status, reorient to surroundings, explain all\n care and interventions. Transfer to VICU\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n NSR HR 50-70\ns sbp 130\ns-150\ns. descending aneurysm, inoperable.\n Managing medically with PO medications. Lungs clear throughout on RA.\n Bowel sounds present, pulses palpable. Skin intact. Denies pain.\n Afebrile. UOP ~100-200cc/h\n Action:\n Blood pressure monitored to keep below 160. eating meals, encouraged to\n cough and deep breath. Out of bed to chair with one assist.\n Response:\n Tolerating medications, feeding self, stands well. Remains compulsive\n with getting up at times\n Plan:\n Continue medical management, advance activity as tolerated\n Pt has IPOD and cell phone locked in safe\n Demographics\n Attending MD:\n L.\n Admit diagnosis:\n TYPE B AORTIC DISSECTION\n Code status:\n Full code\n Height:\n 74 Inch\n Admission weight:\n 90 kg\n Daily weight:\n 91.6 kg\n Allergies/Reactions:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Precautions:\n PMH: Smoker\n CV-PMH: Hypertension\n Additional history: arthritis\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:139\n D:80\n Temperature:\n 97.3\n Arterial BP:\n S:146\n D:74\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 55 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 212 mL\n 24h total out:\n 2,480 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 03:12 AM\n Potassium:\n 4.0 mEq/L\n 03:12 AM\n Chloride:\n 108 mEq/L\n 03:12 AM\n CO2:\n 19 mEq/L\n 03:12 AM\n BUN:\n 41 mg/dL\n 03:12 AM\n Creatinine:\n 2.6 mg/dL\n 03:12 AM\n Glucose:\n 82 mg/dL\n 03:12 AM\n Hematocrit:\n 30.1 %\n 03:12 AM\n Finger Stick Glucose:\n 109\n 05:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: pt has clothing, shoes, and books. in securuty pt has\n cell phone and ipod\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash Amount: none\n Credit Cards: none\n Cash / Credit cards sent home with: NONE\n Jewelry: none\n Transferred from: \n Transferred to: VICU\n Date & time of Transfer: \n" }, { "category": "Physician ", "chartdate": "2141-07-01 00:00:00.000", "description": "ICU Note - CVI", "row_id": 677077, "text": "CVICU\n HPI:\n 62M w/ type B aortic dissection/medical management.\n EF 75 Cr 1.4 WT 185lbs HgbA1c\n PMH: HTN, arthritis\n : ASA\n Current medications:\n Albuterol 0.083% Neb Soln, Amlodipine, Artificial Tears Preserv. Free,\n Aspirin, Atorvastatin, Beclomethasone Dipropionate, Bisacodyl,\n Clonidine Patch 0.2 mg/24 hr, CloniDINE, Famotidine, Fentanyl Citrate,\n Haloperidol, Heparin, HydrALAzine, Insulin, Ipratropium Bromide Neb,\n Metoprolol Tartrate, Metoclopramide, Lopressor, Multiple Vitamins Liq,\n Nitroglycerin, Piperacillin-Tazobactam Na\n 24 Hour Events:\n Remains in ICU for neurological monitoring\n Sitter for safety\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 03:11 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:31 PM\n Hydralazine - 12:58 AM\n Other medications:\n Flowsheet Data as of 12:16 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 36.3\nC (97.3\n HR: 55 (48 - 68) bpm\n BP: 139/80(94) {131/62(80) - 172/100(117)} mmHg\n RR: 15 (13 - 24) insp/min\n SPO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 91.6 kg (admission): 90 kg\n Height: 74 Inch\n Total In:\n 1,870 mL\n 221 mL\n PO:\n 640 mL\n Tube feeding:\n 473 mL\n IV Fluid:\n 758 mL\n 221 mL\n Blood products:\n Total out:\n 3,520 mL\n 2,600 mL\n Urine:\n 3,520 mL\n 2,300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,650 mL\n -2,379 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///19/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, 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 2), Follows simple commands,\n Moves all extremities, knew he was in clinic not hospital\n Labs / Radiology\n 379 K/uL\n 10.2 g/dL\n 82 mg/dL\n 2.6 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 41 mg/dL\n 108 mEq/L\n 142 mEq/L\n 30.1 %\n 16.6 K/uL\n [image002.jpg]\n 10:02 PM\n 02:27 AM\n 06:55 AM\n 07:04 AM\n 12:58 PM\n 02:47 AM\n 02:37 AM\n 03:03 AM\n 03:05 AM\n 03:12 AM\n WBC\n 11.9\n 12.9\n 15.1\n 16.2\n 16.8\n 16.6\n Hct\n 26.9\n 27.8\n 28.1\n 27.9\n 26.5\n 27.4\n 27.2\n 30.1\n Plt\n 263\n 287\n 317\n \n Creatinine\n 3.6\n 3.4\n 3.2\n 3.1\n 3.0\n 2.6\n TCO2\n 24\n 19\n Glucose\n 108\n 122\n 180\n 80\n 90\n 82\n Other labs: PT / PTT / INR:14.2/28.9/1.2, CK / CK-MB / Troponin\n T:1384/11/0.02, ALT / AST:50/39, Alk-Phos / T bili:216/0.6, Amylase /\n Lipase:94/140, Lactic Acid:0.9 mmol/L, Albumin:3.2 g/dL, LDH:498 IU/L,\n Ca:8.7 mg/dL, Mg:2.1 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), ALTERED MENTAL STATUS (NOT DELIRIUM), RENAL FAILURE,\n ACUTE (ACUTE RENAL FAILURE, ARF)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, Pain controlled, fentanyl prn pain,\n continue haldol for delirium\n Cardiovascular: Aspirin, Beta-blocker, Statins, increased clonodine\n patch for blood pressure management,\n Pulmonary: IS, cough and deep breath\n Gastrointestinal / Abdomen: no issues\n Nutrition: Regular diet\n Renal: Foley, Adequate UO\n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: continues on zosyn wbc remains 16\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Consults: Vascular surgery\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:47 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\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": "Nursing", "chartdate": "2141-07-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 677069, "text": "Altered mental status (not Delirium)\n Assessment:\n ? withdrawal from unknown substance. Pt oriented x3 at times, mostly\n oriented just to self. Pleasant\n Action:\n Reoriented easily, non-aggressive. Haldol given every 6hours PO.\n Response:\n Responds well to staff when they take time to explain interventions and\n rationals. Concerned with fine details of actions and information,\n rambles at times, not making any sense.\n Plan:\n Continue to assess mental status, reorient to surroundings, explain all\n care and interventions. Transfer to VICU\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n NSR HR 50-70\ns sbp 130\ns-150\ns. descending aneurysm, inoperable.\n Managing medically with PO medications. Lungs clear throughout on RA.\n Bowel sounds present, pulses palpable. Skin intact. Denies pain.\n Afebrile. UOP ~100-200cc/h\n Action:\n Blood pressure monitored to keep below 160. eating meals, encouraged to\n cough and deep breath. Out of bed to chair with one assist.\n Response:\n Tolerating medications, feeding self, stands well. Remains compulsive\n with getting up at times\n Plan:\n Continue medical management, advance activity as tolerated\n Pt has IPOD and cell phone locked in safe\n" }, { "category": "Nursing", "chartdate": "2141-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676954, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt oriented X3 this am, MAE appropriate with staff. Occasionally has\n compulsions to get up, easily redirected and reoriented to his\n surroundings\n Action:\n Frequent assessment of orientation, haldol given round the clock\n Response:\n Pt consistently oriented x2, sometimes x3. remains restrained for his\n safety, pulled out NG tube, and ECG leads. Pt responds well to empathy\n from RN and time taken to listen to his feelings.\n Plan:\n Continue to assess mental status and reorient as needed. Take time to\n explain all interventions with pt and listen to concerns pt has.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n HR 40\ns-70\ns NSR with PAC\ns SBP 130\ns-140\ns. nitro gtt. Lungs clear on\n RA sats 94-96%. Bowel sounds present, stooling via Flexiseal. Pulses\n easily palpable. UOP ~80cc/hour\n Action:\n Nitro gtt off this AM per PA to monitor effect. Receiving\n multiple PO medications for BP maintenance\n Response:\n No change with bp with nitro gtt off, tolerating PO meds well. Diet\n changed to heart healthy once NG tube pulled by pt. tolerating diet\n well, requires assistance and supervision with meals\n Plan:\n ? transfer to 5, maintain sbp <160\ns per PA \n" }, { "category": "Nursing", "chartdate": "2141-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676914, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt oriented X3 this am, MAE appropriate with staff. Occasionally has\n compulsions to get up, easily redirected and reoriented to his\n surroundings\n Action:\n Frequent assessment of orientation, haldol given round the clock\n Response:\n Pt consistently oriented x2, sometimes x3. remains restrained for his\n safety, pulled out NG tube, and ECG leads. Pt responds well to empathy\n from RN and time taken to listen to his feelings.\n Plan:\n Continue to assess mental status and reorient as needed. Take time to\n explain all interventions with pt and listen to concerns pt has.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n HR 40\ns-70\ns NSR with PAC\ns SBP 130\ns-140\ns. nitro gtt. Lungs clear on\n RA sats 94-96%. Bowel sounds present, stooling via Flexiseal. Pulses\n easily palpable. UOP ~80cc/hour\n Action:\n Nitro gtt off this AM per PA to monitor effect. Receiving\n multiple PO medications for BP maintenance\n Response:\n No change with bp with nitro gtt off, tolerating PO meds well. Diet\n changed to heart healthy once NG tube pulled by pt. tolerating diet\n well, requires assistance and supervision with meals\n Plan:\n ? transfer to 5, maintain sbp <150\n" }, { "category": "Nursing", "chartdate": "2141-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677019, "text": "Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Remains confused, oriented to self only. Talkative at\n times, but content not appropriate to conversation at hand. Pt\n generally calm. Attempted to get out of bed multiple times.\n Redirected and reoriented patient. Compliant with requests. No\n verbalization of pain or discomfort. Haldol PO given as ordered.\n Hypertensive with SBP ranging from 150-170s. BP higher when\n agitated and will decrease as patient falls asleep. Hydralazine IV\n given to decrease BP. Little effect noted. Lopressor (IV or PO) not\n given due to bradycardia in 40-50s. Pulses palpable x 4 extremities.\n Lungs clear bilaterally. No cough, SOB, dyspnea noted. At\n times, pt purse-lip breathing, but when asked if he\ns having trouble\n sleeping, he states\n Abdomen soft, non-tender. BS x 4 present. Flexiseal in\n place, but little stool observed. Will continue to monitor.\n Urine output copious with output > 90 cc/hr.\n Skin intact.\n Blood glucose WNL.\n Plan:\n Monitor mental status and reorient as necessary. Monitor BP closely.\n Per CVICU team, keep SBP <= 150. Possible transfer to VICU today.\n ------ Protected Section ------\n Little to no stool present during shift. Flexiseal dc\nd this am with\n goal to avoid skin integrity issues secondary to rectal tube.\n ------ Protected Section Addendum Entered By: , RN\n on: 05:41 ------\n" }, { "category": "Nursing", "chartdate": "2141-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677011, "text": "Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Remains confused, oriented to self only. Talkative at\n times, but content not appropriate to conversation at hand. Pt\n generally calm. Attempted to get out of bed multiple times.\n Redirected and reoriented patient. Compliant with requests. No\n verbalization of pain or discomfort. Haldol PO given as ordered.\n Hypertensive with SBP ranging from 150-170s. BP higher when\n agitated and will decrease as patient falls asleep. Hydralazine IV\n given to decrease BP. Little effect noted. Lopressor (IV or PO) not\n given due to bradycardia in 40-50s. Pulses palpable x 4 extremities.\n Lungs clear bilaterally. No cough, SOB, dyspnea noted. At\n times, pt purse-lip breathing, but when asked if he\ns having trouble\n sleeping, he states\n Abdomen soft, non-tender. BS x 4 present. Flexiseal in\n place, but little stool observed. Will continue to monitor.\n Urine output copious with output > 90 cc/hr.\n Skin intact.\n Blood glucose WNL.\n Plan:\n Monitor mental status and reorient as necessary. Monitor BP closely.\n Per CVICU team, keep SBP <= 150. Possible transfer to VICU today.\n" }, { "category": "Nursing", "chartdate": "2141-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675807, "text": "Pt is 62 year old male with h/o of htn, arthritis who presented to ED\n on with complaints of chest pain. Pt was riding the T to a\n ballgame today when he had a sudden urge to have a bowel movement. Pt\n went to restroom and was unable to have a bowel movement, but hen\n developed severe knife-life chest pain which radiated to back. He felt\n lightheaded, dizzy, nausea and short of breath. Pt had a CT scan with\n large type B dissection of aorta. Plan for medical management\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US no normal arterial waveforms seen in the right kidney or\n right main renal artery.\n :Intubated 2'resp.failure/P edema\n head ct for ?posturing/neuro changes- head ct was neg\n rapid afib/flutter required cardioversion x1\n Extubated\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-06-28 00:00:00.000", "description": "Generic Note", "row_id": 676526, "text": "TITLE: Intensivist Daily Note\n CVICU\n HPI:\n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMHx:\n PMH: HTN, arthritis\n Current medications:\n Amlodipine 4. Artificial Tears Preserv. Free 5. Aspirin 6.\n Atorvastatin 7. Beclomethasone Dipropionate 8. Bisacodyl 9. Calcium\n Gluconate 10. Clonidine Patch 0.1 mg/24 hr 11. CloniDINE 12. CloniDINE\n 13. Famotidine 14. Fentanyl Citrate 15. Haloperidol . Haloperidol 18.\n Heparin Flush (10 units/ml) 19. Heparin 20. Insulin 21. Ipratropium\n Bromide Neb 22. Labetalol 23. Metoprolol Tartrate 24. Metoprolol\n Tartrate 25. Metoclopramide 26. Multiple Vitamins Liq. 27.\n Nitroglycerin 28. Piperacillin-Tazobactam Na 29. Sodium Chloride Nasal\n 30.\n 24 Hour Events:\n STOOL CULTURE - At 11:00 PM\n URINE CULTURE - At 02:55 AM\n EKG - At 06:23 AM\n to confirm qtc\n - CTA torso:type B aortic dissection, true lumen in upper abd near\n completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -renal US R>L perfusion. nl size.\n Labetolol/Nicardipine(IV),Norvasc\n :Intubated 2'resp.failure/P edema\n :Extubated. restless, agitated at times.Labetalol GTT for BP\n control\n -PP DHT, TF begun. fenanyl for pain, calmer.Cr:3.6\n -more awake. Ativan/haldol scheduled, Haldol for breakthru. Psych\n saw.Pulled DHT out. Back to stomach,feeds resumed.\n Post operative day:\n 62M w/ type B aortic dissection/medical management.\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Piperacillin/Tazobactam (Zosyn) - 07:44 PM\n Infusions:\n Nitroglycerin - 2 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 02:00 AM\n Haloperidol (Haldol) - 07:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Flowsheet Data as of 12:39 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.6\nC (97.9\n HR: 58 (58 - 85) bpm\n BP: 128/71(84) {115/61(72) - 167/100(154)} mmHg\n RR: 15 (14 - 25) insp/min\n SPO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 91.6 kg (admission): 90 kg\n Height: 74 Inch\n Total In:\n 2,254 mL\n 1,501 mL\n PO:\n Tube feeding:\n 618 mL\n 554 mL\n IV Fluid:\n 1,296 mL\n 757 mL\n Blood products:\n Total out:\n 2,190 mL\n 860 mL\n Urine:\n 1,890 mL\n 860 mL\n NG:\n Stool:\n Drains:\n Balance:\n 64 mL\n 641 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular), PAC's\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : throughout)\n Abdominal: Soft, 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 1), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, oriented only to\n person\n Labs / Radiology\n 317 K/uL\n 9.2 g/dL\n 180 mg/dL\n 3.2 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 68 mg/dL\n 112 mEq/L\n 144 mEq/L\n 26.5 %\n 15.1 K/uL\n [image002.jpg]\n 09:37 AM\n 06:20 PM\n 09:45 PM\n 10:02 PM\n 02:27 AM\n 06:55 AM\n 07:04 AM\n 12:58 PM\n 02:47 AM\n 02:37 AM\n WBC\n 11.9\n 12.9\n 15.1\n Hct\n 26.9\n 27.8\n 28.1\n 27.9\n 26.5\n Plt\n 263\n 287\n 317\n Creatinine\n 3.6\n 3.4\n 3.2\n TCO2\n 24\n 22\n 23\n 24\n 19\n Glucose\n 108\n 122\n 180\n Other labs: PT / PTT / INR:14.2/28.9/1.2, CK / CK-MB / Troponin\n T:1384/11/0.02, ALT / AST:53/47, Alk-Phos / T bili:213/0.7, Amylase /\n Lipase:82/108, Lactic Acid:0.9 mmol/L, Albumin:2.6 g/dL, LDH:598 IU/L,\n Ca:8.6 mg/dL, Mg:2.3 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, ALTERED MENTAL STATUS (NOT DELIRIUM), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), PNEUMONIA,\n Assessment and Plan: 62yo man type B dissection currently medically\n managed.\n Neurologic: Restraints, haldol/fentanyl-prn\n Cardiovascular: Beta-blocker, Statins, add clonidine to meds\n Pulmonary: IS, OOB-chair\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO\n Hematology: stable hct\n Endocrine: RISS\n Infectious Disease: cultures all negative\n but wbc remains elevated on zosyn\n Lines / Tubes / Drains: Foley, Dobhoff, left subclav tlc\n Consults: Vascular surgery, CT surgery, psychiatry\n Billing diagnosis: aortic dissection\n ICU Care\n Nutrition: Nutren Renal (Full) - 07:02 AM 45 mL/hour\n Lines: Multi Lumen - 09:47 AM\n Prophylaxis: DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Disposition: ICU\n Time spent : 32 minutes\n" }, { "category": "Nutrition", "chartdate": "2141-06-26 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 675999, "text": "Subjective\n Moaning; x-ray being taken.\n Objective\n Height\n Admit weight\n Daily weight\n 188 cm\n 90 kg\n 91.6 kg ( 04:00 AM)\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n 86.2 kg\n Pertinent medications: Labelatol drip, Nitroglycerin drip, Dextrose 5%\n @ 10ml/hr, RISS, ABX, Pantoprazole; MVI, Thiamine, Folic Acid held due\n to NPO\n Labs:\n Value\n Date\n Glucose\n 108 mg/dL\n 02:27 AM\n Glucose Finger Stick\n 114\n 12:00 PM\n BUN\n 76 mg/dL\n 02:27 AM\n Creatinine\n 3.6 mg/dL\n 02:27 AM\n Sodium\n 144 mEq/L\n 02:27 AM\n Potassium\n 4.5 mEq/L\n 02:27 AM\n Chloride\n 113 mEq/L\n 02:27 AM\n TCO2\n 21 mEq/L\n 02:27 AM\n PO2 (arterial)\n 82. mm Hg\n 12:58 PM\n PCO2 (arterial)\n 28 mm Hg\n 12:58 PM\n pH (arterial)\n 7.42 units\n 12:58 PM\n pH (urine)\n 5.0 units\n 12:52 PM\n CO2 (Calc) arterial\n 19 mEq/L\n 12:58 PM\n Albumin\n 2.6 g/dL\n 01:56 AM\n Calcium non-ionized\n 8.7 mg/dL\n 02:27 AM\n Phosphorus\n 3.4 mg/dL\n 02:27 AM\n Ionized Calcium\n 1.19 mmol/L\n 06:20 PM\n Magnesium\n 2.7 mg/dL\n 02:27 AM\n ALT\n 44 IU/L\n 01:56 AM\n Alkaline Phosphate\n 288 IU/L\n 01:56 AM\n AST\n 52 IU/L\n 01:56 AM\n Amylase\n 55 IU/L\n 01:56 AM\n Total Bilirubin\n 0.8 mg/dL\n 01:56 AM\n WBC\n 11.9 K/uL\n 02:27 AM\n Hgb\n 9.4 g/dL\n 02:27 AM\n Hematocrit\n 28.1 %\n 06:55 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feeding: OFF (Novasource Renal @ 40ml/hr)\n GI: soft, (+) bowel sounds; black liquid stool, guiac (+) this AM\n Assessment of Nutritional Status\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n 62 YO male admitted with Type B dissection. s/p extubation .\n Patient with lethargy and confusion overnight. Feeding tube placed,\n x-ray checked, which showed feeding tube coiled in stomach (team would\n like post pyloric). New x-ray being taken at this time. Previously,\n patient was tolerating tube feeding at goal without residuals until\n held for extubation. Tube feed goal provides calories and\n 71g protein, which underfeeds protein. Also, Phos and K+ WNL,\n therefore would change to non-renal formula. Noted elevated Magnesium.\n Medical Nutrition Therapy Plan - Recommend the Following\n Once feeding tube confirmed; ok to begin tube feeding\n Tube feeding recommendations: Nutren Pulmonary @ 25ml/hr; advance as\n tol to goal of 65ml/hr = 2340 calories and 106g protein\n No residual checks with PPFT; monitor abdominal exam\n Check chemistry 10 panel\n Recommend S+S evaluation when MS improves\n Will follow, page if questions *\n" }, { "category": "Nursing", "chartdate": "2141-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676598, "text": "Altered mental status, delirious at times\n Assessment:\n Pt oriented x 1 (self) throughout shift. Disoriented, wanting to get\n out of bed, making inappropriate statements. Pt unaware that he\ns in\n hospital. Sitter at bedside.\n Action:\n Required high doses of Haldol and Fentanyl to try and keep pt calm.\n Soft wrist restraints in place to avoid disruption in treatment.\n Reoriented patient frequently, emotional support provided.\n Response:\n Pt had periods of sleep with periods of restlessness and attempts to\n get out of bed. No improvement in mental status noted.\n Plan:\n Continue to monitor mental status closely. Administer Haldol and\n Fentanyl as ordered. Measure QTc q shift. If QTc > 0.5, Haldol may\n need to be changed to seraquil and Ativan.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Hypertension that increases with agitation. NTG gtt continued to keep\n SBP 120-150.\n False lumen perfusing L kidney, ATN improving. Creat/bun decreasing but\n still elevated.?mesenteric ischemia d/t dissection, loose stool cont.\n Cdiff neg x2.\n Action:\n Nitro gtt weaned keeping sbp <150. Unable to wean off. Clonidine patch\n and po load started on previous shift.\n Renal following.\n Response:\n Continues to be hypertensive requiring nitro gtt despite po meds. Good\n HUO. Loose stools cont.\n Plan:\n Wean nitro gtt keeping sbp <150. Cont po clonidine load, pt wearing\n patch. Vascular want to re-image dissection when pt neurologically\n appropriate. ?stenting renal artery. Renal will cont to follow until\n creat improves. Third cdiff to be sent.\n" }, { "category": "Physician ", "chartdate": "2141-06-27 00:00:00.000", "description": "Intensivist Note", "row_id": 676242, "text": "CVICU\n HPI:\n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMH: HTN, arthritis\n : ASA\n - CTA torso:type B aortic dissection, true lumen in upper abd near\n completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -renal US R>L perfusion. nl size.\n Labetolol/Nicardipine(IV),Norvasc\n :Intubated 2'resp.failure/P edema\n :Extubated. restless, agitated at times.Labetalol GTT for BP\n control\n -PP DHT, TF begun. fenanyl for pain, calmer.Cr:3.6\n Current medications:\n 1. 2. Albuterol 0.083% Neb Soln 3. Amlodipine 4. Artificial Tears\n Preserv. Free 5. Aspirin 6. Beclomethasone Dipropionate 7. Bisacodyl 8.\n Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10.\n Fentanyl Citrate\n 11. FoLIC Acid 12. Haloperidol 13. Heparin 14. Insulin 15. Ipratropium\n Bromide Neb 16. Labetalol 17. Lorazepam Metoprolol Tartrate 22.\n Multiple Vitamins Liq. 23. Nitroglycerin 24. Ondansetron 25.\n Pantoprazole 26. Piperacillin-Tazobactam Na 27. Quetiapine Fumarate\n 28. Thiamine\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:58 PM\n STOOL CULTURE - At 09:02 PM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Piperacillin/Tazobactam (Zosyn) - 07:44 PM\n Infusions:\n Nitroglycerin - 2 mcg/Kg/min\n Labetalol - 0.5 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:10 AM\n Fentanyl - 01:23 AM\n Haloperidol (Haldol) - 02:46 AM\n Metoprolol - 04:30 AM\n Lorazepam (Ativan) - 06:30 AM\n Other medications:\n Flowsheet Data as of 08:42 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\nC (98.6\n HR: 74 (59 - 80) bpm\n BP: 136/83(96) {109/61(74) - 164/95(112)} mmHg\n RR: 19 (14 - 26) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.6 kg (admission): 90 kg\n Height: 74 Inch\n CVP: 18 (2 - 22) mmHg\n Total In:\n 1,976 mL\n 848 mL\n PO:\n Tube feeding:\n 44 mL\n 211 mL\n IV Fluid:\n 1,812 mL\n 487 mL\n Blood products:\n Total out:\n 1,545 mL\n 760 mL\n Urine:\n 1,545 mL\n 760 mL\n NG:\n Stool:\n Drains:\n Balance:\n 431 mL\n 88 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: 7.42/28/82./22/-4\n PaO2 / FiO2: 207\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 287 K/uL\n 9.5 g/dL\n 122 mg/dL\n 3.4 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 77 mg/dL\n 113 mEq/L\n 147 mEq/L\n 27.9 %\n 12.9 K/uL\n [image002.jpg]\n 05:33 AM\n 09:37 AM\n 06:20 PM\n 09:45 PM\n 10:02 PM\n 02:27 AM\n 06:55 AM\n 07:04 AM\n 12:58 PM\n 02:47 AM\n WBC\n 11.9\n 12.9\n Hct\n 26.9\n 27.8\n 28.1\n 27.9\n Plt\n 263\n 287\n Creatinine\n 3.6\n 3.4\n TCO2\n 23\n 24\n 22\n 23\n 24\n 19\n Glucose\n 108\n 122\n Other labs: PT / PTT / INR:13.2/29.6/1.1, CK / CK-MB / Troponin\n T:1384/11/0.02, ALT / AST:44/52, Alk-Phos / T bili:288/0.8, Amylase /\n Lipase:55/68, Lactic Acid:0.9 mmol/L, Albumin:2.6 g/dL, LDH:598 IU/L,\n Ca:8.6 mg/dL, Mg:2.6 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, ALTERED MENTAL STATUS (NOT DELIRIUM), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), PNEUMONIA, OTHER\n Assessment and Plan: Blood pressure control for descending anyeurism\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Ativan and seraquil\n Cardiovascular: Aspirin, Beta-blocker, Statins, NTG and labetalol.\n Increase lopressor and wean NTG\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley\n Hematology: No evidene of bleeding\n Endocrine: RISS\n Infectious Disease: Check cultures, D/C abx today\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Vascular surgery, CT surgery\n Billing Diagnosis: Other: Aortic dissection, Hypertension\n ICU Care\n Nutren Renal (Full) - 07:45 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:47 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2141-06-27 00:00:00.000", "description": "ICU Note - CVI", "row_id": 676243, "text": "CVICU\n HPI:\n HD10\n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMH: HTN, arthritis\n : ASA\n - CTA torso:type B aortic dissection, true lumen in upper abd near\n completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -renal US R>L perfusion. nl size.\n Labetolol/Nicardipine(IV),Norvasc\n :Intubated 2'resp.failure/P edema\n :Extubated. restless, agitated at times.Labetalol GTT for BP\n control\n -PP DHT, TF begun. fenanyl for pain, calmer.Cr:3.6\n Current medications:\n VAlbuterol 0.083% Neb Soln . Amlodipine . Artificial Tears Preserv.\n Free. Aspirin . Beclomethasone Dipropionate\n Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse . Fentanyl Citrate FoLIC Acid . Haloperidol . Heparin . Insulin\n . Ipratropium Bromide Neb 16. Labetalol . Lorazepam . Metoprolol\n Tartrate . Metoprolol Tartrate . Multiple Vitamins Liq. . Nitroglycerin\n . Ondansetron . Pantoprazole . Piperacillin-Tazobactam Na . Quetiapine\n Fumarate\n Sodium Chloride Nasal Thiamine\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:58 PM\n STOOL CULTURE - At 09:02 PM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Piperacillin/Tazobactam (Zosyn) - 07:44 PM\n Infusions:\n Nitroglycerin - 2 mcg/Kg/min\n Labetalol - 0.5 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:10 AM\n Fentanyl - 01:23 AM\n Haloperidol (Haldol) - 02:46 AM\n Metoprolol - 04:30 AM\n Lorazepam (Ativan) - 06:30 AM\n Other medications:\n Flowsheet Data as of 08:44 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\nC (98.6\n HR: 74 (59 - 80) bpm\n BP: 136/83(96) {109/61(74) - 164/95(112)} mmHg\n RR: 19 (14 - 26) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.6 kg (admission): 90 kg\n Height: 74 Inch\n CVP: 18 (2 - 22) mmHg\n Total In:\n 1,976 mL\n 858 mL\n PO:\n Tube feeding:\n 44 mL\n 214 mL\n IV Fluid:\n 1,812 mL\n 494 mL\n Blood products:\n Total out:\n 1,545 mL\n 760 mL\n Urine:\n 1,545 mL\n 760 mL\n NG:\n Stool:\n Drains:\n Balance:\n 431 mL\n 98 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: 7.42/28/82./22/-4\n PaO2 / FiO2: 207\n Physical Examination\n General Appearance: No acute distress, Lethargic. Knows birthdate.\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 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 1), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 287 K/uL\n 9.5 g/dL\n 122 mg/dL\n 3.4 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 77 mg/dL\n 113 mEq/L\n 147 mEq/L\n 27.9 %\n 12.9 K/uL\n [image002.jpg]\n 05:33 AM\n 09:37 AM\n 06:20 PM\n 09:45 PM\n 10:02 PM\n 02:27 AM\n 06:55 AM\n 07:04 AM\n 12:58 PM\n 02:47 AM\n WBC\n 11.9\n 12.9\n Hct\n 26.9\n 27.8\n 28.1\n 27.9\n Plt\n 263\n 287\n Creatinine\n 3.6\n 3.4\n TCO2\n 23\n 24\n 22\n 23\n 24\n 19\n Glucose\n 108\n 122\n Other labs: PT / PTT / INR:13.2/29.6/1.1, CK / CK-MB / Troponin\n T:1384/11/0.02, ALT / AST:44/52, Alk-Phos / T bili:288/0.8, Amylase /\n Lipase:55/68, Lactic Acid:0.9 mmol/L, Albumin:2.6 g/dL, LDH:598 IU/L,\n Ca:8.6 mg/dL, Mg:2.6 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, ALTERED MENTAL STATUS (NOT DELIRIUM), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), PNEUMONIA, OTHER\n Assessment and Plan: More awake, although still restless at times.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Restraints\n Cardiovascular: Aspirin, Beta-blocker, Statins, NTG/Labetolol gtts.\n increase BB today.\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Cr falling\n Endocrine: RISS\n Infectious Disease: Check cultures, BAL neg. enterobacter in sp. D/C\n antibiotics today\n Lines / Tubes / Drains: Foley, Dobhoff\n luids: Other\n Consults: P.T.\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 07:45 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:47 AM\n Prophylaxis:\n Stress ulcer: PPI\n :\n ommunication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2141-06-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676247, "text": "62M w/ type B aortic dissection/medical management.\n CTA torso: large type B aortic dissection, true lumen in upper abd near\n completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US R>L perfusion. nl size. Labetolol/Nicardipine(IV),Norvasc\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Intubated on CPAP, sedated on fentanyl and versed gtts. Does not follow\n commands, PERRL. Grimaces to sternal rub only. Appears to posture with\n painful stimulation. HR NSR with PAC\ns sbp 90\ns-100\ns. pulses easily\n palpable bowel sounds present, skin intact. No central access, 3\n peripheral IV\ns running well. UOP ~100cc/h creat 2.5\n Action:\n Central line placed in Left subclavian\n Pt received vecuronium for Line placement, due to pt\n posturing during insertion\n Put on CMV due to paralysis\n CT scan of head to rule out bleed or ischemia due to\n posturing and non responsive\n Ultrasound to determine if pt dissected up into carotids\n Turning every 2 hours to maintain skin integrity\n Weaning sedation as tolerated to assess neuro status\n Fluid bolus given for rise in creat to 3.1\n Neuro assessments every 2 hours\n All blood pressure medications held per team due to sbp 90\n Response:\n Central line OK for use per post placement CXR\n Pt back to CPAP with 4/4 twitches TOF and responding to\n verbal stimuli\n CT scan negative\n Ultrasound negative for carotid dissection\n CVP transduced for fluid volume assessment\n Pt slow to wake related to renal involvement of dissection\n Pt opens eyes to verbal stimuli, does not track. Postures to\n painful stimuli and to care.\n Arms extend outward, lower extremities do not respond to\n babinski assessment. Extend down and inward unrelated to pain or\n movement\n Plan:\n Alteration in Nutrition\n Assessment:\n Pt has not received nutrition in a number of days. Is intubated and\n sedated\n Action:\n Tube feedings started for enteral nutrition\n Response:\n Pt tolerating tube feeds, with no residual\n Plan:\n Continue to advance tube feeds every 4 hours, as tolerated for a goal\n rate of 40. treat per care plan\n Hypoxemia\n Assessment:\n Intubated on CPAP, PEEP 10. sats 94%, lungs clear\n Action:\n ABG this AM within normal limits, FIO2 down to 50%\n Paralyzed related to line placement- see above documentation, put back\n on a rate for duration of paralytic effect\n Response:\n Once pt responding to painful stimuli, over breathing set rate and TOF\n assessed for twitches put back on CPAP 50%\n Plan:\n Wean vent as tolerated,? Extubate pending neuro status to neuro status\n Sons in to visit. Stayed briefly, stated that sitting with him for that\n long was\nenough\n. Made comments that they found seeing him in this\n state was very emotionally difficult for them. Social work is\n following, was not here when family visited.\n" }, { "category": "Physician ", "chartdate": "2141-06-29 00:00:00.000", "description": "ICU Note - CVI", "row_id": 676662, "text": "CVICU\n HPI:\n w/ type B aortic dissection/medical management.\n EF 75 Cr 1.4 WT 185lbs HgbA1c\n PMH: HTN, arthritis\n : ASA\n PMHx:\n PMH: HTN, arthritis\n : ASA\n Current medications:\n Albuterol 0.083% Neb Soln 3. Amlodipine 4. Artificial Tears Preserv.\n Free 5. Aspirin 6. Atorvastatin\n 7. Beclomethasone Dipropionate 8. Bisacodyl 9. Calcium Gluconate 10.\n Clonidine Patch 0.1 mg/24 hr\n 11. CloniDINE . Famotidine 14. Fentanyl Citrate 17. Haloperidol 18.\n Heparin 19. Insulin 20. Ipratropium Bromide Neb 21. Metoprolol Tartrate\n 23. Metoclopramide . Multiple Vitamins Liq. 26. Nitroglycerin 27.\n Piperacillin-Tazobactam Na\n 24 Hour Events:\n EKG - At 05:30 PM\n to confirm qtc\n - CTA torso:type B aortic dissection, true lumen in upper abd near\n completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -renal US R>L perfusion. nl size.\n Labetolol/Nicardipine(IV),Norvasc\n :Intubated 2'resp.failure/P edema\n :Extubated. restless, agitated at times.Labetalol GTT for BP\n control\n -PP DHT, TF begun. fenanyl for pain, calmer.Cr:3.6\n -more awake. Ativan/haldol scheduled, Haldol for breakthru. Psych\n saw.Pulled DHT out. Back to stomach,feeds resumed.\n - episodes of agitation. Ativan stopped-cont haldol/Fentanyl\n Post operative day:\n / type B aortic dissection/medical management\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Piperacillin/Tazobactam (Zosyn) - 05:21 AM\n Infusions:\n Nitroglycerin - 2.25 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Fentanyl - 11:54 PM\n Haloperidol (Haldol) - 02:07 AM\n Flowsheet Data as of 08:13 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: 37.4\nC (99.3\n HR: 81 (58 - 81) bpm\n BP: 159/90(107) {120/63(78) - 161/113(125)} mmHg\n RR: 17 (13 - 19) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.6 kg (admission): 90 kg\n Height: 74 Inch\n Total In:\n 3,009 mL\n 829 mL\n PO:\n 60 mL\n Tube feeding:\n 1,080 mL\n 333 mL\n IV Fluid:\n 1,219 mL\n 316 mL\n Blood products:\n Total out:\n 1,840 mL\n 2,090 mL\n Urine:\n 1,840 mL\n 1,290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,169 mL\n -1,261 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 93%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : scattered)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n diarrhea-Cdiff negative\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 1), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, oriented only to\n person. able to communicate more coherently today\n Labs / Radiology\n 320 K/uL\n 9.3 g/dL\n 80 mg/dL\n 3.1 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 59 mg/dL\n 114 mEq/L\n 148 mEq/L\n 27.4 %\n 16.2 K/uL\n [image002.jpg]\n 06:20 PM\n 09:45 PM\n 10:02 PM\n 02:27 AM\n 06:55 AM\n 07:04 AM\n 12:58 PM\n 02:47 AM\n 02:37 AM\n 03:03 AM\n WBC\n 11.9\n 12.9\n 15.1\n 16.2\n Hct\n 26.9\n 27.8\n 28.1\n 27.9\n 26.5\n 27.4\n Plt\n 263\n 287\n 317\n 320\n Creatinine\n 3.6\n 3.4\n 3.2\n 3.1\n TCO2\n 22\n 23\n 24\n 19\n Glucose\n 108\n 122\n 180\n 80\n Other labs: PT / PTT / INR:14.2/28.9/1.2, CK / CK-MB / Troponin\n T:1384/11/0.02, ALT / AST:50/39, Alk-Phos / T bili:216/0.6, Amylase /\n Lipase:94/140, Lactic Acid:0.9 mmol/L, Albumin:3.2 g/dL, LDH:498 IU/L,\n Ca:8.7 mg/dL, Mg:2.3 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, ALTERED MENTAL STATUS (NOT DELIRIUM), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), PNEUMONIA, OTHER\n Assessment and Plan: 62yo man with type B dissection-currently\n medically managed.\n Neurologic: Restraints, continue haldol\n fentanyl for pain control\n restraints for safety\n Cardiovascular: Aspirin, Beta-blocker, Statins, clonidine, amlopidine\n iv NTG-wean as tolerated\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding, tube feeds at goal\n Renal: Foley, Adequate UO, creat remains elevated but trending down\n will continue to monitor\n Hematology: stable hct\n Endocrine: RISS, Lantus (R)\n Infectious Disease: all cultures negative\n wbc 16 on Zosyn for presumed asp pneumonia\n Lines / Tubes / Drains: Foley, flexiseal\n triple lumen cvl\n Consults: Vascular surgery, CT surgery, Psychiatry\n ICU Care\n Nutrition: Nutren Renal (Full) - 02:35 AM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines: Multi Lumen - 09:47 AM\n Prophylaxis: DVT: SQ UF Heparin (OOB-chair)\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: ICU\n" }, { "category": "General", "chartdate": "2141-06-29 00:00:00.000", "description": "Generic Note", "row_id": 676664, "text": "TITLE:\n CVICU\n HPI:\n w/ type B aortic dissection/medical management.\n EF 75 Cr 1.4 WT 185lbs HgbA1c\n PMH: HTN, arthritis\n : ASA\n PMHx:\n PMH: HTN, arthritis\n Current medications:\n Albuterol 0.083% Neb Soln 3. Amlodipine 4. Artificial Tears Preserv.\n Free 5. Aspirin 6. Atorvastatin\n 7. Beclomethasone Dipropionate 8. Bisacodyl 9. Calcium Gluconate 10.\n Clonidine Patch 0.1 mg/24 hr\n 11. CloniDINE . Famotidine 14. Fentanyl Citrate 17. Haloperidol 18.\n Heparin 19. Insulin 20. Ipratropium Bromide Neb 21. Metoprolol Tartrate\n 23. Metoclopramide . Multiple Vitamins Liq. 26. Nitroglycerin 27.\n Piperacillin-Tazobactam Na\n 24 Hour Events:\n EKG - At 05:30 PM\n to confirm qtc\n - CTA torso:type B aortic dissection, true lumen in upper abd near\n completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -renal US R>L perfusion. nl size.\n Labetolol/Nicardipine(IV),Norvasc\n :Intubated 2'resp.failure/P edema\n :Extubated. restless, agitated at times.Labetalol GTT for BP\n control\n -PP DHT, TF begun. fenanyl for pain, calmer.Cr:3.6\n -more awake. Ativan/haldol scheduled, Haldol for breakthru. Psych\n saw.Pulled DHT out. Back to stomach,feeds resumed.\n - episodes of agitation. Ativan stopped-cont haldol/Fentanyl\n Post operative day:\n / type B aortic dissection/medical management\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Piperacillin/Tazobactam (Zosyn) - 05:21 AM\n Infusions:\n Nitroglycerin - 2.25 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Fentanyl - 11:54 PM\n Haloperidol (Haldol) - 02:07 AM\n Flowsheet Data as of 08:13 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: 37.4\nC (99.3\n HR: 81 (58 - 81) bpm\n BP: 159/90(107) {120/63(78) - 161/113(125)} mmHg\n RR: 17 (13 - 19) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.6 kg (admission): 90 kg\n Height: 74 Inch\n Total In:\n 3,009 mL\n 829 mL\n PO:\n 60 mL\n Tube feeding:\n 1,080 mL\n 333 mL\n IV Fluid:\n 1,219 mL\n 316 mL\n Blood products:\n Total out:\n 1,840 mL\n 2,090 mL\n Urine:\n 1,840 mL\n 1,290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,169 mL\n -1,261 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 93%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : scattered)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n diarrhea-Cdiff negative\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 1), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, oriented only to\n person. able to communicate more coherently today\n Labs / Radiology\n 320 K/uL\n 9.3 g/dL\n 80 mg/dL\n 3.1 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 59 mg/dL\n 114 mEq/L\n 148 mEq/L\n 27.4 %\n 16.2 K/uL\n [image002.jpg]\n 06:20 PM\n 09:45 PM\n 10:02 PM\n 02:27 AM\n 06:55 AM\n 07:04 AM\n 12:58 PM\n 02:47 AM\n 02:37 AM\n 03:03 AM\n WBC\n 11.9\n 12.9\n 15.1\n 16.2\n Hct\n 26.9\n 27.8\n 28.1\n 27.9\n 26.5\n 27.4\n Plt\n 263\n 287\n 317\n 320\n Creatinine\n 3.6\n 3.4\n 3.2\n 3.1\n TCO2\n 22\n 23\n 24\n 19\n Glucose\n 108\n 122\n 180\n 80\n Other labs: PT / PTT / INR:14.2/28.9/1.2, CK / CK-MB / Troponin\n T:1384/11/0.02, ALT / AST:50/39, Alk-Phos / T bili:216/0.6, Amylase /\n Lipase:94/140, Lactic Acid:0.9 mmol/L, Albumin:3.2 g/dL, LDH:498 IU/L,\n Ca:8.7 mg/dL, Mg:2.3 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, ALTERED MENTAL STATUS (NOT DELIRIUM), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), PNEUMONIA, O\n Assessment and Plan: 62yo man with type B dissection-currently\n medically managed.\n Neurologic: Restraints, continue haldol, fentanyl for pain control,\n restraints for safety\n Cardiovascular: Aspirin, Beta-blocker, Statins, clonidine, amlopidine,\n iv NTG-wean as tolerated\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding, tube feeds at goal\n Renal: Foley, Adequate UO, creat remains elevated but trending down\n will continue to monitor\n Hematology: stable hct\n Endocrine: RISS, Lantus (R)\n Infectious Disease: all cultures negative\n wbc 16 on Zosyn for presumed asp pneumonia\n Lines / Tubes / Drains: Foley, flexiseal, triple lumen cvl\n Consults: Vascular surgery, CT surgery, Psychiatry\n Billing diagnosis: Aortic dissection\n ICU Care\n Nutrition: Nutren Renal (Full) - 02:35 AM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines: Multi Lumen - 09:47 AM\n Prophylaxis: DVT: SQ UF Heparin (OOB-chair)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Time spent : 32 minutes\n" }, { "category": "Physician ", "chartdate": "2141-06-28 00:00:00.000", "description": "ICU Note - CVI", "row_id": 676511, "text": "CVICU\n HPI:\n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n : ASA\n PMHx:\n PMH: HTN, arthritis\n Current medications:\n Amlodipine 4. Artificial Tears Preserv. Free 5. Aspirin 6.\n Atorvastatin 7. Beclomethasone Dipropionate 8. Bisacodyl 9. Calcium\n Gluconate 10. Clonidine Patch 0.1 mg/24 hr 11. CloniDINE 12. CloniDINE\n 13. Famotidine 14. Fentanyl Citrate 15. Haloperidol . Haloperidol 18.\n Heparin Flush (10 units/ml) 19. Heparin 20. Insulin 21. Ipratropium\n Bromide Neb 22. Labetalol 23. Metoprolol Tartrate 24. Metoprolol\n Tartrate 25. Metoclopramide 26. Multiple Vitamins Liq. 27.\n Nitroglycerin 28. Piperacillin-Tazobactam Na 29. Sodium Chloride Nasal\n 30.\n 24 Hour Events:\n STOOL CULTURE - At 11:00 PM\n URINE CULTURE - At 02:55 AM\n EKG - At 06:23 AM\n to confirm qtc\n - CTA torso:type B aortic dissection, true lumen in upper abd near\n completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -renal US R>L perfusion. nl size.\n Labetolol/Nicardipine(IV),Norvasc\n :Intubated 2'resp.failure/P edema\n :Extubated. restless, agitated at times.Labetalol GTT for BP\n control\n -PP DHT, TF begun. fenanyl for pain, calmer.Cr:3.6\n -more awake. Ativan/haldol scheduled, Haldol for breakthru. Psych\n saw.Pulled DHT out. Back to stomach,feeds resumed.\n Post operative day:\n 62M w/ type B aortic dissection/medical management.\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Piperacillin/Tazobactam (Zosyn) - 07:44 PM\n Infusions:\n Nitroglycerin - 2 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 02:00 AM\n Haloperidol (Haldol) - 07:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Flowsheet Data as of 12:39 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.6\nC (97.9\n HR: 58 (58 - 85) bpm\n BP: 128/71(84) {115/61(72) - 167/100(154)} mmHg\n RR: 15 (14 - 25) insp/min\n SPO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 91.6 kg (admission): 90 kg\n Height: 74 Inch\n Total In:\n 2,254 mL\n 1,501 mL\n PO:\n Tube feeding:\n 618 mL\n 554 mL\n IV Fluid:\n 1,296 mL\n 757 mL\n Blood products:\n Total out:\n 2,190 mL\n 860 mL\n Urine:\n 1,890 mL\n 860 mL\n NG:\n Stool:\n Drains:\n Balance:\n 64 mL\n 641 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular), PAC's\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : throughout)\n Abdominal: Soft, 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 1), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, oriented only to\n person\n Labs / Radiology\n 317 K/uL\n 9.2 g/dL\n 180 mg/dL\n 3.2 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 68 mg/dL\n 112 mEq/L\n 144 mEq/L\n 26.5 %\n 15.1 K/uL\n [image002.jpg]\n 09:37 AM\n 06:20 PM\n 09:45 PM\n 10:02 PM\n 02:27 AM\n 06:55 AM\n 07:04 AM\n 12:58 PM\n 02:47 AM\n 02:37 AM\n WBC\n 11.9\n 12.9\n 15.1\n Hct\n 26.9\n 27.8\n 28.1\n 27.9\n 26.5\n Plt\n 263\n 287\n 317\n Creatinine\n 3.6\n 3.4\n 3.2\n TCO2\n 24\n 22\n 23\n 24\n 19\n Glucose\n 108\n 122\n 180\n Other labs: PT / PTT / INR:14.2/28.9/1.2, CK / CK-MB / Troponin\n T:1384/11/0.02, ALT / AST:53/47, Alk-Phos / T bili:213/0.7, Amylase /\n Lipase:82/108, Lactic Acid:0.9 mmol/L, Albumin:2.6 g/dL, LDH:598 IU/L,\n Ca:8.6 mg/dL, Mg:2.3 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, ALTERED MENTAL STATUS (NOT DELIRIUM), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), PNEUMONIA, OTHER\n Assessment and Plan: 62yo man type B dissection currently medically\n managed.\n Neurologic: Restraints, haldol/fentanyl-prn\n Cardiovascular: Beta-blocker, Statins, add clonidine to meds\n Pulmonary: IS, OOB-chair\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO\n Hematology: stable hct\n Endocrine: RISS\n Infectious Disease: cultures all negative\n but wbc remains elevated on zosyn\n Lines / Tubes / Drains: Foley, Dobhoff, left subclav tlc\n Consults: Vascular surgery, CT surgery, psychiatry\n ICU Care\n Nutrition: Nutren Renal (Full) - 07:02 AM 45 mL/hour\n Glycemic Control:\n Lines: Multi Lumen - 09:47 AM\n Prophylaxis: DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2141-06-28 00:00:00.000", "description": "ICU Note - CVI", "row_id": 676512, "text": "CVICU\n HPI:\n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMH: HTN, arthritis\n : ASA\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n Remains in ICU requiring IV nitro and labetolol for blood pressure\n management\n Psychiatry continues to follow for confusion\n STOOL CULTURE - At 11:00 PM\n URINE CULTURE - At 02:55 AM\n EKG - At 06:23 AM\n to confirm qtc\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Piperacillin/Tazobactam (Zosyn) - 07:44 PM\n Infusions:\n Nitroglycerin - 2 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 02:00 AM\n Haloperidol (Haldol) - 07:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Flowsheet Data as of 12:48 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.6\nC (97.9\n HR: 58 (58 - 85) bpm\n BP: 128/71(84) {115/61(72) - 167/100(154)} mmHg\n RR: 15 (14 - 25) insp/min\n SPO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 91.6 kg (admission): 90 kg\n Height: 74 Inch\n Total In:\n 2,254 mL\n 1,510 mL\n PO:\n Tube feeding:\n 618 mL\n 559 mL\n IV Fluid:\n 1,296 mL\n 762 mL\n Blood products:\n Total out:\n 2,190 mL\n 860 mL\n Urine:\n 1,890 mL\n 860 mL\n NG:\n Stool:\n Drains:\n Balance:\n 64 mL\n 650 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n felxiseal in place\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 1), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 317 K/uL\n 9.2 g/dL\n 180 mg/dL\n 3.2 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 68 mg/dL\n 112 mEq/L\n 144 mEq/L\n 26.5 %\n 15.1 K/uL\n [image002.jpg]\n 09:37 AM\n 06:20 PM\n 09:45 PM\n 10:02 PM\n 02:27 AM\n 06:55 AM\n 07:04 AM\n 12:58 PM\n 02:47 AM\n 02:37 AM\n WBC\n 11.9\n 12.9\n 15.1\n Hct\n 26.9\n 27.8\n 28.1\n 27.9\n 26.5\n Plt\n 263\n 287\n 317\n Creatinine\n 3.6\n 3.4\n 3.2\n TCO2\n 24\n 22\n 23\n 24\n 19\n Glucose\n 108\n 122\n 180\n Other labs: PT / PTT / INR:14.2/28.9/1.2, CK / CK-MB / Troponin\n T:1384/11/0.02, ALT / AST:53/47, Alk-Phos / T bili:213/0.7, Amylase /\n Lipase:82/108, Lactic Acid:0.9 mmol/L, Albumin:2.6 g/dL, LDH:598 IU/L,\n Ca:8.6 mg/dL, Mg:2.3 mg/dL, PO4:3.1 mg/dL\n Imaging: cxr worsening volume status\n Microbiology: urine pending\n and stool negative cdiff - third specimen today\n MRSA no growth\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, ALTERED MENTAL STATUS (NOT DELIRIUM), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), PNEUMONIA, OTHER\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, QTC q6h due to haldol\n Cardiovascular: Aspirin, Beta-blocker, Statins, start clonodine to\n transition off IV antihypertensives, patch today with oral doses to\n transition, wean gtt for B/P < 130\n Pulmonary: chest pt, continue with nebs\n Gastrointestinal / Abdomen: amylase nl, lipase 108, recheck in am \n no abdominal pain\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, acute renal failure\n Hematology: stable anemia\n Endocrine: RISS, add lantus 10 units and adjust scale for bg management\n - goal BG < 150\n Infectious Disease: wbc 15 from 12, afebrile, continues on Zosyn for\n question pneumonia, started \n Lines / Tubes / Drains: Foley, Dobhoff\n Wounds:\n Imaging:\n Fluids:\n Consults: Vascular surgery, P.T., Nutrition\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 07:02 AM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Multi Lumen - 09:47 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2141-06-28 00:00:00.000", "description": "ICU Note - CVI", "row_id": 676513, "text": "CVICU\n HPI:\n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMH: HTN, arthritis\n : ASA\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n Remains in ICU requiring IV nitro and labetolol for blood pressure\n management\n Psychiatry continues to follow for confusion\n STOOL CULTURE - At 11:00 PM\n URINE CULTURE - At 02:55 AM\n EKG - At 06:23 AM\n to confirm qtc\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Piperacillin/Tazobactam (Zosyn) - 07:44 PM\n Infusions:\n Nitroglycerin - 2 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 02:00 AM\n Haloperidol (Haldol) - 07:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Flowsheet Data as of 12:48 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.6\nC (97.9\n HR: 58 (58 - 85) bpm\n BP: 128/71(84) {115/61(72) - 167/100(154)} mmHg\n RR: 15 (14 - 25) insp/min\n SPO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 91.6 kg (admission): 90 kg\n Height: 74 Inch\n Total In:\n 2,254 mL\n 1,510 mL\n PO:\n Tube feeding:\n 618 mL\n 559 mL\n IV Fluid:\n 1,296 mL\n 762 mL\n Blood products:\n Total out:\n 2,190 mL\n 860 mL\n Urine:\n 1,890 mL\n 860 mL\n NG:\n Stool:\n Drains:\n Balance:\n 64 mL\n 650 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n felxiseal in place\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 1), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 317 K/uL\n 9.2 g/dL\n 180 mg/dL\n 3.2 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 68 mg/dL\n 112 mEq/L\n 144 mEq/L\n 26.5 %\n 15.1 K/uL\n [image002.jpg]\n 09:37 AM\n 06:20 PM\n 09:45 PM\n 10:02 PM\n 02:27 AM\n 06:55 AM\n 07:04 AM\n 12:58 PM\n 02:47 AM\n 02:37 AM\n WBC\n 11.9\n 12.9\n 15.1\n Hct\n 26.9\n 27.8\n 28.1\n 27.9\n 26.5\n Plt\n 263\n 287\n 317\n Creatinine\n 3.6\n 3.4\n 3.2\n TCO2\n 24\n 22\n 23\n 24\n 19\n Glucose\n 108\n 122\n 180\n Other labs: PT / PTT / INR:14.2/28.9/1.2, CK / CK-MB / Troponin\n T:1384/11/0.02, ALT / AST:53/47, Alk-Phos / T bili:213/0.7, Amylase /\n Lipase:82/108, Lactic Acid:0.9 mmol/L, Albumin:2.6 g/dL, LDH:598 IU/L,\n Ca:8.6 mg/dL, Mg:2.3 mg/dL, PO4:3.1 mg/dL\n Imaging: cxr worsening volume status\n Microbiology: urine pending\n and stool negative cdiff - third specimen today\n MRSA no growth\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, ALTERED MENTAL STATUS (NOT DELIRIUM), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), PNEUMONIA, OTHER\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, QTC q6h due to haldol\n Cardiovascular: Aspirin, Beta-blocker, Statins, start clonodine to\n transition off IV antihypertensives, patch today with oral doses to\n transition, wean gtt for B/P < 130\n Pulmonary: chest pt, continue with nebs\n Gastrointestinal / Abdomen: amylase nl, lipase 108, recheck in am \n no abdominal pain\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, acute renal failure\n Hematology: stable anemia\n Endocrine: RISS, add lantus 10 units and adjust scale for bg management\n - goal BG < 150\n Infectious Disease: wbc 15 from 12, afebrile, continues on Zosyn for\n question pneumonia, started \n Lines / Tubes / Drains: Foley, Dobhoff\n Wounds:\n Imaging:\n Fluids:\n Consults: Vascular surgery, P.T., Nutrition\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 07:02 AM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Multi Lumen - 09:47 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n ------ Protected Section------\n Already written\n ------ Protected Section Error Entered By: , NP\n on: 12:51 ------\n" }, { "category": "Nursing", "chartdate": "2141-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676813, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt. having intermittent periods of escalated confusion and agitation\n whereby he tries to get OOB or sitting up in the chair. Pt. stating\n get me my pants so I can take the bus to . Why \n you let me have my phone?\n pt. pulling at clothing and taking blanket\n off. Throwing pillows to the floor. Using vulgar words when extremely\n agitated.\n Action:\n Repeated explanations given as to where he is and why he\ns here. Soft\n wrist restraints maintained to prevent pt. from pulling out feeding\n tube or central line. Haldol 5mg po given Q6 hrs with additional IV\n haldol total 15 mg through the night. . EKG done last evening to eval.\n QTC = 440ms.\n Response:\n Pt. becomes calm and drowsy after haldol IV doses. Remains confused as\n to the recent events of his hospitalization.\n Plan:\n Maintain 1:1 supervision for safety issues.Provide safe environment and\n to prevent falls. Monitor QTC throughout the day to eval haldol\n effects.\n" }, { "category": "Nursing", "chartdate": "2141-06-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675594, "text": "Pneumonia, other\n Assessment:\n Intubated on PSV overnoc. LS clear w/ some scattered crackles and\n rhonchi. Stable 02sats. Copious oral secretions. Poor toleration\n of ETT while awake. Cont on abx. WBC 12.4\n Action:\n Sxned q3-4hrs for moderate amt thick yellow sputum. Extubated at\n 0500.\n Response:\n Initially snoring but with stable breathing pattern. LS clear\n throughout with stable 02sat on 40% face mask. SRR 15-20. Stable abg\n but with p02 78.\n Plan:\n Titrate fi02 to stable 02sat >92%. Cont CDB and pulm toilet. ABX for\n pneumonia.\n Altered mental status (not Delirium)\n Assessment:\n Intermittent severe agitation w/ thrashing and restlessness, severe\n htn. Unable to focus, gagging around ETT.\n MAE but flexing and not following commands.\n Action:\n Increasaed Fentanyl gtt w/ intermittent bolus for pain. IV Ativan 2mg\n given x2. Fentanyl gtt d/ced postextubation.\n Response:\n Pt remained agitated until postextubation. Now able to focus and follow\n some simple commands. Answering yes/no to questions. Remains restless\n in the bed.\n Plan:\n Cont to monitor mental status and reorient prn. Evaluate for\n appropriate pain control.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cont to make adequate u/o. Body balance even this am. Lytes wnl.\n Bun/Cre 76/3.6\n Action:\n Monitored u/o and elytes. SBP maintained >120.\n Response:\n Improving renal status. Bun/Cre trending down.\n Plan:\n Cont to monitor.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n HTN severe associated w/ wakeful state and restless agitation. HR\n 70\ns-88 nsr w/ frequent pac\ns. Pedal pulses palpable.\n Action:\n IV ntg restarted up to 3mcg/kg/min. Pt also given hydralazine and IV\n lopressor.\n Response:\n Remains HTN at this time.\n Plan:\n Repeat iv lopressor and reevaluate med reqime. need to treat\n restlessness.\n" }, { "category": "Nursing", "chartdate": "2141-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676059, "text": "Altered mental status (not Delirium)\n Assessment:\n Incomprehensible words. Unable to elicit startle reflex in am. Periods\n of elevated agitation, unable to calm pt or redirect. Tremors noted in\n afternoon. No gag.\n Action:\n Standing & prn Ativan. Reorientation. Non-violent restraints applied\n for treatment interference. Dophoff placed for\n nutrition/hydration/meds.\n Response:\n Pt remains confused/agitated when Ativan wears off. Spoke briefly in\n afternoon, saying\nno, stop\n when dophoff was being placed.\n Plan:\n Continue Ativan as needed. ?withdrawing. Start feeding when pump\n arrives.\n Pneumonia, other\n Assessment:\n Known RML pneumonia.\n Action:\n Pulm toilet. Oxygen weaned. Vanco dc\nd. Standing nebs. Pt\n expectorating thick yellow secretions.\n Response:\n Able to wean to 4L NC with sats >95%.\n Plan:\n Pulm toilet. Nebs. C&DB. Cont iv zosyn.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Hypertensive. False lumen perfusing L kidney. ATN improving per\n renal. HUO adequate. Bun/creat remain elevated. Pt appeared to be\n flinching this am when L arm/L flank touched-team made aware.\n Action:\n Liberalized BP parameters. Nipride/nitro gtts titrated to keep sbp\n <150. PRN ivp fentanyl ordered.\n Response:\n Able to wean nitro gtt after Ativan admin. Requires increased doses\n when Ativan wearing off. No further flinching noted.\n Plan:\n SBP goal <150. Non-surgical candidate for dissection repair. Pt to\n remain on vascular team for ?needing renal artery stent.\n" }, { "category": "Nursing", "chartdate": "2141-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676060, "text": " admit to CCU for chest/back pain. CT scan showed lg type B\n dissection.\n transferred to cvicu for management. Team decided pt not surgical\n candidate, plan to medically manage.\n intub for severe hypoxia\n head ct for ?posturing/neuro changes- head ct was neg\n rapid afib/flutter required cardioversion at change of shift\n extub\n Altered mental status (not Delirium)\n Assessment:\n Incomprehensible words. Unable to elicit startle reflex in am. Periods\n of elevated agitation, unable to calm pt or redirect. Tremors noted in\n afternoon. No gag.\n Action:\n Standing & prn Ativan. Reorientation. Non-violent restraints applied\n for treatment interference. Dophoff placed for\n nutrition/hydration/meds.\n Response:\n Pt remains confused/agitated when Ativan wears off. Spoke briefly in\n afternoon, saying\nno, stop\n when dophoff was being placed.\n Plan:\n Continue Ativan as needed. ?withdrawing. Start feeding when pump\n arrives.\n Pneumonia, other\n Assessment:\n Known RML pneumonia.\n Action:\n Pulm toilet. Oxygen weaned. Vanco dc\nd. Standing nebs. Pt\n expectorating thick yellow secretions.\n Response:\n Able to wean to 4L NC with sats >95%.\n Plan:\n Pulm toilet. Nebs. C&DB. Cont iv zosyn.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Hypertensive. False lumen perfusing L kidney. ATN improving per\n renal. HUO adequate. Bun/creat remain elevated. Pt appeared to be\n flinching this am when L arm/L flank touched-team made aware.\n Action:\n Liberalized BP parameters. Nipride/nitro gtts titrated to keep sbp\n <150. PRN ivp fentanyl ordered.\n Response:\n Able to wean nitro gtt after Ativan admin. Requires increased doses\n when Ativan wearing off. No further flinching noted.\n Plan:\n SBP goal <150. Non-surgical candidate for dissection repair. Pt to\n remain on vascular team for ?needing renal artery stent.\n" }, { "category": "Nursing", "chartdate": "2141-06-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676461, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt remains confused and delirious. Side rails up bed alarm on, soft\n wrist restraints due to pulling at iv\ns and dopoff. Psych consult.\n Haldol and ativan given for anxiety. When asked if patient drinks he\n states\nnot enough.\n Or\nI take about 3-4 beers a day, maybe.\n Speech\n is still slurred. Pupils equal/reactive. Moaning constantly, but denies\n pain.\n Action:\n Pt c/o back pain in evening, 100mcg of fentanyl given with good relief.\n Pt slept soundly for 1 hour. Then was back to climbing out of bed and\n pullint lines. Psych in to see patient. Reccomendation iv haldol if qtc\n remains normal. 5-10mg iv every 4 hours prn with standing dose of po\n ativan and im haldol. Pt hypertensive to 160\ns when very agitated but\n when haldol calms patient his sbp 110\ns. Vascular team aware.\n Response:\n Pt very restless at 4am. Co-worker at bedside for patient safety. 10mg\n iv haldol given, pt still moaning and restless, but better. Pt less\n hypertensive than earlier in evening.\n Plan:\n Safety, 1:1 sitter, haldol/ativan for agitation.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Pt has a AAA that is not a surgical candidate. Goal sbp<150. When\n patient becomes very agitated he can be hypertensive to 170\n Action:\n Labetolol drip and nitro drip overnight for bp control. Nitro remains\n at 2mck/kg/min, and labetolol titrated per order for sbp <150.\n Response:\n Pt seems to be less agitated after haldol, sbp 120\ns-130\ns labetolol\n off. Nitro continues. Clonidine patch ordered with loading doses.\n Loading dose given. Ekg done to confirm qtc which was 0.44. Np \n aware.\n Plan:\n Sbp<150, clonidine patch, wean nitro as tolerates.\n" }, { "category": "Nursing", "chartdate": "2141-06-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676579, "text": "Altered mental status, delirious at times\n Assessment:\n Behavior labile. Worsened as haldol admin decreased. Received pt\n calm. Slept in short naps this am. Cooperative w/care despite\n confusion. Oriented to self. Became combative, delirious, and attempted\n to assault staff in afternoon.\n Action:\n RN in room all shift doubling as sitter, pt 1:1. Redirecting & verbal\n calming unsuccessful. Pt delirious & disoriented- did not believe he\n was in the hospital, dose not understand his condition. Unable to\n reorient. Add\nl haldol and ivp fentanyl admin in afternoon to control\n pt\ns combative and abusive behavior. 12 lead ecg obtained to verify\n qtc. Psych involved, po Ativan dc\nd d/t continued confusion. Cont on\n tube feeds. Encouraged pt to eat/drink this afternoon.\n Response:\n Pt more cooperative in afternoon. Holding longer conversations though\n confused. Delirious in late afternoon, argumentative/combative\n requiring ivp fent again. QTC wnl. Pt became bradycardic (hr 30s)/sob\n when swallowing water, unable to take more than sips before tiring.\n Plan:\n Continue ivp haldol standing and prn (less paroxysmal effects than IM\n per psych). Reorient freq. Redirect inappropriate behavior. Maintain\n restraints for treatment interference. Maintain 1:1 for safety. Monitor\n qtc with 12 lead ecg every shift. Encourage eating/drinking when pt\n can safely do so.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Hypertension that increases with agitation. Labetalol shut off on\n previous shift. Bradycardic on tid po Lopressor.\n False lumen perfusing L kidney, ATN improving. Creat/bun decreasing but\n still elevated.?mesenteric ischemia d/t dissection, loose stool cont.\n Cdiff neg x2.\n Action:\n Nitro gtt weaned keeping sbp <150. Unable to wean off. PO Lopressor\n dose decreased and afternoon dose held d/t hr in the 40s. Clonidine\n patch and po load started on previous shift.\n Renal following. Standing iv reglan changed to prn and dose decreased\n d/t renal toxicity.\n Response:\n Continues to be hypertensive requiring nitro gtt despite po meds. Good\n HUO. Loose stools cont.\n Plan:\n Wean nitro gtt keeping sbp <150. Cont po clonidine load, pt wearing\n patch. Vascular want to re-image dissection when pt neurologically\n appropriate. ?stenting renal artery. Renal will cont to follow until\n creat improves. Third cdiff to be sent.\n" }, { "category": "Nursing", "chartdate": "2141-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675834, "text": "Pt is 62 year old male with h/o of htn, arthritis who presented to ED\n on with complaints of chest pain. Pt was riding the T to a\n ballgame today when he had a sudden urge to have a bowel movement. Pt\n went to restroom and was unable to have a bowel movement, but hen\n developed severe knife-life chest pain which radiated to back. He felt\n lightheaded, dizzy, nausea and short of breath. Pt had a CT scan with\n large type B dissection of aorta. Plan for medical management\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US no normal arterial waveforms seen in the right kidney or\n right main renal artery.\n :Intubated 2'resp.failure/P edema\n head ct for ?posturing/neuro changes- head ct was neg\n rapid afib/flutter required cardioversion x1\n Extubated\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Pt remains confused and lethargic. (see below). Pt remains NSR with\n frequent Pac\ns. continues on Nitro and Labetalol gtt\ns. + palpable PP.\n Remains on 60% high flow mask. O2 sats 97-100%. LS clear with Rhonchi\n in the bases. Audible wheezing noted at times with\n restlessness/agitation. + BS. 4 Stools overnight. Guiac +. Hct this am\n 27.8 (HCT yesterday 29.6). Pt continues on vanco and zoysn\n Action:\n Ntiro gtt tirated to keep SBP < 140\n Labetalol gtt titrated to keep SBP < 140\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Pt with periods of restlessness/aggitiation. Pt confused, thrashing in\n bed. With these periods the pt will desat, BP will increase and audible\n wheezing noted at times. Pt unable to speak. Pt making incomprehensible\n sounds, groaning. Unable to follow commands. Pt appear to be tremoring\n at times - ?? DT\ns.MAE on bed. PERRL\n Action:\n Pt given 10 mg haldol IV x 2\n 12 lead EKG done\n Pt given 1 mg Ativan IV x1\n Nitro gtt and Labetalol gtt titrated for BP control\n keep\n SBP < 140\n Pt given alb/atrovent nebs as ordered\n Response:\n Haldol was noted to have minimal effect on the patient. After Haldol\n was given the pt was rest ~ 15-30 minutes and then would have another\n episode of aggiation/restlessness. After Ativan given the patient\n appeared calm, VSS, slept in short naps, pt would wake and have\n episodes of restlessness although not as severe as easlier in the night\n (before the Ativan). VSS. SBP < 140\ns on labetalol and nitro gtt\n Plan:\n Monitor neuro status, ??DT\ns (although patient denied EHOH use when he\n was admitted to the hospital)\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley draining yellow urine with sediment. UO ~ 25-60 cc/hr. Bun and\n Creatinine 76 and 3.6\n Action:\n Monitored UO\n Monitor lytes/Bun and Creatinie\n Response:\n Pt continues to make acceptable UO. Bun and Creatinine same as\n yesterday ()\n Plan:\n Monitor UO, monitor lytes/Bun and Creatine\n" }, { "category": "Nursing", "chartdate": "2141-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675835, "text": "Pt is 62 year old male with h/o of htn, arthritis who presented to ED\n on with complaints of chest pain. Pt was riding the T to a\n ballgame today when he had a sudden urge to have a bowel movement. Pt\n went to restroom and was unable to have a bowel movement, but hen\n developed severe knife-life chest pain which radiated to back. He felt\n lightheaded, dizzy, nausea and short of breath. Pt had a CT scan with\n large type B dissection of aorta. Plan for medical management\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US no normal arterial waveforms seen in the right kidney or\n right main renal artery.\n :Intubated 2'resp.failure/P edema\n head ct for ?posturing/neuro changes- head ct was neg\n rapid afib/flutter required cardioversion x1\n Extubated\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Pt remains confused and lethargic. (see below). Pt remains NSR with\n frequent Pac\ns. continues on Nitro and Labetalol gtt\ns. + palpable PP.\n Remains on 60% high flow mask. O2 sats 97-100%. LS clear with Rhonchi\n in the bases. Audible wheezing noted at times with\n restlessness/agitation. + BS. 4 Stools overnight. Guiac +. Hct this am\n 27.8 (HCT yesterday 29.6). Pt continues on vanco and zoysn\n Action:\n Ntiro gtt tirated to keep SBP < 140\n Labetalol gtt titrated to keep SBP < 140\n Response:\n SBP < 140\ns on nitro and labetalol gtt\ns. Pt becomes hypertensive with\n periods of agitation\n Plan:\n BP control, monitor rhythm\n Altered mental status (not Delirium)\n Assessment:\n Pt with periods of restlessness/aggitiation. Pt confused, thrashing in\n bed. With these periods the pt will desat, BP will increase and audible\n wheezing noted at times. Pt unable to speak. Pt making incomprehensible\n sounds, groaning. Unable to follow commands. Pt appear to be tremoring\n at times - ?? DT\ns.MAE on bed. PERRL\n Action:\n Pt given 10 mg haldol IV x 2\n 12 lead EKG done\n Pt given 1 mg Ativan IV x1\n Nitro gtt and Labetalol gtt titrated for BP control\n keep\n SBP < 140\n Pt given alb/atrovent nebs as ordered\n Response:\n Haldol was noted to have minimal effect on the patient. After Haldol\n was given the pt was rest ~ 15-30 minutes and then would have another\n episode of aggiation/restlessness. After Ativan given the patient\n appeared calm, VSS, slept in short naps, pt would wake and have\n episodes of restlessness although not as severe as easlier in the night\n (before the Ativan). VSS. SBP < 140\ns on labetalol and nitro gtt\n Plan:\n Monitor neuro status, ??DT\ns (although patient denied EHOH use when he\n was admitted to the hospital)\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley draining yellow urine with sediment. UO ~ 25-60 cc/hr. Bun and\n Creatinine 76 and 3.6\n Action:\n Monitored UO\n Monitor lytes/Bun and Creatinie\n Response:\n Pt continues to make acceptable UO. Bun and Creatinine same as\n yesterday ()\n Plan:\n Monitor UO, monitor lytes/Bun and Creatine\n" }, { "category": "Nursing", "chartdate": "2141-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675836, "text": "Pt is 62 year old male with h/o of htn, arthritis who presented to ED\n on with complaints of chest pain. Pt was riding the T to a\n ballgame today when he had a sudden urge to have a bowel movement. Pt\n went to restroom and was unable to have a bowel movement, but hen\n developed severe knife-life chest pain which radiated to back. He felt\n lightheaded, dizzy, nausea and short of breath. Pt had a CT scan with\n large type B dissection of aorta. Plan for medical management\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US no normal arterial waveforms seen in the right kidney or\n right main renal artery.\n :Intubated 2'resp.failure/P edema\n head ct for ?posturing/neuro changes- head ct was neg\n rapid afib/flutter required cardioversion x1\n Extubated\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Pt remains confused and lethargic. (see below). Pt remains NSR with\n frequent Pac\ns. continues on Nitro and Labetalol gtt\ns. + palpable PP.\n Remains on 60% high flow mask. O2 sats 97-100%. LS clear with Rhonchi\n in the bases. Audible wheezing noted at times with\n restlessness/agitation. + BS. 4 Stools overnight. Guiac +. Hct this am\n 27.8 (HCT yesterday 29.6). Pt continues on vanco and zoysn\n Action:\n Ntiro gtt tirated to keep SBP < 140\n Labetalol gtt titrated to keep SBP < 140\n Response:\n SBP < 140\ns on nitro and labetalol gtt\ns. Pt becomes hypertensive with\n periods of agitation\n Plan:\n BP control, monitor rhythm\n Altered mental status (not Delirium)\n Assessment:\n Pt with periods of restlessness/aggitiation. Pt confused, thrashing in\n bed. With these periods the pt will desat, BP will increase and audible\n wheezing noted at times. Pt unable to speak. Pt making incomprehensible\n sounds, groaning. Unable to follow commands. Pt appear to be tremoring\n at times - ?? DT\ns.MAE on bed. PERRL\n Action:\n Pt given 10 mg haldol IV x 2\n 12 lead EKG done\n Pt given 1 mg Ativan IV x1\n Nitro gtt and Labetalol gtt titrated for BP control\n keep\n SBP < 140\n Pt given alb/atrovent nebs as ordered\n Response:\n Haldol was noted to have minimal effect on the patient. After Haldol\n was given the pt was rest ~ 15-30 minutes and then would have another\n episode of aggiation/restlessness. After Ativan given the patient\n appeared calm, VSS, slept in short naps, pt would wake and have\n episodes of restlessness although not as severe as easlier in the night\n (before the Ativan). VSS. SBP < 140\ns on labetalol and nitro gtt\n Plan:\n Monitor neuro status, ??DT\ns (although patient denied EHOH use when he\n was admitted to the hospital)\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley draining yellow urine with sediment. UO ~ 25-60 cc/hr. Bun and\n Creatinine 76 and 3.6\n Action:\n Monitored UO\n Monitor lytes/Bun and Creatinie\n Response:\n Pt continues to make acceptable UO. Bun and Creatinine same as\n yesterday ()\n Plan:\n Monitor UO, monitor lytes/Bun and Creatine\n" }, { "category": "Nursing", "chartdate": "2141-06-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676577, "text": "Altered mental status (not Delirium)\n Assessment:\n Behavior labile. Worsened as haldol admin decreased. Received pt\n calm. Slept in short naps this am. Cooperative w/care despite\n confusion. Oriented to self. Became combative, delirious, and attempted\n to assault staff in afternoon.\n Action:\n RN in room all shift doubling as sitter, pt 1:1. Redirecting & verbal\n calming unsuccessful. Pt delirious & disoriented- did not believe he\n was in the hospital, dose not understand his condition. Unable to\n reorient. Add\nl haldol and ivp fentanyl admin in afternoon to control\n pt\ns combative and abusive behavior. 12 lead ecg obtained to verify\n qtc. Psych involved, po Ativan dc\nd d/t continued confusion. Cont on\n tube feeds. Encouraged pt to eat/drink this afternoon.\n Response:\n Pt more cooperative in afternoon. Holding longer conversations though\n confused. Delirious in late afternoon, argumentative/combative\n requiring ivp fent again. QTC wnl. Pt became bradycardic (hr 30s)/sob\n when swallowing water, unable to take more than sips before tiring.\n Plan:\n Continue ivp haldol standing and prn (less paroxysmal effects than IM\n per psych). Reorient freq. Redirect inappropriate behavior. Maintain\n restraints for treatment interference. Maintain 1:1 for safety. Monitor\n qtc with 12 lead ecg every shift. Encourage eating/drinking when pt\n can safely do so.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Hypertension that increases with agitation. Labetalol shut off on\n previous shift. Bradycardic on tid po Lopressor.\n False lumen perfusing L kidney, ATN improving. Creat/bun decreasing but\n still elevated.?mesenteric ischemia d/t dissection, loose stool cont.\n Cdiff neg x2.\n Action:\n Nitro gtt weaned keeping sbp <150. Unable to wean off. PO Lopressor\n dose decreased and afternoon dose held d/t hr in the 40s. Clonidine\n patch and po load started on previous shift.\n Renal following. Standing iv reglan changed to prn and dose decreased\n d/t renal toxicity.\n Response:\n Continues to be hypertensive requiring nitro gtt despite po meds. Good\n HUO. Loose stools cont.\n Plan:\n Wean nitro gtt keeping sbp <150. Cont po clonidine load, pt wearing\n patch. Vascular want to re-image dissection when pt neurologically\n appropriate. ?stenting renal artery. Renal will cont to follow until\n creat improves. Third cdiff to be sent.\n" }, { "category": "Nursing", "chartdate": "2141-06-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676451, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt remains confused and delirious. Side rails up bed alarm on, soft\n wrist restraints due to pulling at iv\ns and dopoff. Psych consult.\n Haldol and ativan given for anxiety. When asked if patient drinks he\n states\nnot enough.\n Or\nI take about 3-4 beers a day, maybe.\n Speech\n is still slurred. Pupils equal/reactive. Moaning constantly, but denies\n pain.\n Action:\n Pt c/o back pain in evening, 100mcg of fentanyl given with good relief.\n Pt slept soundly for 1 hour. Then was back to climbing out of bed and\n pullint lines. Psych in to see patient. Reccomendation iv haldol if qtc\n remains normal. 5-10mg iv every 4 hours prn with standing dose of po\n ativan and im haldol. Pt hypertensive to 160\ns when very agitated but\n when haldol calms patient his sbp 110\ns. Vascular team aware.\n Response:\n Pt very restless at 4am. Co-worker at bedside for patient safety. 10mg\n iv haldol given, pt still maoning and restless, but better. Pt less\n hypertensive than earlier in evening.\n Plan:\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Pt has a AAA that is not a surgical candidate. Goal sbp<150. When\n patient becomes very agitated he can be hypertensive to 170\n Action:\n Labetolol drip and nitro drip overnight for bp control. Nitro remains\n at 2mck/kg/min, and labetolol titrated per order for sbp <150.\n Response:\n Pt seems to be less agitated after haldol, sbp 120\ns-130\ns labetolol\n off. Nitro continues. Clonidine patch ordered with loading doses.\n Loading dose given. Ekg done to confirm qtc which was 0.44. Np \n aware.\n Plan:\n Sbp<150, clonidine patch, wean nitro as tolerates.\n" }, { "category": "Nursing", "chartdate": "2141-06-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676571, "text": "Altered mental status (not Delirium)\n Assessment:\n Behavior labile. Worsened as haldol admin decreased. Received pt\n calm. Slept in short naps this am. Cooperative w/care despite\n confusion. Oriented to self. Became combative, delirious, and attempted\n to assault staff in afternoon.\n Action:\n RN in room all shift doubling as sitter, pt 1:1. Redirecting & verbal\n calming unsuccessful. Pt delirious & disoriented- did not believe he\n was in the hospital, dose not understand his condition. Unable to\n reorient. Add\nl haldol and ivp fentanyl admin in afternoon to control\n pt\ns combative and abusive behavior. 12 lead ecg obtained to verify\n qtc. Psych involved, po Ativan dc\nd d/t continued confusion. Cont on\n tube feeds. Encouraged pt to eat/drink this afternoon.\n Response:\n Pt more cooperative in afternoon. Holding longer conversations though\n confused. Delirious in late afternoon, argumentative/combative\n requiring ivp fent again. QTC wnl. Pt became bradycardic (hr 30s)/sob\n when swallowing water, unable to take more than sips before tiring.\n Plan:\n Continue ivp haldol standing and prn (less paroxysmal effects than IM\n per psych). Reorient freq. Redirect inappropriate behavior. Maintain\n restraints for treatment interference. Maintain 1:1 for safety. Monitor\n qtc with 12 lead ecg every shift. Encourage eating/drinking when pt\n can safely do so.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Hypertension that increases with agitation. Labetalol shut off on\n previous shift. Bradycardic on tid po Lopressor.\n False lumen perfusing L kidney, ATN improving. Creat/bun decreasing but\n still elevated.?mesenteric ischemia d/t dissection, loose stool cont.\n Cdiff neg x2.\n Action:\n Nitro gtt weaned keeping sbp <150. Unable to wean off. PO Lopressor\n dose decreased and afternoon dose held d/t hr in the 40s.\n Renal following. Standing iv reglan changed to prn and dose decreased\n d/t renal toxicity.\n Response:\n Continues to be hypertensive requiring nitro gtt despite po meds. Good\n HUO. Loose stools cont.\n Plan:\n Vascular want to re-image dissection when pt neurologically\n appropriate. ?stenting renal artery. Renal will cont to follow until\n creat improves. Third cdiff to be sent.\n" }, { "category": "Nursing", "chartdate": "2141-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676626, "text": "Altered mental status, delirious at times\n Assessment:\n Pt oriented x 1 (self) throughout shift. Disoriented, wanting to get\n out of bed, making inappropriate statements. Pt unaware that he\ns in\n hospital. Sitter at bedside.\n Action:\n Required high doses of Haldol and Fentanyl to try and keep pt calm.\n Soft wrist restraints in place to avoid disruption in treatment.\n Reoriented patient frequently, emotional support provided.\n Response:\n Pt had periods of sleep with periods of restlessness and attempts to\n get out of bed. No improvement in mental status noted.\n Plan:\n Continue to monitor mental status closely. Administer Haldol and\n Fentanyl as ordered. Measure QTc q shift. If QTc > 0.5, Haldol may\n need to be changed to seraquil and Ativan.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Hypertension that increases with agitation. NTG gtt continued to keep\n SBP 120-150.\n False lumen perfusing L kidney, ATN improving. Creat/bun decreasing but\n still elevated.?mesenteric ischemia d/t dissection, loose stool cont.\n Cdiff neg x2.\n Action:\n Nitro gtt weaned keeping sbp <150. Unable to wean off. Clonidine patch\n and po load started on previous shift.\n Renal following.\n Response:\n Continues to be hypertensive requiring nitro gtt despite po meds. Good\n HUO. Loose stools cont.\n Plan:\n Wean nitro gtt keeping sbp <150. Cont po clonidine load, pt wearing\n patch. Vascular want to re-image dissection when pt neurologically\n appropriate. ?stenting renal artery. Renal will cont to follow until\n creat improves. Third cdiff to be sent.\n" }, { "category": "Nursing", "chartdate": "2141-06-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676386, "text": "Altered mental status (not Delirium)\n Assessment:\n More coherent than yesterday. Able to hold conversations but still\n confused. Oriented to self. Pulled out dophoff today, pulling at all\n other lines/tubes. Pt and pt\ns family deny alcohol/drug abuse. Pt has\n significant family history of alcoholism.\n Action:\n Psych consult. IVP Ativan changed to PO and dose decreased to help\n with confusion. Ativan will stay on board for ?withdrawing. Standing\n IM haldol and prn ordered for agitation. Requires freq redirecting.\n Does listen but not for long.\n Response:\n Pt more agitated as shift progressed. Slept in intervals in am.\n Swearing, kicking and combative late in afternoon. 1x ivp haldol admin\n per PA.\n Plan:\n Reorient. Haldol/Ativan standing and prn. ?increase haldol prn\n overnight as agitation worsens severely at night. Psych staying\n involved.\n Pneumonia, other\n Assessment:\n Known RML pneumonia. Improving on iv zosyn. No adventitious breath\n sounds.\n Action:\n Weaned O2. Pulm toilet.\n Response:\n Currently tolerating RA w/sats >96%. Does cough when asked but does\n not always spit out sputum.\n Plan:\n Continue to encourage pulm toilet.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Hypertensive.\n Action:\n Nitro and labetalol gtts cont. Increased PO antihypertensives.\n Response:\n Cont to be hypertensive when awake and agitated needing restarting of\n labetalol gtts.\n Plan:\n ?staring po labetalol. Increase PO antihypertensives. Wean gtts as\n tol keeping sbp <150.\n" }, { "category": "Physician ", "chartdate": "2141-06-25 00:00:00.000", "description": "Generic Note", "row_id": 675665, "text": "TITLE:\n CVICU\n HPI:\n HD8\n 62M w/ type B aortic dissection/medical management.\n EF Cr 1.4 WT HgbA1c\n PMH: HTN, arthritis\n : ASA\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US R>L perfusion. nl size.\n Labetolol/Nicardipine(IV),Norvasc\n :Intubated 2'resp.failure/P edema\n : Extubated\n Chief complaint:\n PMHx:\n Current medications:\n Albuterol Inhaler 3. Artificial Tears Preserv. Free 4. Aspirin 5.\n Beclomethasone Dipropionate\n 6. Bisacodyl 7. Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral\n Rinse 9. Fentanyl Citrate\n 10. FoLIC Acid 11. Heparin 12. HydrALAzine 13. Insulin 14. Ipratropium\n Bromide MDI 15. Labetalol\n 16. Metoprolol Tartrate 17. Midazolam 18. Multiple Vitamins Liq. 19.\n Nitroglycerin 20. Ondansetron\n 21. Oxymetazoline 22. Pantoprazole 23. Piperacillin-Tazobactam Na 24.\n Sodium Chloride Nasal 25. Sodium Chloride 0.9% Flush\n 26. Sodium Chloride 0.9% Flush 27. Sodium Chloride 0.9% Flush 28.\n Thiamine 29. Vancomycin\n 24 Hour Events:\n :Renal US done. ATN improving. Extubated\n Post operative day:\n HD8\n 62M w/ type B aortic dissection/medical management.\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 11:38 AM\n Infusions:\n Midazolam (Versed) - 0.5 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Hydralazine - 08:26 AM\n Pantoprazole (Protonix) - 11:31 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Flowsheet Data as of 05:19 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 37.7\nC (99.9\n HR: 84 (64 - 87) bpm\n BP: 114/56(73) {84/44(56) - 152/70(93)} mmHg\n RR: 12 (11 - 22) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.5 kg (admission): 90 kg\n Height: 74 Inch\n CVP: 19 (7 - 26) mmHg\n Total In:\n 3,579 mL\n 2,006 mL\n PO:\n Tube feeding:\n 950 mL\n 682 mL\n IV Fluid:\n 2,254 mL\n 949 mL\n Blood products:\n 375 mL\n 375 mL\n Total out:\n 1,655 mL\n 1,185 mL\n Urine:\n 1,655 mL\n 1,185 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,924 mL\n 821 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 800 (800 - 800) mL\n Vt (Spontaneous): 1,137 (944 - 1,137) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 14\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: Agitated\n PIP: 13 cmH2O\n Plateau: 23 cmH2O\n Compliance: 39.3 cmH2O/mL\n SPO2: 95%\n ABG: 7.32/43/94./22/-3\n Ve: 8.3 L/min\n PaO2 / FiO2: 235\n Physical Examination\n Pt. Extubated, moaning. NAD\n CVS: RRR\n Lungs: CTA\n Abd: benign\n Extr: moves all extr. Spont. Not to command. LUE PIV site improving.\n Cord palpable.\n Labs / Radiology\n 243K/uL\n L\n 192\n 3.6 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n mg/dL\n 110 mEq/L\n 142 mEq/L\n 29.6 %\n 12.4 K/uL\n [image002.jpg]\n 06:09 PM\n 09:30 PM\n 09:47 PM\n 01:50 AM\n 01:59 AM\n 06:00 AM\n 07:54 AM\n 10:40 AM\n 12:00 PM\n 01:06 PM\n WBC\n 9.4\n Hct\n 26.3\n 25.6\n 27.7\n 30.3\n Plt\n 229\n Creatinine\n 3.9\n Troponin T\n 0.02\n TCO2\n 23\n 24\n 23\n Glucose\n 107\n 153\n 149\n 128\n 192\n Other labs: PT / PTT / INR:13.4/34.0/1.2, CK / CK-MB / Troponin\n T:1384/11/0.02, ALT / AST:33/49, Alk-Phos / T bili:132/0.4, Amylase /\n Lipase:62/37, Lactic Acid:0.8 mmol/L, Albumin:2.6 g/dL, LDH:732 IU/L,\n Ca:8.6 mg/dL, Mg:3.2 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, ANXIETY, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA), HYPOXEMIA, RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE,\n ARF), PNEUMONIA, OTHER\n Assessment and Plan: HD7\n 62M w/ type B aortic dissection/medical management. eintubated5/13 2'\n resp. failure. Hemodynamically stable. postop complicated with acute\n renal failure\n Neurologic: Neuro checks Q: 4 hr, Cont Thiamine/Folate. Fentanyl prn\n pain. Haldol for agitation\n Cardiovascular: Aspirin, Beta-blocker, Statins, Maintain BP<140 as\n discussed with Vasc. team. Hydralazine/NTG/Labetalol prn\n Pulmonary: Extunated this AM. Cont Nebs\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, ARF:Renal US left kidney neg.. Renal following->ATN\n showing improvement\n Hematology: Stable anemia. Plan to Tx for HCT <28 per Vasc team\n Endocrine: RISS\n Infectious Disease: Check cultures, Mini Bal prelim=no growth. CXs PND.\n Cont Vanco/Zosyn\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging:\n Fluids:\n Consults: Vascular surgery, CT surgery, Nephrology\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:05 PM\n Multi Lumen - 09:47 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\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" }, { "category": "Nursing", "chartdate": "2141-06-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675685, "text": "Altered mental status (not Delirium)\n Assessment:\n Patient writhing in bed, with incomprehensible sounds (moaning and\n whaling). When spoken to and his name is called he will appropriately\n answer\nwhat?\n but says really nothing else. Legs and arms flailing\n and moving about all over the bed.\n Action:\n 1mg total of haldol given IM, with little effect, his favorite music\n was brought in by family and played which seems to calm him slightly.\n Emotional support provided.\n Response:\n Patient still agitated, patient to clear of all meds and to\n not\nload up\n Plan:\n Continue to monitor and maintain safety, bed alarm activated and in the\n low locked position\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Renal enzymes trending downward. HUO more than adequate with\n amber/dark yellow urine with sediment\n Action:\n Seen by renal team several times today and they also spoke with the\n family\n Response:\n No dialysis needed at this point, renal enzymes improving\n Plan:\n Continue to monitor output, enzymes and continue with renal evals\n" }, { "category": "Nursing", "chartdate": "2141-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675809, "text": "Pt is 62 year old male with h/o of htn, arthritis who presented to ED\n on with complaints of chest pain. Pt was riding the T to a\n ballgame today when he had a sudden urge to have a bowel movement. Pt\n went to restroom and was unable to have a bowel movement, but hen\n developed severe knife-life chest pain which radiated to back. He felt\n lightheaded, dizzy, nausea and short of breath. Pt had a CT scan with\n large type B dissection of aorta. Plan for medical management\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US no normal arterial waveforms seen in the right kidney or\n right main renal artery.\n :Intubated 2'resp.failure/P edema\n head ct for ?posturing/neuro changes- head ct was neg\n rapid afib/flutter required cardioversion x1\n Extubated\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Pt with periods of restlessness/aggitiation. Pt confused, thrashing in\n bed. With these periods the pt will desat, BP will increase and audible\n wheezing noted at times. Pt unable to speak. Pt making incomprehensible\n sounds, groaning. Unable to follow commands. Pt appear to be tremoring\n at times - ?? DT\ns.MAE on bed. PERRL\n Action:\n Pt given 10 mg haldol IV x 2\n Pt given 1 mg Ativan IV x1\n Nitro gtt and Labetalol gtt titrated for BP control\n keep\n SBP < 140\n Pt given alb/atrovent nebs as ordered\n Response:\n Haldol was noted to have minimal effect on the patient. After Haldol\n was given the pt was rest ~ 15-30 minutes and then would have another\n episode of aggiation/restlessness. After Ativan given the patient\n appeared calm, VSS, slept in short naps, pt would wake and have\n episodes of restlessness although not as severe as easlier in the night\n (before the Ativan). VSS. SBP < 140\ns on labetalol and nitro gtt\n Plan:\n Monitor neuro status, ??DT\ns (although patient denied EHOH use when he\n was admitted to the hospital)\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley draining yellow urine with sediment. UO ~ 25-60 cc/hr. Bun and\n Creatinine\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675810, "text": "Pt is 62 year old male with h/o of htn, arthritis who presented to ED\n on with complaints of chest pain. Pt was riding the T to a\n ballgame today when he had a sudden urge to have a bowel movement. Pt\n went to restroom and was unable to have a bowel movement, but hen\n developed severe knife-life chest pain which radiated to back. He felt\n lightheaded, dizzy, nausea and short of breath. Pt had a CT scan with\n large type B dissection of aorta. Plan for medical management\n - CTA torso: large type B aortic dissection, true lumen in upper abd\n near completely occluded, false lumen supplies celiac, SMA, L renal, R\n kidney asymmetrically hypoperfused\n -card neg x 3\n -renal US no normal arterial waveforms seen in the right kidney or\n right main renal artery.\n :Intubated 2'resp.failure/P edema\n head ct for ?posturing/neuro changes- head ct was neg\n rapid afib/flutter required cardioversion x1\n Extubated\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Pt with periods of restlessness/aggitiation. Pt confused, thrashing in\n bed. With these periods the pt will desat, BP will increase and audible\n wheezing noted at times. Pt unable to speak. Pt making incomprehensible\n sounds, groaning. Unable to follow commands. Pt appear to be tremoring\n at times - ?? DT\ns.MAE on bed. PERRL\n Action:\n Pt given 10 mg haldol IV x 2\n Pt given 1 mg Ativan IV x1\n Nitro gtt and Labetalol gtt titrated for BP control\n keep\n SBP < 140\n Pt given alb/atrovent nebs as ordered\n Response:\n Haldol was noted to have minimal effect on the patient. After Haldol\n was given the pt was rest ~ 15-30 minutes and then would have another\n episode of aggiation/restlessness. After Ativan given the patient\n appeared calm, VSS, slept in short naps, pt would wake and have\n episodes of restlessness although not as severe as easlier in the night\n (before the Ativan). VSS. SBP < 140\ns on labetalol and nitro gtt\n Plan:\n Monitor neuro status, ??DT\ns (although patient denied EHOH use when he\n was admitted to the hospital)\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley draining yellow urine with sediment. UO ~ 25-60 cc/hr. Bun and\n Creatinine 76 and 3.6\n Action:\n Response:\n Plan:\n" }, { "category": "Social Work", "chartdate": "2141-06-27 00:00:00.000", "description": "Social Work Progress Note", "row_id": 676366, "text": "SW continuing to meet with pt\ns son for support. Son indicates that he\n is heartened by pt\ns progress, despite its slowness. Pt\ns son has been\n visiting daily and he is observed today speaking very tenderly towards\n pt. every time pt. shows signs of agitation. Pt\ns son indicates that\n he is supported by his best friend who is surgical RN and who helps\n him understand in layman\ns terms what is happening to pt..\n SW has obtained SSDI information requested by pt\ns son. Pt\ns son\n indicates that one of pt\ns doctors pt. will be able to return\n to work in . Pt\ns son indicates that he is not convinced\n this will happen and accepts SSDI paperwork.\n SW will continue to follow. Pt\ns son has contact information.\n" }, { "category": "Nutrition", "chartdate": "2141-06-29 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 676716, "text": "Subjective\n confused, disoriented, co-worker in as 1:1 sitter\n Objective\n Height\n Admit weight\n Daily weight\n 188 cm\n 90 kg\n 91.6 kg ( 04:00 AM)\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n 86.2 kg\n Pertinent medications: RISS, Glargine 10 units at lunch, Nitroglycerin\n drip, Fentanyl bolus, ABX, MVI, Famotidine\n Labs:\n Value\n Date\n Glucose\n 80 mg/dL\n 03:03 AM\n Glucose Finger Stick\n 132\n 12:00 PM\n BUN\n 59 mg/dL\n 03:03 AM\n Creatinine\n 3.1 mg/dL\n 03:03 AM\n Sodium\n 148 mEq/L\n 03:03 AM\n Potassium\n 3.5 mEq/L\n 03:03 AM\n Chloride\n 114 mEq/L\n 03:03 AM\n TCO2\n 23 mEq/L\n 03:03 AM\n PO2 (arterial)\n 82. mm Hg\n 12:58 PM\n PCO2 (arterial)\n 28 mm Hg\n 12:58 PM\n pH (arterial)\n 7.42 units\n 12:58 PM\n pH (urine)\n 6.5 units\n 02:38 AM\n CO2 (Calc) arterial\n 19 mEq/L\n 12:58 PM\n Albumin\n 3.2 g/dL\n 03:03 AM\n Calcium non-ionized\n 8.7 mg/dL\n 03:03 AM\n Phosphorus\n 3.8 mg/dL\n 03:03 AM\n Ionized Calcium\n 1.19 mmol/L\n 06:20 PM\n Magnesium\n 2.3 mg/dL\n 03:03 AM\n ALT\n 50 IU/L\n 03:03 AM\n Alkaline Phosphate\n 216 IU/L\n 03:03 AM\n AST\n 39 IU/L\n 03:03 AM\n Amylase\n 94 IU/L\n 03:03 AM\n Total Bilirubin\n 0.6 mg/dL\n 03:03 AM\n WBC\n 16.2 K/uL\n 03:03 AM\n Hgb\n 9.3 g/dL\n 03:03 AM\n Hematocrit\n 27.4 %\n 03:03 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: Novasource Renal @ 45ml/hr\n GI: soft, (+) bowel sounds; loose stool\n Assessment of Nutritional Status\n Specifics:\n Patient with type B aortic dissection, not surgical candidate; remains\n confused and delirious. PPFT placed for nutrition support. Tube\n feeding running at goal to provides calories and 71g protein,\n which is within calorie needs, but underfeeds protein (0.8g/kg).\n Consider changing to higher protein, non renal tube feeding. (+) loose\n stool\n receiving banana flakes TID. Noted C-difficile negative x2.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: continue current\n Tube feeding recommendations: Consider changing to Nutren Pulmonary @\n 65ml/hr = 2340 calories and 106g protein (1.2g/kg)\n No residual checks with PPFT, monitor abdominal exam\n Check chemistry 10 panel\n Will follow\n page if questions *\n PM\n" }, { "category": "Nursing", "chartdate": "2141-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676086, "text": " admit to CCU for chest/back pain. CT scan showed lg type B\n dissection.\n transferred to cvicu for management. Team decided pt not surgical\n candidate, plan to medically manage.\n intub for severe hypoxia\n head ct for ?posturing/neuro changes- head ct was neg\n rapid afib/flutter required cardioversion at change of shift\n extub\n Altered mental status (not Delirium)\n Assessment:\n Incomprehensible words. Unable to elicit startle reflex in am. Periods\n of elevated agitation, unable to calm pt or redirect. Tremors noted in\n afternoon. No gag.\n Action:\n Standing & prn Ativan. Reorientation. Non-violent restraints applied\n for treatment interference. Dophoff placed for\n nutrition/hydration/meds.\n Response:\n Pt remains confused/agitated when Ativan wears off. Spoke briefly in\n afternoon, saying\nno, stop\n when dophoff was being placed.\n Plan:\n Continue Ativan as needed. ?withdrawing. Start tube feeding when pump\n arrives.\n Pneumonia, other\n Assessment:\n Known RML pneumonia.\n Action:\n Pulm toilet. Oxygen weaned. Vanco dc\nd. Standing nebs. Pt\n expectorating thick yellow secretions.\n Response:\n Able to wean to 4L NC with sats >95%.\n Plan:\n Pulm toilet. Nebs. C&DB. Cont iv zosyn.\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Hypertensive. False lumen perfusing L kidney. ATN improving per\n renal. HUO adequate. Bun/creat remain elevated. Pt appeared to be\n flinching this am when L arm/L flank touched-team made aware.\n Action:\n Liberalized BP parameters. Nipride/nitro gtts titrated to keep sbp\n <150. PRN ivp fentanyl ordered.\n Response:\n Able to wean nitro gtt after Ativan admin. Requires increased doses\n when Ativan wearing off. No further flinching noted.\n Plan:\n SBP goal <150. Start po antihypertensives. Non-surgical candidate for\n dissection repair. Pt to remain on vascular team for ?needing renal\n artery stent.\n" }, { "category": "Echo", "chartdate": "2141-06-21 00:00:00.000", "description": "Report", "row_id": 98347, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Type B dissection\nHeight: (in) 74\nWeight (lb): 185\nBSA (m2): 2.10 m2\nBP (mm Hg): 94/81\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 10:55\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic sinus. Moderately dilated ascending aorta.\nMildly dilated aortic arch. Moderately dilated descending aorta Moderately\ndilated abdominal aorta Descending aorta intimal flap/aortic dissection.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No valvular AS. The\nincreased transaortic velocity is related to high cardiac output. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Trivial\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nBorderline PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Regional left ventricular wall motion is\nnormal. Left ventricular systolic function is hyperdynamic (EF>75%). Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmoderately dilated at the sinus level. The ascending aorta is moderately\ndilated. The aortic arch is mildly dilated. The descending thoracic aorta is\nmoderately dilated. The abdominal aorta is moderately dilated. A mobile\ndensity is seen in the descending aorta consistent with an intimal flap/aortic\ndissection. The aortic valve leaflets (3) are mildly thickened. There is no\nvalvular aortic stenosis. The increased transaortic velocity is likely related\nto high cardiac output. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Trivial\nmitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is borderline pulmonary artery systolic hypertension. There\nis no pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-06-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078023, "text": " 9:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with aortic dissection, now w/fever, increased WBC\n REASON FOR THIS EXAMINATION:\n please evaluate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:13 A.M., :\n\n HISTORY: Aortic dissection, now with fever and an increased white count.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs, but\n read in conjunction with CT of the chest on :\n\n New consolidation at both lung bases, and new small bilateral pleural\n effusions are concerning for aspiration. Heart size top normal. No\n pneumothorax or evidence of central adenopathy. Dr. was paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-06-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078575, "text": " 7:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess opacities\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with type B aortic dissection, has diffuse bilateral lung\n opacities.\n REASON FOR THIS EXAMINATION:\n assess opacities\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 12:10 PM\n PFI - ETT 7.8 cm above the carina. Nasogastric tube proximal stomach. Left\n subclavian upper SVC. Widespread bilateral opacity decreased, likely improved\n edema. No other change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n REASON FOR EXAM: 62-year-old man with type B dissection, has diffuse\n bilateral lung opacities.\n\n Since earlier the same day, widespread bilateral opacities significantly\n improved, likely due to improved pulmonary edema. More focal left\n retrocardiac opacity, likely atelectasis, is unchanged. Note that the right\n costophrenic angle was excluded. ETT tip is 7.8 cm above the carina at the\n level of clavicular heads. Nasogastric tube ends in the proximal stomach and\n left subclavian catheter ends in the upper SVC. There is no other change.\n\n" }, { "category": "Radiology", "chartdate": "2141-06-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1077725, "text": " 12:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for thoracic pathology\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with chest pain radiating to back\n REASON FOR THIS EXAMINATION:\n eval for thoracic pathology\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest pain radiating to back.\n\n COMPARISON: No prior studies available for comparison.\n\n FINDINGS: Single bedside AP upright chest radiograph shows the lungs to be\n clear. Cardiac silhouette is unremarkable. The mediastinal contours are\n notable for unfolding of the aorta and prominence of the ascending aorta.\n Visualized osseous structures and soft tissue structures are unremarkable.\n\n IMPRESSION: Prominence of the ascending aorta. Recommend comparison with\n cross-sectional imaging for evaluation of an aneurysm.\n\n" }, { "category": "Radiology", "chartdate": "2141-06-18 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1077726, "text": " 12:52 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: eval for dissection\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with chest and epigastric pain radiating to back\n REASON FOR THIS EXAMINATION:\n eval for dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc SUN 1:37 PM\n Large type B dissection of the aorta. True lumen in the upper abdomen is\n nearly completely occluded and false lumen supplies the celiac, SMA, and left\n renal artery. Right kidney is assymetrically hypoperfused indicating likely\n vascular compromise. D/ at ~1:35PM\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest and epigastric pain radiating to the back.\n\n COMPARISON: No prior studies available for comparison.\n\n TECHNIQUE: Axial CT images were acquired through the chest in the absence of\n intravenous contrast. Subsequently, following administration of 100 cc of\n intravenous Optiray, axial CT images were acquired through the chest, abdomen,\n and pelvis. Multiplanar reformatted images were also reviewed.\n\n CT CHEST WITH AND WITHOUT CONTRAST: The lungs are notable for multiple\n bilateral subpleural blebs, most notably involving both apices. The lungs are\n otherwise clear. There is no pleural or pericardial effusion. There is no\n mediastinal or axillary lymphadenopathy.\n\n Post-contrast images show dilation of the ascending aorta (3:52) where it\n measures ~5.2 cm. In the aortic arch, distal to the origin of the left\n subclavian artery is a large intimal flap indicates aortic dissection. This\n flap is ruptured in the descending thoracic aorta at the level of the left\n pulmonary artery, (3:36) indicating communication of the true and false lumens\n at that site. Caudal to that area, in the lower thorax and upper abdomen, the\n aorta is primarily occupied by the false lumen with the true lumen appearing\n primary collapsed. Pulmonary arterial vasculature opacifies normally, without\n evidence of pulmonary embolism.\n\n CT ABDOMEN WITH CONTRAST: The abdominal aorta supplies the origin of the\n celiac, SMA, and left renal arteries from the large false lumen. The true\n lumen again appears primarily collapsed, though an intimal flap is visualized\n in the infrarenal aorta, possibly representing a second dissection flap. There\n appear to be two right renal arteries with the uppermost artery patent and\n supplying the upper pole. The large, more caudal branch appears to originate\n from the collapsed true lumen. Aneurysmal dilatation of the infrarenal aorta\n measures 4.3cm (5:45). The collapsed true lumen extends into the right common\n iliac artery, though mixed atherosclerotic plaque at this level may also\n explain this appearance.\n (Over)\n\n 12:52 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: eval for dissection\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The stomach, proximal small bowel, spleen, adrenal glands, gallbladder are\n unremarkable. The liver is unremarkable with focal fat noted adjacent to the\n falciform ligament. The left kidney contains multiple round hypodensities\n (5:35) in the interpolar region consistent with renal cysts. The right kidney\n is notable for asymmetric hypodensity, indicating compromise of the perfusion\n to the lower pole and mid- pole. The upper pole perfusion appears relatively\n spared and contains an exophytic round hypodensity (5:26) measuring ~1.7 x 1.5\n cm, again consistent with a cyst. There is no retroperitoneal or mesenteric\n lymphadenopathy. The pancreas is unremarkable. There is no free fluid or gas\n in the abdomen.\n\n CT PELVIS WITH CONTRAST: Aneurysm of the right common iliac artery measures\n 2.7 cm (5:61). The urinary bladder, distal ureters, seminal vesicles are\n unremarkable. Note is made of dystrophic calcifications within the prostate.\n The rectum and colon are unremarkable. There is no pelvic or inguinal\n lymphadenopathy. Limited visualization of the scrotum is notable for fluid\n bilaterally, consistent with likely hydrocele.\n\n OSSEOUS FINDINGS: There are no suspicious sclerotic or lytic lesions.\n\n IMPRESSION:\n 1. Type B aortic dissection with evidence of end-organ vascular compromise of\n the right kidney.\n 2. Aneurysmal dilatation of the ascending aorta, infrarenal abdominal aorta,\n and right common iliac artery as above.\n 3. Fluid in the scrotum bilaterally, consistent with possible hydrocele.\n Recommend comparison to clinical examination.\n\n Findings were discussed over the telephone by with Dr. from\n the emergency room at approximately 1:40 p.m. on .\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2141-06-22 00:00:00.000", "description": "P CAROTID SERIES COMPLETE PORT", "row_id": 1078375, "text": " 7:59 AM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: evaluate flow ? of dissection into carotids from dissection\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with type dissection\n REASON FOR THIS EXAMINATION:\n evaluate flow ? of dissection into carotids from dissection\n ______________________________________________________________________________\n FINAL REPORT\n\n Study: Carotid Series Complete\n\n Reason: 62 year old man with aortic dissection. ? of carotid dissection.\n\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\n the right there is mild heterogeneous plaque in the ICA . On the left there\n is mild heterogeneous plaque in the ICA .\n\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 103/35, 69/36, 76/25, cm/sec. CCA peak systolic\n velocity is 138 cm/sec. ECA peak systolic velocity is 131 cm/sec. The ICA/CCA\n ratio is 76. These findings are consistent with <40% stenosis.\n\n On the left systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 83/16, 100/18, 79/27, cm/sec. CCA peak systolic\n velocity is 152/36 cm/sec. ECA peak systolic velocity is 151 cm/sec. The\n ICA/CCA ratio is .66. 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 stenosis <40%.\n Left ICA stenosis <40\n No evidence of carotid dissection.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2141-06-22 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1078417, "text": " 10:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed or ischemia\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with type b dissection\n REASON FOR THIS EXAMINATION:\n r/o bleed or ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:56 PM\n PFI:\n 1. No acute intracranial process.\n 2. Circumferential opacification of the left maxillary sinus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old man with type B dissection, query bleed or ischemia.\n\n COMPARISON: None available.\n\n CT HEAD WITHOUT INTRAVENOUS CONTRAST:\n\n FINDINGS: There is no intracranial hemorrhage, infarct in major vascular\n territory, mass, mass effect or edema. Ventricles, sulci and cisterns are of\n normal size and configuration for age. Soft tissues appear normal. There is\n no fracture. Mastoid air cells are clear. There is circumferential sinus\n mucosal thickening in the left maxillary sinus.\n\n IMPRESSION:\n 1. No acute intracranial process.\n 2. Left maxillary sinus mucosal disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-06-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1078410, "text": " 10:16 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: evaluate for L subclavian line position\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with type B dissection\n REASON FOR THIS EXAMINATION:\n evaluate for L subclavian line position\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with type B aortic dissection\n repair.\n\n Portable AP chest radiograph was compared to the prior study obtained on , at 5:06 p.m.\n\n The ET tube tip is 7.5 cm above the carina at the level of the clavicular\n heads. The cardiomediastinal silhouette is stable but there is worsening of\n the left basal consolidation consistent with newly developed left lower lobe\n atelectasis. There is interval improvement of bilateral perihilar opacities\n consistent with slow resolution of aspiration versus pulmonary edema. NG tube\n tip is in the proximal stomach. The minimal apical pneumothorax on the right\n is again demonstrated and appears to be slightly smaller than on the prior\n study.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-06-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078546, "text": " 12:03 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: type B disection w/new hypoxia-r/o effusion/infiltrate\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with as above\n REASON FOR THIS EXAMINATION:\n type B disection w/new hypoxia-r/o effusion/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of a patient after surgery of type B\n dissection with new hypoxia.\n\n Portable AP chest radiograph was compared to obtained at 10:37\n a.m.\n\n The ET tube tip is about 8 cm above the carina. The NG tube tip is in the\n proximal stomach and should be advanced. The mediastinum is central, most\n likely due to improvement of left retrocardiac atelectasis but there is\n interval development of perihilar opacities with significantly worsened left\n perihilar opacity that might be consistent with asymmetric pulmonary edema or\n aspiration. Infectious process giving its rapid development is unlikely.\n Evaluation of the patient after diuresis is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2141-06-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078799, "text": " 2:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for Pneumonia\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with sputum growing GNRs and prior CXRs showing infiltrate\n REASON FOR THIS EXAMINATION:\n Eval for Pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON \n\n COMPARISON: .\n\n INDICATION: Pneumonia.\n\n FINDINGS: Indwelling devices are in standard position except for nasogastric\n tube, which has a side port in close proximity to the GE junction, and could\n be advanced slightly for standard positioning. Heart size is normal.\n Previously identified asymmetrically distributed parenchymal opacities have\n improved on the left, but are now slightly worse in the right perihilar\n region. This could reflect a developing site of infection.\n\n" }, { "category": "Radiology", "chartdate": "2141-06-24 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 1078775, "text": " 10:02 AM\n RENAL U.S. PORT; DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: Eval for Left kidney flow, please obtain doppler/duplex stud\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with type B dissection extending to renal arteries\n REASON FOR THIS EXAMINATION:\n Eval for Left kidney flow, please obtain doppler/duplex study as well\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SAT 12:45 PM\n 1. Left kidney 13.8 cm without hydronephrosis, nephrolithiasis or renal mass.\n 2. Main renal artery demonstrates prompt upstroke and antegrade diastolic\n flow.\n 3. Normal arterial flow demonstrated to the upper mid and lower portion of\n the left kidney. Left main renal venous flow normal.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old man with type B dissection extending to renal\n arteries, evaluate for left kidney flow.\n\n COMPARISON: .\n\n PORTABLE LEFT RENAL ULTRASOUND:\n\n Grayscale and color Doppler son images were obtained that demonstrate\n the left kidney to measure 13.8 cm pole to pole without hydronephrosis,\n nephrolithiasis or renal mass. Main renal arterial flow to the left kidney\n demonstrates prompt upstroke and antegrade diastolic flow with resistive index\n of 0.72 - 0.74. Normal arterial flow is demonstrated to the upper, mid and\n lower polar regions with resitive indices of 0.64, 0.69 and 0.72. Main left\n renal venous flow is normal at the hilum. Power Doppler demonstrates\n homogenous flow inside the left kidney. The bladder is visualized with a Foley\n within it.\n\n IMPRESSION:\n 1. No left renal hydronephrosis, nephrolithiasis or renal mass.\n\n 2. Normal arterial and venous flow to the left kidney.\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2141-06-24 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 1078776, "text": ", L. VSURG CSRU 10:02 AM\n RENAL U.S. PORT; DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: Eval for Left kidney flow, please obtain doppler/duplex stud\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with type B dissection extending to renal arteries\n REASON FOR THIS EXAMINATION:\n Eval for Left kidney flow, please obtain doppler/duplex study as well\n ______________________________________________________________________________\n PFI REPORT\n 1. Left kidney 13.8 cm without hydronephrosis, nephrolithiasis or renal mass.\n 2. Main renal artery demonstrates prompt upstroke and antegrade diastolic\n flow.\n 3. Normal arterial flow demonstrated to the upper mid and lower portion of\n the left kidney. Left main renal venous flow normal.\n\n" }, { "category": "Radiology", "chartdate": "2141-06-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078576, "text": ", L. VSURG CSRU 7:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess opacities\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with type B aortic dissection, has diffuse bilateral lung\n opacities.\n REASON FOR THIS EXAMINATION:\n assess opacities\n ______________________________________________________________________________\n PFI REPORT\n PFI - ETT 7.8 cm above the carina. Nasogastric tube proximal stomach. Left\n subclavian upper SVC. Widespread bilateral opacity decreased, likely improved\n edema. No other change.\n\n" }, { "category": "Radiology", "chartdate": "2141-06-20 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 1078139, "text": " 7:52 PM\n RENAL U.S. PORT Clip # \n Reason: duplex to assess flow\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with type B dissection. PT on IV antihypertensives. Must be\n done portably.\n REASON FOR THIS EXAMINATION:\n duplex to assess flow\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy TUE 11:30 PM\n PFI: No normal arterial waveforms identified in the right kidney or right\n main renal artery. Right main renal vein demonstrates normal waveforms.\n Right kidney appears normal in echotexture, with no hydronephrosis or stones.\n Left kidney is also normal, with no hydronephrosis or stones. Normal arterial\n waveforms are seen in left main renal artery, as well as in the left renal\n parenchyma, although full evaluation is limited due to inability of patient to\n comply with breath-holding instructions. Findings are concordant with those\n seen on CT dated , where there is decreased perfusion of the right\n kidney.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old male with type B aortic dissection and decreased\n perfusion of the right kidney seen on CT dated . Assess for renal\n vascular flow.\n\n COMPARISON: CT dated .\n\n FINDINGS: Exam is technically limited due to patient's inability to comply\n with breath-holding instructions. Within this limitation, the right kidney\n appears normal in echotexture and size, measuring 11.6 cm. There are several\n small subcentimeter cystic lesions identified, as seen on prior CT. A larger\n 1.2-cm exophytic cyst is seen in the upper pole of the right kidney. The left\n kidney is also normal in size and appearance, with no cysts or renal mass\n lesions. There is no hydronephrosis bilaterally. There are no echogenic\n renal calculi.\n\n Doppler evaluation of the kidneys demonstrates normal arterial and venous\n waveforms in the left main renal artery. There were no normal waveforms\n identified in the right main renal artery or in the right parenchymal\n arteries. Normal waveforms, however, were seen in the right renal vein.\n\n IMPRESSION:\n\n 1. No normal arterial waveforms seen in the right kidney or right main renal\n artery. This is concordant with findings of decreased end organ perfusion\n secondary to dissection seen on CT dated .\n\n 2. Normal arterial waveforms in the left main renal artery and kidney,\n although full evaluation was technically limited as above.\n\n 3. No hydronephrosis or renal stones identified.\n (Over)\n\n 7:52 PM\n RENAL U.S. PORT Clip # \n Reason: duplex to assess flow\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2141-06-20 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 1078140, "text": ", L. VSURG CSRU 7:52 PM\n RENAL U.S. PORT Clip # \n Reason: duplex to assess flow\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with type B dissection. PT on IV antihypertensives. Must be\n done portably.\n REASON FOR THIS EXAMINATION:\n duplex to assess flow\n ______________________________________________________________________________\n PFI REPORT\n PFI: No normal arterial waveforms identified in the right kidney or right\n main renal artery. Right main renal vein demonstrates normal waveforms.\n Right kidney appears normal in echotexture, with no hydronephrosis or stones.\n Left kidney is also normal, with no hydronephrosis or stones. Normal arterial\n waveforms are seen in left main renal artery, as well as in the left renal\n parenchyma, although full evaluation is limited due to inability of patient to\n comply with breath-holding instructions. Findings are concordant with those\n seen on CT dated , where there is decreased perfusion of the right\n kidney.\n\n" }, { "category": "Radiology", "chartdate": "2141-06-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078183, "text": " 7:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate and effusion\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with type b dissection\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate and effusion\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DDBc WED 8:59 AM\n New bilateral airspace disease, most suggestive of pneumonia. Consider\n aspiration.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH.\n\n INDICATION: 62-year-old man with history of type B dissection, for\n evaluation.\n\n TECHNIQUE: Portable AP radiograph was obtained.\n\n COMPARISON: .\n\n REPORT: Compared to prior radiographs, there has been dramatic interval\n development of bilateral airspace consolidation suggestive of pneumonia. Given\n the underlying history and rapid progression, alternative etiologies such as\n CHF, Aspirtaion, ARDS and pulmonary hemorrhage are considered, but thought\n less likely. Clinical correlation is recommended. Ongoing contour deformity\n with unfolding of the dorsal aorta is seen. Visualized osseous structures are\n unchanged.\n\n CONCLUSION:\n\n New bilateral mid zone mainly peripheral patchy airspace change, most\n suggestive of pneumonia. Atypical pulmonary edema, ARDS or pulmonary\n hemorrhage while considered would be less likely. Given the rapid onset,\n aspiration must be considered.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-06-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078184, "text": ", L. VSURG CSRU 7:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate and effusion\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with type b dissection\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate and effusion\n ______________________________________________________________________________\n PFI REPORT\n New bilateral airspace disease, most suggestive of pneumonia. Consider\n aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2141-06-22 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1078418, "text": ", L. VSURG CSRU 10:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed or ischemia\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with type b dissection\n REASON FOR THIS EXAMINATION:\n r/o bleed or ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. No acute intracranial process.\n 2. Circumferential opacification of the left maxillary sinus.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-06-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078292, "text": " 4:15 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p intubation\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with type b dissection\n REASON FOR THIS EXAMINATION:\n s/p intubation\n ______________________________________________________________________________\n WET READ: GWp WED 8:11 PM\n ETT tube 7cm from carina, OGT tip below diaphragm, multifocal opacities in\n lungs pna or ARDS more likely than pulm hemorr, atypical edema GWlms\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of the patient after repair of type B\n dissection.\n\n Portable AP chest radiograph was compared to prior study obtained on the same\n day earlier at 07:48 a.m.\n\n The ET tube tip is 7 cm above the carina. The NG tube tip in proximal stomach\n and might be advanced. There is slight interval increase in cardiac size that\n might be due to accumulation of pericardial effusion and should be closely\n followed with echocardiography. The mediastinal contours are unchanged. There\n is slight interval improvement in the right perihilar opacity with the left\n perihilar opacity remaining unchanged. Bilateral pleural effusions are\n present. As was previously mentioned rapid onset of parenchymal abnormalities\n in this particular clinical setup might be consistent with aspiration or\n asymmetric pulmonary edema with infection process being less likely giving the\n rapidity of the process. Apical pneumothorax is seen on the right, small and\n not clearly seen on the prior study from the same day obtained earlier.\n\n ADDENDUM: Findings were discussed with over the phone by Dr.\n approximately at 9:30 a.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2141-06-27 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1079233, "text": " 12:04 PM\n PORTABLE ABDOMEN Clip # \n Reason: for DhT replacement\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with tYPE b DISSECTION\n REASON FOR THIS EXAMINATION:\n for DhT replacement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN\n\n COMPARISON: .\n\n HISTORY: Dobbhoff tube placed.\n\n FINDINGS: A Dobbhoff tube is identified coiled within the stomach. Small\n bowel loops are normal in caliber.\n\n IMPRESSION: Dobbhoff tube coiling within the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-06-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1079059, "text": " 1:00 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: DHT repositioned\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with type B dissection\n REASON FOR THIS EXAMINATION:\n DHT repositioned\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Repositioning of Dobbhoff tube.\n\n CHEST, ONE VIEW: Dobbhoff tube has been repositioned, and tip now extends\n below the diaphragm into the stomach, and out of view. Of note, there does\n appear to have been interval worsening of ill-defined perihilar airspace\n opacities, particularly in the left upper lung, which may suggest worsening\n volume status.\n\n IMPRESSION:\n\n 1. Dobbhoff tube now extends below the diaphragm and out of view.\n\n 2. Likely worsening of volume status.\n\n" }, { "category": "Radiology", "chartdate": "2141-06-26 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1079085, "text": " 3:33 PM\n PORTABLE ABDOMEN Clip # \n Reason: Is DHT postpyloris?\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with Type B dissection\n REASON FOR THIS EXAMINATION:\n Is DHT postpyloris?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN, ONE VIEW.\n\n COMPARISON: None.\n\n HISTORY: Dubhoff position.\n\n FINDINGS: A Dobbhoff tube is identified terminating in the second portion of\n the duodenum. Small bowel loops are non-dilated. The osseous structures are\n grossly unremarkable.\n\n IMPRESSION: Dobbhoff tube in post-pyloric position.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-06-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1079053, "text": " 12:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? post pyloric DHT\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with Type B dissection\n REASON FOR THIS EXAMINATION:\n ? post pyloric DHT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Type B dissection. Please evaluate post-pyloric tube position.\n\n CHEST, ONE VIEW: Dobhoff tube enters the stomach, but the tube is coiled, and\n the tip is positioned pointing retrograde within the distal esophagus.\n Cardiomediastinal contours are unchanged. Ill-defined perihilar opacities and\n mild interstitial prominence is less apparent, suggesting improved\n interstitial pulmonary edema.\n\n IMPRESSION: Malpositioned Dobbhoff coiled in the stomach, with tip pointing\n retrograde in the distal esophagus.\n\n Findings were discussed by telephone with at 13:30 on\n .\n\n" }, { "category": "ECG", "chartdate": "2141-06-29 00:00:00.000", "description": "Report", "row_id": 280016, "text": "Sinus bradycardia. Left ventricular hypertrophy. Left atrial abnormality.\nCompared to the previous tracing of there is no change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2141-06-29 00:00:00.000", "description": "Report", "row_id": 280017, "text": "Normal sinus rhythm. Voltage criteria for left ventricular hypertrophy.\nCompared to the previous tracing of no diagnostic interval change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2141-06-28 00:00:00.000", "description": "Report", "row_id": 280018, "text": "Sinus bradycardia. Voltage criteria for left ventricular hypertrophy.\nCompared to the previous tracing of no diagnostic interval change.\n\n" }, { "category": "ECG", "chartdate": "2141-06-28 00:00:00.000", "description": "Report", "row_id": 280019, "text": "Technically difficult study\nSinus rhythm\nSupraventricular extrasystoles\nLeft ventricular hypertrophy\nSince previous tracing of , the heart rate has increased\n\n" }, { "category": "ECG", "chartdate": "2141-06-25 00:00:00.000", "description": "Report", "row_id": 280020, "text": "Normal sinus rhythm. Axis is 0 degrees. Early transition. Left ventricular\nhypertrophy. Compared to the previous tracing of no diagnostic\ninterval change.\n\n" }, { "category": "ECG", "chartdate": "2141-06-23 00:00:00.000", "description": "Report", "row_id": 280021, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing QRS voltage\nis slightly less.\n\n" }, { "category": "ECG", "chartdate": "2141-06-20 00:00:00.000", "description": "Report", "row_id": 280022, "text": "Sinus rhythm. Prominent voltage. Compared to the previous tracing of \nno diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2141-06-19 00:00:00.000", "description": "Report", "row_id": 280023, "text": "Sinus rhythm. Prominent precordial lead QRS voltage suggests left ventricular\nhypertrophy. Low lateral lead T wave amplitude is non-specific and unstable\nbaseline in leads V4-V6 makes assessment difficult. Since the previous tracing\nof probably no significant change.\n\n" }, { "category": "ECG", "chartdate": "2141-06-18 00:00:00.000", "description": "Report", "row_id": 280243, "text": "Sinus bradycardia with atrial premature beat. Prominent precordial lead\nQRS voltage suggests left ventricular hypertrophy. No previous tracing\navailable for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2132-01-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991697, "text": " 2:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: S/P L PICC PLACEMENT, FAILED R IJ, QUESTION NG TUBE PLACEMENT\n Admitting Diagnosis: END STAGE RENAL DISEASE;FAILED AV GRAFT;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with GIB, hypotension, assess for PICC placement and no PTX\n after failed R IJ - could not advice the wire\n REASON FOR THIS EXAMINATION:\n s/p L picc placement, failed R IJ\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57-year-old man with failed right IJ placement, assess for PICC\n placement.\n\n COMPARISON: at 11:00 a.m.\n\n PORTABLE SUPINE CHEST, ONE VIEW: Tip of right PICC line overlies the right\n lateral hemithorax, and may be in a lateral thoracic vein. No evidence of\n pneumothorax. Mild perihilar prominence and vascular redistribution is\n consistent with mild fluid overload. Cardiomediastinal silhouette is stable.\n\n Tip of endotracheal tube is 6 cm from the carina. Tip of NG tube is in the\n stomach.\n\n IMPRESSION:\n 1. Tip of right PICC line overlies the right lateral hemithorax. No evidence\n of pneumothorax.\n\n 2. Mild pulmonary edema.\n\n Findings discussed by telephone with the venous access team.\n\n" }, { "category": "Radiology", "chartdate": "2132-01-26 00:00:00.000", "description": "R FOOT AP,LAT & OBL RIGHT", "row_id": 991107, "text": " 12:39 PM\n HEEL (AXIAL & LATERAL) RIGHT; FOOT AP,LAT & OBL RIGHT Clip # \n Reason: pls eval for evidence of osteomyelitis\n Admitting Diagnosis: END STAGE RENAL DISEASE;FAILED AV GRAFT;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with MRSA endocarditis and right heel ulcer (?septic)\n REASON FOR THIS EXAMINATION:\n pls eval for evidence of osteomyelitis\n ______________________________________________________________________________\n FINAL REPORT\n HEEL.\n\n HISTORY: Endocarditis and right heel ulcer, question septic.\n\n FINDINGS: Diffuse osteopenia limits this evaluation. There are vascular\n calcifications noted. Please note that the technologist noted that they were\n unable to get better views of the foot due to difficulty in positioning the\n patient in the ICU. There are diffuse degenerative changes with osteophytes\n and joint space narrowing. No region of osteomyelitis is identified, but bone\n scan would be more sensitive if clinically indicated.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-01-26 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 991111, "text": " 1:09 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Pls assess for evidence of septic embolization\n Admitting Diagnosis: END STAGE RENAL DISEASE;FAILED AV GRAFT;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with left-sided MRSA endocarditis and worsening mental status,\n peripheral septic emboli\n REASON FOR THIS EXAMINATION:\n Pls assess for evidence of septic embolization\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO ON \n\n CLINICAL HISTORY: MRSA endocarditis. Septic emboli. Question additional\n source.\n\n TECHNIQUE: Helical acquisition of CT images was performed from the thoracic\n inlet through the ischial tuberosities following administration of both oral\n and 130 cc of intravenous nonionic contrast. Coronal and sagittal reformats\n also provided.\n\n Comparison made to prior study of , and .\n\n FINDINGS:\n\n CHEST: There is an incompletely occlusive thrombus seen within the right IJ\n and subclavian vein which may extend slightly into the SVC. Left IJ appears\n patent. No mediastinal lymphadenopathy. Heart size is within normal limits.\n There are dense mitral annular calcifications and coronary artery\n calcifications. Aortic root calcification is also noted. A 5-mm pulmonary\n nodule noted at the right lung apex (2, 9). Scarring or linear atelectatic\n changes at the bases. No discrete focal airspace disease.\n\n ABDOMEN: The liver is overall normal in appearance. Gallbladder is present.\n There is no biliary dilatation. Within the spleen, there are multiple\n hypodense areas, some of which are peripheral and wedge-shaped, and suggestive\n of small-to-moderate size infarcts. Splenic and portal vein appear patent.\n Pancreas is atrophic but no focal lesions are seen. There is no\n peripancreatic inflammatory abnormality. Adrenal glands remain normal. The\n kidneys are multicystic and atrophic, in keeping with given history of end-\n stage renal disease.\n\n PELVIS: Bowel loops are unremarkable. No dilated loops. No free air or free\n fluid. There is a small anterior abdominal wall hernia in the deep pelvis\n containing a loop of small bowel, which is not obstructed. There is no free\n air or free fluid in the pelvis. Bladder is not well visualized and likely\n completely decompressed. There is a normal-sized prostate.\n\n There is normal-caliber vascular system, however there are diffuse\n calcifications seen throughout all vessels.\n (Over)\n\n 1:09 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Pls assess for evidence of septic embolization\n Admitting Diagnosis: END STAGE RENAL DISEASE;FAILED AV GRAFT;SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Review of bone windows again demonstrates extensive demineralization and\n degenerative changes in keeping with the patient's history of\n renal osteodystrophy. There are stable erosive and destructive changes of the\n thoracolumbar spine, most notably at L2-3. These are not significantly\n changed when compared to prior CTs of . Additionally, there is\n thickening of the periarticular soft tissues around the large joints, most\n notably in the right shoulder, sternoclavicular joints and right hip but\n present at most of the large joints. This may be related to renal\n osteodystrophy, and is only slightly more prominent than on prior study of . No discrete focal fluid collections are seen. There is a lucency within\n the posterior aspect of the sternum to the right of midline, which may\n represent a small brown tumor.\n\n A 3 x 2 cm fluid collection is seen within the left flank subcutaneous\n tissues, likely resorbing hematoma.\n\n IMPRESSION:\n 1. Incompletely occlusive right IJ thrombus.\n\n 2. No discrete source for reported septic emboli. Multifocal splenic\n hypodensities, likely infarcts.\n\n 3. Stable degenerative changes of the osseous skeleton, in keeping with renal\n osteodystrophy. Periarticular soft tissue thickening, also likely related to\n the same process, only slightly more prominent than on prior study.\n\n The findings were discussed with Dr. by Dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2132-01-26 00:00:00.000", "description": "CT HEAD W/ & W/O CONTRAST", "row_id": 991110, "text": " 1:09 PM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: Pls assess for evidence of septic emboli\n Admitting Diagnosis: END STAGE RENAL DISEASE;FAILED AV GRAFT;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with MRSA endocarditis and worsening mental status\n REASON FOR THIS EXAMINATION:\n Pls assess for evidence of septic emboli\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD.\n\n CLINICAL INFORMATION: Patient with MRSA endocarditis and worsening mental\n status.\n\n TECHNIQUE: Axial images of the head were obtained from skull base to vertex\n with and without intravenous contrast. Comparison was made with the previous\n CT examination of .\n\n FINDINGS: There is mild prominence of ventricles and sulci indicating brain\n atrophy. There is no evidence of midline shift, mass effect, or hydrocephalus\n identified. Following contrast administration, there is no evidence of\n abnormal parenchymal, vascular, or meningeal enhancement identified.\n\n As previously, extensive vascular and soft tissue calcifications are\n identified.\n\n IMPRESSION: No enhancing brain lesions are identified. No evidence of\n hemorrhage or mass effect.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-01-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991045, "text": " 9:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna, CHF\n Admitting Diagnosis: END STAGE RENAL DISEASE;FAILED AV GRAFT;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with MRSA endocarditis\n REASON FOR THIS EXAMINATION:\n eval for pna, CHF\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW CHEST ON \n\n Comparison made to prior study of .\n\n There has been interval removal of a right-sided dialysis catheter. the right\n lateral lung base is off the film. Surgical clips are seen in the superior\n mediastinum. Hazy opacity in the apices, right greater than left, likely\n pleural parenchymal scarring.\n\n IMPRESSION: Limited film. No discrete airspace consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2132-01-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991500, "text": " 11:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: spiking fevers on daptomycin\n Admitting Diagnosis: END STAGE RENAL DISEASE;FAILED AV GRAFT;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with bacteremia, endocarditis\n REASON FOR THIS EXAMINATION:\n spiking fevers on daptomycin\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 12:22 P.M. \n\n HISTORY: Bacteremia and endocarditis.\n\n IMPRESSION: AP chest compared to :\n\n Interstitial abnormality at the lung bases is probably edema, new since\n . Heart size though normal is slightly larger today. There is\n less mediastinal fullness, projecting to the right of the trachea than it was\n on the previous study. No pleural effusion and no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-01-27 00:00:00.000", "description": "GI BLEEDING STUDY", "row_id": 991202, "text": "GI BLEEDING STUDY Clip # \n Reason: MRSA, BRBPR, ENDOCARDITIS, BACTEREMIA, ESRD ON HD\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 14.9 mCi Tc-m RBC ();\n HISTORY: Acute onset rectal bleeding\n\n INTERPRETATION: Following intravenous injection of autologous red blood cells\n labeled with Tc-m, blood flow and dynamic images of the abdomen for minutes\n were obtained. A left lateral view of the pelvis was also obtained.\n\n Blood flow images show normal vasculure flow.\n\n Dynamic blood pool images show GI bleeding in the region of the distal sigmoid\n colon/rectum as early as 3 minutes.\n\n IMPRESSION:\n\n Positive active rectosigmoid GI bleed.\n\n D/w with Dr. .\n\n Suggested Follow-up: Can consider angio evaluation based on clinical stability.\n\n\n , M.D.\n , M.D. Approved: WED 4:02 PM\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": "Radiology", "chartdate": "2132-01-29 00:00:00.000", "description": "ART EXT (REST ONLY)", "row_id": 991534, "text": " 2:59 PM\n ART EXT (REST ONLY) Clip # \n Reason: RT HEEL ULCER\n Admitting Diagnosis: END STAGE RENAL DISEASE;FAILED AV GRAFT;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with known PVD, ESRD, here with heel ulcer in setting of MRSA\n endocarditis\n REASON FOR THIS EXAMINATION:\n Pls eval for evidence of arterial vascular disease\n ______________________________________________________________________________\n FINAL REPORT\n ARTERIAL ULTRASOUND\n\n INDICATION: 57-year-old man with known peripheral vascular disease and heel\n ulcer.\n\n FINDINGS: RIGHT LEG: There is triphasic flow pattern on the femoral and\n popliteal arteries and monophasic flow pattern on the dorsalis pedis artery.\n The vessels at the thigh, calf, and ankle are non-compressible. The pulse\n volume recording demonstrates diminished amplitude at the ankle and metatarsal\n level. The ankle brachial index was not calculated due to non-compressible\n vessels.\n\n LEFT LEG: There is triphasic flow pattern on the femoral, popliteal, and\n dorsalis pedis arteries. The pulse volume recording demonstrates diminished\n amplitude at the ankle and metatarsal level. The segmental limb pressures are\n unremarkable at all levels. The ankle brachial index at rest 1.02.\n\n The patient was not exercised.\n\n IMPRESSION: Right tibial arterial disease at rest.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2132-01-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991644, "text": " 10:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for tube placement\n Admitting Diagnosis: END STAGE RENAL DISEASE;FAILED AV GRAFT;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with GIB, respiratory distress\n REASON FOR THIS EXAMINATION:\n evaluate for tube placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess NG tube placement, patient with respiratory distress\n and GI bleed.\n\n Comparison is made with prior study, .\n\n NG tube tip is out of view below the diaphragm. Cardiomediastinal contours\n are unchanged with prominence of the azygos vein. Cardiac size is top normal.\n Bibasilar atelectases are greater in the left side. There is no pneumothorax\n or pleural effusion. ET tube is in standard position. No overt CHF.\n\n jr\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2132-01-28 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 991362, "text": " 5:34 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: please do CTA of vessles to evaluate for any mycotic aneurys\n Admitting Diagnosis: END STAGE RENAL DISEASE;FAILED AV GRAFT;SEPSIS\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with MRSA endocarditits, bacteremia, with delirium. Head CT\n earlier w/o evidence of emboli.\n REASON FOR THIS EXAMINATION:\n please do CTA of vessles to evaluate for any mycotic aneurysms\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KYg MON 8:55 PM\n No hemorrhage, shift, mass effect or hydrocephalus. Note is made of extensive\n soft tissue calcification and cystic changes throughout the osseous structure\n for which correlation with history of metabolic/systemic disease is\n recommended.\n\n CTA: Patent tributaries of the circle of . no evidence of aneurysm.\n Awaiting reconstructions for final read.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MRSA endocarditis, bacteremia now with delirium, head CT without\n evidence of emboli; CTA to evaluate for any mycotic aneurysms.\n\n COMPARISON: CT of the head with and without contrast dated .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n contrast material. Subsequently rapid axial imaging was performed from the\n aortic arch through the brain during infusion of 80 cc of Omnipaque\n intravenous contrast material. Images were processed on a separate\n workstation with display of the curved reformats, volume-rendered images, and\n maximum intensity projection images.\n\n FINDINGS:\n HEAD CT: There is no evidence of hemorrhage, edema, masses, mass effect or\n abnormal focal lesions.\n There is mild prominence of ventricles and sulci indicating diffuse\n parenchymal volume loss, which is inappropriate for the age but is\n unchanged since . There is altered density of the bones related to the\n renal disease and there are soft tissue, vascular and globe calcifications,\n unchanged.\n\n HEAD AND NECK CTA: The imaged portion of the carotid and vertebral arteries\n and the major branches are patent with no evidence of stenosis. The circle of\n and its major tributaries are patent with no evidence of stenoses or\n aneurysms.\n\n IMPRESSION: No evidence of aneurysms in the major intracranial\n arteries. However, CTA is not the ideal study for the detection of mycotic\n aneurysms; if clinical suspicion is high consider MR with and without contrast\n to detect any parenchymal abnormalities and conventional angiogram is the\n (Over)\n\n 5:34 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: please do CTA of vessles to evaluate for any mycotic aneurys\n Admitting Diagnosis: END STAGE RENAL DISEASE;FAILED AV GRAFT;SEPSIS\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ideal study to detect mycotic aneurysms.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-01-28 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 991363, "text": " 5:35 PM\n CT PELVIS W/CONTRAST Clip # \n Reason: evaluate for prior hardware and ? infectious changes around\n Admitting Diagnosis: END STAGE RENAL DISEASE;FAILED AV GRAFT;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with bacteremia, endocarditis, and L hip pain\n REASON FOR THIS EXAMINATION:\n evaluate for prior hardware and ? infectious changes around the hardware\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT PELVIS, \n\n INDICATION: A 57-year-old male with bacteremia and left hip pain, evaluate\n for hardware infection.\n\n TECHNIQUE: Axial non-contrast images were obtained through the pelvis.\n Sagittal and coronal images were reformatted. No prior CT examination exists\n for comparison.\n\n FINDINGS:\n\n There is a total left hip prosthesis. There is significant beam hardening\n artifact, which limits evaluation of the hip prosthesis. No definitive\n lucency is present at the proximal or distal aspect of the hardware. There is\n a small left hip joint effusion and a moderate right hip joint effusion. The\n prosthesis appears in place and no fracture or dislocation is seen. Extensive\n degenerative changes of residual left acetabulum are present with marked\n subchondral cyst formation. There is severe osteoarthritic degenerative\n change of the right hip with subchondral cyst formation, joint space narrowing\n and osteophyte formation. There is a geographic focus of sclerotic bone in\n the anterosuperior aspect of the right femoral head which most likely\n represents a focus of avascular necrosis of bone. Again, a moderate right hip\n joint effusion is present.\n\n Extensive vascular calcifications are present. Additionally, there is\n calcification along the tensor fascia lata bilaterally. Enthesopathy at the\n anteroinferior and anterior superior iliac spine is present. There are\n extensive degenerative changes of the lower lumbar spine. There are short\n congenitally short pedicles. Extensive hypertrophic changes of the facets of\n the visualized lower lumbar spine are present with associated central canal\n stenosis. Sclerotic degenerative change with subchondral cyst formation is\n noted at both sacroiliac joints. There is degenerative change with\n subchondral cyst formation and sclerosis at the pubic symphysis as well.\n\n Soft tissue windows demonstrate a 3.5 x 2.2 x 4.3 cm soft tissue mass in the\n left lateral subcutaneous fat at the level of the inferior iliac spine.\n Neoplasm cannot be excluded. Additionally, there are multiple enlarged pelvic\n sidewall lymph nodes, which are nonspecific in appearance. The largest of\n these is noted along the left pelvic sidewall and measures 1.2 cm in short\n axis. Extensive vascular calcification is again seen in multiple mesenteric\n vessels as well as the distal aorta and iliac vessels as well as branches of\n (Over)\n\n 5:35 PM\n CT PELVIS W/CONTRAST Clip # \n Reason: evaluate for prior hardware and ? infectious changes around\n Admitting Diagnosis: END STAGE RENAL DISEASE;FAILED AV GRAFT;SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the iliac vessels. There is a right femoral dual-lumen catheter. There is\n residual contrast within the colon. No free fluid is seen in the pelvis.\n\n IMPRESSION:\n 1. Total left hip prosthesis with significant beam hardening artifact, which\n limits evaluation. No evidence of hardware failure, fracture, or dislocation\n is seen of the left hip.\n 2. Severe osteoarthritis of the right hip. Focus of devascularized bone\n representing avascular necrosis of the anterosuperior aspect of the right\n femoral head.\n 3. Bilateral hip joint effusions, right greater than left.\n 4. Soft tissue mass measuring up to 4.3 cm in the left lateral subcutaneous\n fat. Neoplasm cannot be excluded.\n 5. Multiple enlarged pelvic sidewall lymph nodes for which additional\n followup is recommended.\n 6. Extensive small vessel atherosclerosis.\n 7. Extensive degenerative changes of the lumbosacral spine, sacroiliac\n joints, and pubic symphysis.\n\n" }, { "category": "Echo", "chartdate": "2132-01-28 00:00:00.000", "description": "Report", "row_id": 68624, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nBP (mm Hg): 107/43\nHR (bpm): 107\nStatus: Inpatient\nDate/Time: at 17:52\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No mass/thrombus in the LAA. Good (>20 cm/s) LAA ejection\nvelocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or\ncolor Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Complex (>4mm) atheroma in the aortic arch. Simple atheroma in\ndescending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve. No AS. No AR.\n\nMITRAL VALVE: Small vegetation on mitral valve. No mitral valve abscess.\nModerate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). 0.2\nmg of IV glycopyrrolate was given as an antisialogogue prior to TEE probe\ninsertion. No TEE related complications.\n\nConclusions:\nNo mass/thrombus is seen in the left atrium or left atrial appendage. No\natrial septal defect is seen by 2D or color Doppler. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. There are complex (>4mm) atheroma in the aortic\narch. There are simple atheroma in the descending thoracic aorta. The aortic\nvalve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No\naortic regurgitation is seen. There is a small, mobile, echodense 0.3 cm\nvegetation on the anterior leaflet of the mitral valve. No mitral valve\nabscess is seen. Moderate (2+) mitral regurgitation is seen. There is no\npericardial effusion.\n\nIMPRESSION: Mitral valve vegetation consistent with endocarditis and moderate\nmitral regurgitation. There is no echocardiographic evidence of paravalvular\nabscess. Preserved biventricular function without other significant valvular\nabnormality.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-01-27 00:00:00.000", "description": "Report", "row_id": 1667826, "text": "Addendum:\n\nAt 1715 pt became hypotensive 72/48. HCT remains unchanged @ 27 post transfusion. Increased tachy 110-115. Temp 100.2. 500cc NS bolus IV, 1 unit PRBC transfusing. Levophed gtt begun in blue port of HD line (after drawing out instilled haparin) at 0.08mcg/kg/min. Peripheral draw blood culture sent. ABG sent: 7.42/36/102. Current BP on 0.07mcg levo is 110/48 (71). Weaning as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2132-01-28 00:00:00.000", "description": "Report", "row_id": 1667827, "text": "MICU 7 RN REPORT 1900-0700\n\nEVENTS: PRBC'S 2UNITS.\n\nNEURO: Pt is alert and oriented x1 delirious knows his name only. Slept most of night. Follows commands inconsistently. Moves all four limbs on the bed but limbs are rigid and contracted.\n\nCV: HR 90-110 ST w/ occ to freq ectopics. SBP 110-120. Received the pt on levophed 0.06mic/kg/min. Weaning cont and @ 0000 levophed GTT turned off but sbp dropped to 80's in 15 min so levophed restarted in 0.08 mics/kg/min, currently running @ 0.02 mic/kg/min. Rt radial A line sharp. Blood culture done. Am labs pending.\n\nACCESS: PIV x2, Fem HD cath. Levophed running in blue port of HD cath.\n\nRESP: LS clear. Sats 100% on room air.\n\nGI/GU: NPO.Abd soft. BS x4. No bleeding per rectum in this shift.\nAnuric.\n\nID: T max 100.8 Abx daptomycin on HD protocol.\n\nSKIN: Impaired. Coccyx stage 2 ulcer dressing allevyn dressing intact.\nNecrotic area in the tip of penis. Necrotic area in both heels and elbows. Lt thumb dressing intact. Vascular team following the pt.\n\nSOCIAL: Full code. No call from family in this shift.\n\nPLAN: HD today.\n CT head Xray hip in AM\n Check Hct Q 4-6 hrs.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-01-28 00:00:00.000", "description": "Report", "row_id": 1667828, "text": "ADDENDUM:\n\n @ 0700 LEVOPHED D/C SBP IN 120-130 AND HD CATHETER FLUSHED W/ 1.6ML HEPARIN.\n" }, { "category": "Nursing/other", "chartdate": "2132-01-26 00:00:00.000", "description": "Report", "row_id": 1667822, "text": "MICU 7 RN REPORT 1900-0700\n\n 57 YO Male tx from 7 w/ hypotension and HD line sepsis. Received 500cc NS in the floor upon arrival to ICU SBP in 95-105. Blood cultures done. lactate 1.8.\n\nNEURO: Pt is alert and oriented x1. He knows his name. He thinks he is in . Inspite of repeated reorientation he is not yet sure about the place and person. All joints contracted including the metacarpals. Moves the lt arm easily. Received percocet 1 tab @ 2130 for back pain. pt was unable to score pain. Follows commands inconsistently.\n\nCV: HR 95-110 w/ occ to freq PVC's. SBP 95-110 received 500ml NS bolus @ 0100 for SBP 83 w/ good response. Second set of blood cultures done this AM. Vanco on hold d/t high level.\n\nACCESS: PIV x2. Rt fem HD line.\n\nGI/GU: Abd soft. BS x4. BM X1. NPO except meds. Swallow pills without any difficulty. Anuric. Not voided in this shift. HD on mon/wed/fri.\n\nID: T max 99.6. Abx gentamycin as HD protocol. On contact precaution for MRSA.\n\nSKIN: Impaired. Necrotic area in tip of penis, both heels and elbows. Coccyx w/ stage 1-2 ulcer Allevyn dressing done. Pt is been followed by vascular team visited this night also.\n\nSOCIAL: Full code. No family contact in this shift.\n\nPLAN: Follow up blood cultures and antibiotics.\n Wound care.\n Freq reorientation to place person and date.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-01-26 00:00:00.000", "description": "Report", "row_id": 1667823, "text": "57 y.o. male presented to Hosp with altered mental status x12hrs and generalized weakness x24hrs . Pt was fevbrile in ED, BC grew MRSA. Tunneled HD line was removed in OR; tip and 2 sets of BC grew MRSA. TEE showed 3 vegetations on mitral valve. BC have continued to come back positve for MRSA as recently as in spite of tx with multiple antibiotics. Pt. bounced back and forth between ICU and floor at OSH, was transferred to per family request.\n\nFull Code\nContact Precautions\nAccess: R #20, L #18, temp. HD cath R groin.\nAllergies: Levaquin, Tetracycline, Carbamazipine\n\nPMH: CAD, HTN, PVD s/p L fem bypass, ESRD s/p 2 failed transplants, on HD since ' (M-W-F), depression, chronic back pain T11-12 wedge compression, restless leg syndrome, peripheral neuropathy, secondary hyperparathyroidism, psoriatic arthritis, hx Parkinson White, hx fibrocystoma L axilla s/p removal and XRT ', L hip replacement, R AT atherectomy and PTA ', R PT PTA '.\n\nNeuro: Alert, oriented x1(self) and delerious. Follows commands inconsistently. Contractures of bilateral hands and wrists. Able to move extremites to command. Head CT. Percocet 5mg PO for pain control.\n\nResp: 2 L NC, lung sounds clear all fields. SAT 96-100%.\n\nCV: NSR rate 80's. Frequent PVC's. BP 80's-100's/50-70's. 3 vegetations on Mitral valve.\n\nGI: NPO advanced to clears. Swallows pills without problems. Abdomen soft distended, +BS. Senna and Docusate added as no BM. 900cc Barricat for abd/pelvis CT.\n\nGU: Anuric. HD today plan for 3hrs, will attempt to remove fluid if BP tolerates.\n\nSkin: Coccyx with stage 2 decub, bilat elbows with breakdown, L thumb with necrotic spot, necrotic tip of penis, R heel stage 3-4 decub with necrosis, foul odor. R foot xrays negative for osteo. Wound swab culture from OSH grew psudamonas, wound re-cultured today.\n\nID: Vanco D/C'd, Gentamycin and Daptomycin IV. Afebrile.\n\nPlan: ID, Renal, Vascular following. To remain in MICU overnight. HD this evening. Monitor BP. Manage pain with repositioning and Percocet.\n" }, { "category": "Nursing/other", "chartdate": "2132-01-27 00:00:00.000", "description": "Report", "row_id": 1667824, "text": "MICU 7 RN REPORT 1900-0700\n\nNEURO: Pt is alert and confused oriented x1. Received oxycodone 5mg @ 0100 w/ effect. MAE but has contractures in all joints.\n\nCV: HR 95-120 ST w/ occ to freq ectopics. Received 500 ml NS bolus for tachycardia w/ little effect. Lt radial A line placed sharp and SBP 95-140. ACCESS: PIV x2 and rt fem HD line. HD finished @ and removed 2lit ultrafiltrate.\n\nGI/GU: Abd soft, BS x4. BM x1 received all bowel regimen. NPO except meds. Anuric no urine in this shift.\n\nID: T max 100.5 Abx Daptomycin on HD protocol. Contact precaution for MRSA.\n\nSKIN: Impaired refer carevue dressing daily.\n\nSOCIAL: Full code. No call from family.\n\nPLAN: Wound care\n Follow up blood cultures and Abx.\n X ray hip in AM.\n" }, { "category": "Nursing/other", "chartdate": "2132-01-27 00:00:00.000", "description": "Report", "row_id": 1667825, "text": "MICU-7 Nursing Note 7A-7P:\n\nNeuro: Remains oriented to self only, delerious. Follows commands inconsistently, has difficulty hearing/understanding. Moves all extremeties. Contractures and stiffness of limbs. Chronic back pain, percocet as needed for comfort.\n\nCV: NSR/ST. Noted to be more tachy this AM, rate 105-120. During bath @ 0800 noted to be passing bright red blood from rectum along with small amounts hard formed stool. MD called to bedside to assess. Patient continued to bleed, passed large formed stool. Blood soaked 3 blue pads. Transfused 2 units PRBC. Taken down to Red Tag study, positive for bleed low in rectum. Transfused DDAVP and 1 unit FFP when returned to unit.\n\nResp: Lung sounds clear, O2 2L NC. SAT 97-100%.\n\nGI: Positive red tag. 2 units PRBC, DDAVP, 1 unit FFP given. Tap water enema given, then colonoscopy done at bedside. Vessel seen near anus bleeding, surgury came and placed suture at site, packing. Bleeding appears to have stopped.\n\nGU: Anuric. No HD today.\n\nSkin: R heel, L heel, penis, L thumb, coccyx with breakdown. Vascular following, podiatry following-recommend debreidment of R heel at some point.\n\nID: Daptomycin, Gentamycin IV. MRSA bacteremia. Tmax=99.7.\n\nPlan: to remain in MICU. Monitor HCT, BP, signs of re-bleeding.\n" }, { "category": "Nursing/other", "chartdate": "2132-01-29 00:00:00.000", "description": "Report", "row_id": 1667830, "text": "Nursing Progress Note MICU 7\n1900-1700\nAllergies: Tetracycline, Carbamezapine, Levaquin\nICU admx: \nCode: Full\nAccess: Right radial A-Line, 2 peripheral IV's. Right femoral HD cath\n\nNeuro: Pt. . Pleasantly confused. Oriented to self. Cause of delerium unclear. ? Septic emboli vs. uremia vs. toxic metab. Had head CT yesterday, preliminary read was negative for bleed.\n\nCV: Pt. hypotensive overnight. Had HD yesterday, 2 liters taken off. BP labile running from high 90's to high 70's systolic. Received 500cc bolus which he responded well to. BP now 100's to 110's systolic. HR 80's to 100's, NSR. Occasional PVC's. Had TEE yesterday. Preliminary report showed thickened MV, 2+ MR. significant vegetation/mass seen. No abcess seen. Hct 27.7 this am down from 30. Also, INR 1.8. Pt. had surgical c/s yesterday for significant LGIB. Had banding of anal vessel which thought to be source of bleed. No stool overnight to guiac.\n\nResp: LS decreased. No cough noted. Pt. sating 100% on room air.\n\nID: Pt. with low grade fever overnight max yesterday 101. Cultures from 17th pending. Pt. had one set of blood cultures with GPC's from 16th. Blood cultures sent from HD cath overnight. Pt. had CT of hip yesterday to rule out need for hip aspirate. Results pending. On Daptomycin. Gent being dosed per level. Level sent with am labs. WBC 7.2\n\nSkin: Pt. with multiple pressure ulcers (see flow sheet). Vascular following. ? need for recommendations today.\n\nGI/GU: Abdomen soft, non-tender. No stool overnight. Pt. anuric.\n\nPlan: Await results from TEE, head and pelvic CT. Continue abx. Await pending cultures. Monitor Hct.\n" }, { "category": "Nursing/other", "chartdate": "2132-01-30 00:00:00.000", "description": "Report", "row_id": 1667831, "text": "Resp Care\n\nPt intubated on floors for hypotension and transferred to MICU. Placed on full vent support. BS are bilateral. Plan for popssibel extubation in am\n" }, { "category": "Nursing/other", "chartdate": "2132-01-30 00:00:00.000", "description": "Report", "row_id": 1667832, "text": "Nursing Progress Note 0930-1900\n*Full Code\n\n*Allergies: Tetracycline, Carbamazipine, Levaquin\n\n*Access: Rfem TLC (bleeding), Rrad A-line, Rant PICC (do note use). Pt probable to go to IR for HD line placement and PICC revision.\n\n** Please see admit note/FHP for admit info and hx. (less than 48H readmit)\n\nEvents: Post endoscopy and several units PRBC and pt noted to be in tachy rhythm to 170's, noted , MD started chest compressions, connected to defib pads and shocked w/ 200J x2, returned to NSR 90's. Amiodarone 150mg loading dose given over 10min. Later started gtt @ 1.0mg/min. Labs sent, lytes wnl, a-line placed. PVC's still noted this shift but no more runs of v-tach/v-fib. Presumed to be caused by demand ischemia.\n\nNeuro: Mildly sedated on 250mcg/kg/min Fentanyl and 5mg/hr Versed. Arouses to voice and stimulation, inconsistantly follows commands, no c/o pain but noted grimace w/ R arm movement (contractures in arm/shoulder), UE's lift/hold, LE's moves on bed, PERRL 3mm/brisk.\n\nCardiac: NSR (except for event noted above) w/ rare-occasional ectopy, HR 90-103, SBP 84-125, MAP 63-88 w/ goal >65, remains on Levophed currently @ 0.075mcg/kg/min, has received total of 3L NS, 4U PRBC, and 3U . Attempted to wean levo OFF but required again after 30min. hct now 29.6, K 4.6, CK, CK-MB, Troponin being trended. Amiodarone gtt running @ 1.0mg/min for 6H, change @ to 0.5 mg/min for another 18Hrs. Lactate no2 2.7 from 6.9.\n\nResp: Intubated on floor, now on A/c 50%/600/14/5, o2sat 100% (finally able to get pleth on R thumb), rr 21-29, Last ABG 7.36/34/133/20 on current settings. LS coarse upper/diminished lower but also coarse, sxn for minimal secretions. Team may decide to extubate tomorrow.\n\nGI/Gu: OGT inplace, NPO, initially to wall sxn for 200cc coffee ground and bilious fluids prior to EGD. EGD note ulceration, fresh but not actively bleeding, clamped x2, given Pantoprazole 80mg IV bolus and then started on gtt @ 8mg/hr (25cc/hr) for total of 72Hrs. +BS, melena stool x3 (poor rectal tone), abd soft/non-tender. Anuric, ?HD tomorrow after line placement. BUN/Creat 63/5.1.\n\nID: Temp 96.9-99.6, WBC 14.2 from 7.7 on floor. Remains on Daptomycin and Gentamycin (gent beig dosed). Known MV vegitation. HD tip pulled yesterday grew staph. Bld cx's sent today x2 from a-line and TLC.\n\nPsychosocial: fam visited (brother and ex-wife) and updated on episode, condition and POC.\n\ndispo: wean levo (use fluid and/or blood for BP), ? extubate tomorrow, awaiting further cx's, trending card enzymes, HD line placement and PICC revision in IR tomorrow, decrease amio to 0.5mg/min @ , cont med regimen and icu care.\n" }, { "category": "Nursing/other", "chartdate": "2132-01-28 00:00:00.000", "description": "Report", "row_id": 1667829, "text": "NPN 7a-7p\nPlease see carevue and FHP for additional data.\nFull Code\nAllergy: Tetracycline, Carbamazepime, Levaquin\n\nNeuro: Pt , confused, disoriented. MAE. Follows commands. Intermittent c/o non-specific discomfort with turning. Plan for CT head with contrast to r/u aneurysm vs. septic emboli.\nResp: LS CTA. No cough or sob noted. Sats 100% on RA.\nCV: NSR-ST 94-102. Occ. pvc's noted. Sbp 111-135. Weaned off Levo. gtt early this AM. HD today, removed 2.2L, well tolerated. Plan for TEE to visualize known vegetation on Mitral valve and monitor progression. Daily EKG to monitor for heart block. HCT stable at 30.\nGI/GU: S/P LGIB, 5 units PRBC's total, rectal artery stitched. No s&s of bleeding noted. Abd soft, +BS. No stool. NPO for procedures today. Pt anuric at baseline, s/p two failed transplants.\nSKin: Please see carevue for details. Vascular following Rt. heel,dry, gangrene ulcer. NS wet to dry dsg change done. No need for debriedment at this time Necrotic penis, bilat. elbows, and left thumb. Coccyx with allevyn in place. (left thumb s/p debriedment,reportedly grew MRSA at OSH)\nID: Low grade temp 99.8. Cx data negative to date. Following surveillance cx's. Daptomycin and Gentamycin on HD days, s/p HD.\nA/P: Endocarditis- MRSA baceremia, presumed source was old HD line, line removed. On abx. Follow EKG's daily, for evidence of conduction disturbance. Plan for repeat TEE here to eval. vegetation and ? abcess. ID following.\nESRD- On HD. Has temporary HD line bacteremia, will need long term soln. Appreciating renal reqs.\nDelerium- Likely infection from septic emboli vs. uremia, vs. ischemia from recent hypotension. abx as above. ID following.\nAwaiting CT scan of head w/ contrast and hip. F/U on TEE data. F/U on cx data. Cont. providing supportive care.\n" }, { "category": "Nursing/other", "chartdate": "2132-02-02 00:00:00.000", "description": "Report", "row_id": 1667839, "text": "MICU Nursing Death Note\nPt remained on fentanyl and versed drips and appeared comfortable with rates of 250mcg/hour of fentanyl and 5mg/hour of versed. Pt expired at 0205 and pronounced by MD. wife and daughter present at time of death. Declined autopsy.\n\n" }, { "category": "Nursing/other", "chartdate": "2132-01-31 00:00:00.000", "description": "Report", "row_id": 1667833, "text": "npn: 1900-0700\nfull code\n\nall: tetracycline, carbamazipine, levaquin\n\naccess: r fem tlc, r rad aline, r ant picc...pt my go to ir for hd line placement and picc revision\n\n\nevents: pt recieved 2 units of prbc's and one unit for a hct 27.6 and inr of 2.1. pt am hct is pending. attempted to wean levophed to 0.05mcg/kg/min and pt bp dropped into the low 80's within 25 mins. pt has not had any bloody/melena stools on shift. wound care completed. amiodarone decreased at to 0.5mcg/kg/min.\n\nneuro: sedated on fent 250mcg/kg/min and versed 5mg/hr. arouses to voice but will not follow commands. pt did not follow commands. pt did make purposeful movements. pt would grimace when being moved. perrl 3mm/brsk.\n\ncardiac: nsr. pvc's noted rarely. hr 90's. abp 80-100. maps 58-73. remains on levophed 0.075mcgs--attempted wean as above. hct pending. weak ppp bilaterally. generalized edema. lactate 1.3\n\nresp: please see carevue for abg's and vent setting. no vent changes overnight. o2 sats 100%. lungs are coarse to clear and diminshed in bases. pt sux q 4 hours for minimal secretions.\n\ngi/gu: ogt in place, npo. abd is soft and flat. hypoactive bs noted.no stool on shift. protonix 8mg/hr. ogt clamped. poor rectal tone. anuric. no sch dialysis at this time.\n\nsocial: family into visit last night. may consider a family meeting pt poor prognosis. may need to rethink code status\n\nplan: possible red tag study. ir for hd/picc--maybe at this time, hct q 4-6 hours. icu/family support as needed.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-01-31 00:00:00.000", "description": "Report", "row_id": 1667834, "text": "resp Care\nPt remains on vent. Intubated with 7.5 ett @ 21, patent and secure. Suctioned for mod amt of thic yellow secretions. No changes made. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2132-01-31 00:00:00.000", "description": "Report", "row_id": 1667835, "text": "Nursing Progress Note 0700-1900\nFollowing rounds, fam called in to discuss code status. Dr. discussed the patients current medical complications. The fam understood that further treatment may not be effective and will cause the patient discomfort, especially if his heart were to go into a fatal rhythm again. The decision was to start working to CMO, remain on pressors and sedation and the vent until fam members were able to be present. Currently awaiting last fam member and then will remove vent and pressors. Plan for full CMO once all fam members visited.\n" }, { "category": "Nursing/other", "chartdate": "2132-02-01 00:00:00.000", "description": "Report", "row_id": 1667836, "text": "npn: 1900-0700\npt is cmo. pt appears comfortable. pt family at bedside. pt is on fent and versed gtt. family is nice and supportive. cont with family support. keep pt comfortable.\n" }, { "category": "Nursing/other", "chartdate": "2132-02-01 00:00:00.000", "description": "Report", "row_id": 1667837, "text": "Nursing progress Note\nPt continues on fentanyl and versed drip. Appears comfortable. Mouth care provided and secretions removed from back of throat. Scopalamine path applied to back of right ear to aid in drying secretions. Family by bedside and stated that Pt has looked comfortable to them.\n" }, { "category": "Nursing/other", "chartdate": "2132-02-01 00:00:00.000", "description": "Report", "row_id": 1667838, "text": "Nursing Progress Note 1100-1900\nPt remains CMO. Comfortable on Fentanyl and Versed gtts. Frequent PVC's noted. Pt appears comfortable. Sxn back of throat for secretions and moisten mouth. Scapolimine patch in place under R ear. Fam @ bedside, many fam members in to visit throughout the day.\n" }, { "category": "ECG", "chartdate": "2132-01-30 00:00:00.000", "description": "Report", "row_id": 147173, "text": "Probable sinus rhythm at upper limits of normal rate. Consider left atrial\nabnormality. Intraventricular conduction delay. Leftward axis. ST-T wave\nabnormalities. Since the previous tracing of the differences in\nlead V2 are probably related to lead position. ST-T wave abnormalities\nmay be more marked on the present tracing.\n\n" }, { "category": "ECG", "chartdate": "2132-01-29 00:00:00.000", "description": "Report", "row_id": 147174, "text": "Supraventricular rhythm, possibly sinus. Left axis deviation. Probable\nleft anterior fascicular block. Intraventricular conduction delay.\nR wave reversal in leads V1-V2. Consider previous septal myocardial\ninfarction. ST-T wave abnormalities. Since tracing of the\nQRS width is less. The Q wave in lead V2 is new and may be related\nto lead position, since there was R wave regression in leads V2-V3 on that\nprevious tracing. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2132-01-28 00:00:00.000", "description": "Report", "row_id": 147175, "text": "Sinus rhythm. Non-specific QRS widening. Compared to previous tracing\nQRS duration has increased. Otherwise, no major change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2132-01-25 00:00:00.000", "description": "Report", "row_id": 147176, "text": "Sinus tachycardia with ventricular premature depolarizations. Non-diagnostic\nrepolarization abnormalities. Compared to previous tracing of \nheart rate has increased, and there are now ventricular premature\ndepolarizations.\nTRACING #1\n\n" } ]

[ { "category": "Nursing", "chartdate": "2152-04-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 447092, "text": "H/O altered mental status (not Delirium)\n Assessment:\n PATIENT received on propofol at28 mics/kg/mt, requiring bolus sedation.\n Pupil equal and reactive.\n Action:\n Bolused with sedation, Propofol ^ upto 40 mics gtt, MAE, not\n following commands attempting to get OOB. MRI on hold pt has a\n screw on his left elbow not sure its compatible for MRI\n Response:\n Porpofol at 40mics/hr,requitring bolus sedation and given Versed PRN\n total of 4mg last dose was at 0505\n Plan:\n Continue to follow neuro exam/daily wake up. Cont sedation,follow up\n with MRI Plan\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient received on ac 50%/18x500 /5, lungs a little rhonchus to clear\n sx for thin whitte secretion, Sats 94-96% RR in 18-22\n Action:\n Cont same vent setting, retaped ETT. MRI postponed Elbow X ray\n showed metal ,couldn\nt get any records from outside hospital regarding\n metal screw.\n Response:\n Plan:\n Cont vent setting, extubate if MRI delayed. Prezedex before\n extubation for agitation.\n" }, { "category": "Physician ", "chartdate": "2152-04-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 447268, "text": "Chief Complaint:\n 24 Hour Events:\n - Extubated. Was initially hypertensive and tachycardic but normalized.\n Was given 500cc NS bolus.\n - Alert and oriented x 3 but unable to provide good history of what\n prompted his hospitalization\n - MRI attempted(hardware in left elbow okay per radiology tech) - pt\n wouldn't stay still despite 2 mg Ativan IV.\n MAGNETIC RESONANCE IMAGING - At 09:52 PM\n head but patient non compliant therefore not finished\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:52 AM\n Ceftriaxone - 10:53 AM\n Acyclovir - 11:50 AM\n Ampicillin - 12:00 AM\n Doxycycline - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:31 AM\n Midazolam (Versed) - 08:50 AM\n Lorazepam (Ativan) - 09:53 PM\n Heparin Sodium (Prophylaxis) - 01:49 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 05:38 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: 36.4\nC (97.5\n HR: 78 (76 - 124) bpm\n BP: 123/54(71) {114/54(71) - 182/100(112)} mmHg\n RR: 12 (10 - 23) insp/min\n SpO2: 95% on 3L O2 via NC\n (89-92% on room air)\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,254 mL\n 256 mL\n PO:\n TF:\n IVF:\n 3,254 mL\n 256 mL\n Blood products:\n Total out:\n 3,280 mL\n 345 mL\n Urine:\n 2,630 mL\n 345 mL\n NG:\n 650 mL\n Stool:\n Drains:\n Balance:\n -26 mL\n -89 mL\n Physical Examination\n GEN: sleeping\n HEENT: Pupils 4mm->3mm\n CV: Regular. No obvious murmurs.\n PULM: Clear to ausculatation.\n ABD: Soft; no apparent tenderness\n EXT: Warm. No edema. No lesions; right BKA\n SKIN: No rash noted.\n NEURO: alert and oriented x 2.5 (\n instead of ). Otherwise\n appropriate. Moving all extremities. Strength 5/5.\n Labs / Radiology\n 308 K/uL\n 9.4 g/dL\n 76 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 10 mg/dL\n 102 mEq/L\n 139 mEq/L\n 28.5 %\n 10.0 K/uL\n [image002.jpg]\n 11:04 AM\n 04:34 PM\n 10:11 PM\n 03:16 AM\n 03:26 AM\n WBC\n 10.0\n 7.7\n 9.5\n 10.0\n Hct\n 30.5\n 29.9\n 31.1\n 28.5\n Plt\n 298\n 282\n 266\n 308\n Cr\n 0.9\n 0.9\n 0.9\n TCO2\n 29\n Glucose\n 72\n 77\n 76\n Other labs: PT / PTT / INR:14.0/39.5/1.2, ALT / AST:15/17, Alk Phos / T\n Bili:52/0.3, Lactic Acid:0.6 mmol/L, Albumin:3.5 g/dL, LDH:138 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n MRI brain \n incomplete study. Read pending.\n Assessment and Plan\n 71M with history of alcohol abuse, but no recent use, presenting with\n toothache, mental status change, and fever.\n 1. Mental status change, fever: be due simply to medication effect\n (percocet) in an elderly male, though does not explain initial fever.\n Initially, suspicion for infection high, though patient afebrile here\n and WBC count not elevated. LP at OSH was not consistent with\n meningitis. CT head & neck here without evidence of odontogenic or\n soft tissue neck abscess. Attempted MRI of head however pt was able to\n tolerate it (cleared the issue of hardware in left elbow s/p ORIF in\n at pt ok for MRI) Pt not able to remember any events or\n symptoms that led to his hospitalization.\n - cont. doxycycline and unasyn for empiric coverage of ricketsial\n disease and oral flora\n - f/u ID recs\n - repeat thick & thin smear for parasites today & tomorrow for total of\n 3 (so far negative x2 thin smears)\n - f/u microbio studies that were sent at OSH (\n \n hospital)\n 2. Respiratory failure\n Patient initially intubated only for LP per\n report. Was successfully extubated yesterday. Was hypertensive and\n tachycardic post-intubation but both HR and BP normalized after 500cc\n NS bolus. Now satting well on O2 NC\n .\n 3. AMS\n was noted to be altered on presentation to OSH. Pt now alert\n and oriented x 3 after discontinuation of sedation and extubation.\n However unable to give good history of presentation.\n - Ask family about pt\ns baseline mental status\n - f/u MRI head (although incomplete)\n .\n FEN: speech and swallow (on soft solids at home) study then PO diet .\n PPX: SC heparin; d/c PPI as pt no longer intubated\n Code: presumed full\n Communication: Spokesperson is patient\ns daughter who requests\n no info be given to daughter ; also communicate with\n patient\ns wife. Phone numbers on board in room.\n Dispo: likely call out today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 06:11 AM\n 20 Gauge - 12:36 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2152-04-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 447270, "text": ".H/O altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2152-04-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 447273, "text": "71M with history of alcohol abuse, but no recent use, presenting from\n \n with toothache, mental status change, and fever.\n Mental status change, fever: be due simply to medication effect\n (percocet) in an elderly male, though does not explain initial fever.\n Initially, suspicion for infection high, though patient afebrile here\n and WBC count not elevated. LP at OSH was not consistent with\n meningitis. CT head & neck here without evidence of odontogenic or\n soft tissue neck abscess. Attempted MRI of head however pt was able to\n tolerate it (cleared the issue of hardware in left elbow s/p ORIF in\n at pt ok for MRI) Pt not able to remember any events or\n symptoms that led to his hospitalization.\n Respiratory failure\nInitially intubated only for LP per report. Was\n successfully extubated . Was hypertensive and tachycardic\n post-intubation but both HR and BP normalized after 500cc NS bolus. Now\n satting well on O2 NC, currently smokes 1ppd although pt stated 3ppd\n use this am. Lungs with bilateral ins/exp wheezing. Strong productive\n cough for thick tan sputum.\n FEN: speech and swallow (on soft solids at home, has no teeth) study\n then PO diet. Bedside simple evaluation ok as he tolerated water.\n Communication: Spokesperson is patient\ns daughter who requests\n no info be given to daughter ; also communicate with\n patient\ns wife.\n .H/O altered mental status (not Delirium)\n Assessment:\n Alert and oriented x3, cooperative and hungry. Denies pain. Able to\n recall some events such as taking Percocet which he states,\nmade me\n sick\n Action:\n OOB to chair. Encouraged to cough, deep breathe and use incentive\n spirometer. Nicotine Patch offered.\n Response:\n Stable.\n Plan:\n Nicotine patch. Start advancing diet. Transfer to floor.\n" }, { "category": "Physician ", "chartdate": "2152-04-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 447278, "text": "Chief Complaint: 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 71 yo man transferred from OSH with altered MS \n failure. Unclear cause. Was extubated yesterday and has done well.\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 09:52 PM\n head but patient non compliant therefore not finished\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:52 AM\n Ceftriaxone - 10:53 AM\n Acyclovir - 11:50 AM\n Doxycycline - 12:00 AM\n Ampicillin - 05:47 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 09:53 PM\n Heparin Sodium (Prophylaxis) - 01:49 AM\n Other medications:\n protonix\n doxycycline\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) Fever\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain\n : No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:06 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: 36.6\nC (97.8\n HR: 83 (77 - 124) bpm\n BP: 147/70(88) {114/54(71) - 182/100(112)} mmHg\n RR: 11 (10 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,254 mL\n 519 mL\n PO:\n 120 mL\n TF:\n IVF:\n 3,254 mL\n 399 mL\n Blood products:\n Total out:\n 3,280 mL\n 560 mL\n Urine:\n 2,630 mL\n 560 mL\n NG:\n 650 mL\n Stool:\n Drains:\n Balance:\n -26 mL\n -41 mL\n support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n PS : 5 cmH2O\n FiO2: 50%\n SpO2: 91%\n ABG: ///27/\n Ve: 12.4 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 9.4 g/dL\n 308 K/uL\n 76 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 10 mg/dL\n 102 mEq/L\n 139 mEq/L\n 28.5 %\n 10.0 K/uL\n [image002.jpg]\n 11:04 AM\n 04:34 PM\n 10:11 PM\n 03:16 AM\n 03:26 AM\n WBC\n 10.0\n 7.7\n 9.5\n 10.0\n Hct\n 30.5\n 29.9\n 31.1\n 28.5\n Plt\n 298\n 282\n 266\n 308\n Cr\n 0.9\n 0.9\n 0.9\n TCO2\n 29\n Glucose\n 72\n 77\n 76\n Other labs: PT / PTT / INR:14.0/39.5/1.2, ALT / AST:15/17, Alk Phos / T\n Bili:52/0.3, Lactic Acid:0.6 mmol/L, Albumin:3.5 g/dL, LDH:138 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n Acute delirium and failure: Most likely cause is percocet,\n as all tests were negative. Can stop unasyn and doxy.\n Start soft solid diet\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 06:11 AM\n 20 Gauge - 12:36 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\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": "2152-04-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 447279, "text": "Chief Complaint:\n 24 Hour Events:\n - Extubated. Was initially hypertensive and tachycardic but normalized.\n Was given 500cc NS bolus.\n - Alert and oriented x 3 but unable to provide good history of what\n prompted his hospitalization\n - MRI attempted(hardware in left elbow okay per radiology tech) - pt\n wouldn't stay still despite 2 mg Ativan IV.\n MAGNETIC RESONANCE IMAGING - At 09:52 PM\n head but patient non compliant therefore not finished\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:52 AM\n Ceftriaxone - 10:53 AM\n Acyclovir - 11:50 AM\n Ampicillin - 12:00 AM\n Doxycycline - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:31 AM\n Midazolam (Versed) - 08:50 AM\n Lorazepam (Ativan) - 09:53 PM\n Heparin Sodium (Prophylaxis) - 01:49 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 05:38 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: 36.4\nC (97.5\n HR: 78 (76 - 124) bpm\n BP: 123/54(71) {114/54(71) - 182/100(112)} mmHg\n RR: 12 (10 - 23) insp/min\n SpO2: 95% on 3L O2 via NC\n (89-92% on room air)\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,254 mL\n 256 mL\n PO:\n TF:\n IVF:\n 3,254 mL\n 256 mL\n Blood products:\n Total out:\n 3,280 mL\n 345 mL\n Urine:\n 2,630 mL\n 345 mL\n NG:\n 650 mL\n Stool:\n Drains:\n Balance:\n -26 mL\n -89 mL\n Physical Examination\n GEN: sleeping\n HEENT: Pupils 4mm->3mm\n CV: Regular. No obvious murmurs.\n PULM: Clear to ausculatation.\n ABD: Soft; no apparent tenderness\n EXT: Warm. No edema. No lesions; right BKA\n SKIN: No rash noted.\n NEURO: alert and oriented x 2.5 (\n instead of ). Otherwise\n appropriate. Moving all extremities. Strength 5/5.\n Labs / Radiology\n 308 K/uL\n 9.4 g/dL\n 76 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 10 mg/dL\n 102 mEq/L\n 139 mEq/L\n 28.5 %\n 10.0 K/uL\n [image002.jpg]\n 11:04 AM\n 04:34 PM\n 10:11 PM\n 03:16 AM\n 03:26 AM\n WBC\n 10.0\n 7.7\n 9.5\n 10.0\n Hct\n 30.5\n 29.9\n 31.1\n 28.5\n Plt\n 298\n 282\n 266\n 308\n Cr\n 0.9\n 0.9\n 0.9\n TCO2\n 29\n Glucose\n 72\n 77\n 76\n Other labs: PT / PTT / INR:14.0/39.5/1.2, ALT / AST:15/17, Alk Phos / T\n Bili:52/0.3, Lactic Acid:0.6 mmol/L, Albumin:3.5 g/dL, LDH:138 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n MRI brain \n incomplete study. Read pending.\n Assessment and Plan\n 71M with history of alcohol abuse, but no recent use, presenting with\n toothache, mental status change, and fever.\n 1. Mental status change, fever: be due simply to medication effect\n (percocet) in an elderly male, though does not explain initial fever.\n Initially, suspicion for infection high, though patient afebrile here\n and WBC count not elevated. LP at OSH was not consistent with\n meningitis. CT head & neck here without evidence of odontogenic or\n soft tissue neck abscess. Attempted MRI of head however pt was able to\n tolerate it (cleared the issue of hardware in left elbow s/p ORIF in\n at pt ok for MRI) Pt not able to remember any events or\n symptoms that led to his hospitalization.\n - cont. doxycycline and unasyn for empiric coverage of ricketsial\n disease and oral flora\n - f/u ID recs\n - repeat thick & thin smear for parasites today & tomorrow for total of\n 3 (so far negative x2 thin smears)\n - f/u microbio studies that were sent at OSH (\n \n hospital)\n 2. failure\n Patient initially intubated only for LP per\n report. Was successfully extubated yesterday. Was hypertensive and\n tachycardic post-intubation but both HR and BP normalized after 500cc\n NS bolus. Now satting well on O2 NC\n .\n 3. AMS\n was noted to be altered on presentation to OSH. Pt now alert\n and oriented x 3 after discontinuation of sedation and extubation.\n However unable to give good history of presentation.\n - Ask family about pt\ns baseline mental status\n - f/u MRI head (although incomplete)\n .\n FEN: speech and swallow (on soft solids at home) study then PO diet .\n PPX: SC heparin; d/c PPI as pt no longer intubated\n Code: presumed full\n Communication: Spokesperson is patient\ns daughter who requests\n no info be given to daughter ; also communicate with\n patient\ns wife. Phone numbers on board in room.\n Dispo: likely call out today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 06:11 AM\n 20 Gauge - 12:36 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n After AM rounds, the following were adjusted/added:\n D/C Unasyn today since no evidence of odontogenic abscesses/infection\n Pt had h/o coffee ground material that was aspirated upon intubation\n and PPI was thus added. Will still d/c PPI now, since pt is taking POs\n and no longer intubated with no further episodes of coffee ground\n emesis, but will need to monitor for recurrence.\n Cancel Sp and Sw eval; RN will monitor how pt does on soft solids and\n use clinical judgement (pt did well with water this AM). Pt is mostly\n adentulous with no dentures.\n Pt had marked hematuria when foley was placed; likely was due to trauma\n since it has cleared now but will d/c foley today and send next void\n for U/A\n ------ Protected Section Addendum Entered By: , MD\n on: 10:15 ------\n" }, { "category": "Nursing", "chartdate": "2152-04-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 447284, "text": "71M with history of alcohol abuse, but no recent use, presenting from\n \n with toothache, mental status change, and fever.\n Mental status change, fever: be due simply to medication effect\n (percocet) in an elderly male, though does not explain initial fever.\n Initially, suspicion for infection high, though patient afebrile here\n and WBC count not elevated. LP at OSH was not consistent with\n meningitis. CT head & neck here without evidence of odontogenic or\n soft tissue neck abscess. Attempted MRI of head however pt was able to\n tolerate it (cleared the issue of hardware in left elbow s/p ORIF in\n at pt ok for MRI) Pt not able to remember any events or\n symptoms that led to his hospitalization.\n Respiratory failure\nInitially intubated only for LP per report. Was\n successfully extubated . Was hypertensive and tachycardic\n post-intubation but both HR and BP normalized after 500cc NS bolus. Now\n satting well on O2 NC, currently smokes 1ppd although pt stated 3ppd\n use this am. Lungs with bilateral ins/exp wheezing. Strong productive\n cough for thick tan sputum.\n FEN: speech and swallow (on soft solids at home, has no teeth) study\n then PO diet. Bedside simple evaluation ok as he tolerated water.\n Communication: Spokesperson is patient\ns daughter who requests\n no info be given to daughter ; also communicate with\n patient\ns wife.\n .H/O altered mental status (not Delirium)\n Assessment:\n Alert and oriented x3, cooperative and hungry. Denies pain. Able to\n recall some events such as taking Percocet which he states,\nmade me\n sick\n Action:\n OOB to chair. Encouraged to cough, deep breathe and use incentive\n spirometer. Nicotine Patch offered.\n Response:\n Stable.\n Plan:\n Nicotine patch. Start advancing diet. Transfer to floor.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Height:\n Admission weight:\n 80 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: ETOH\n CV-PMH:\n Additional history: recovering alcholic x 3 years\n Surgery / Procedure and date: bka from trauma \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:156\n D:79\n Temperature:\n 97.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 95 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 50% %\n 24h total in:\n 992 mL\n 24h total out:\n 720 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 03:26 AM\n Potassium:\n 3.8 mEq/L\n 03:26 AM\n Chloride:\n 102 mEq/L\n 03:26 AM\n CO2:\n 27 mEq/L\n 03:26 AM\n BUN:\n 10 mg/dL\n 03:26 AM\n Creatinine:\n 0.9 mg/dL\n 03:26 AM\n Glucose:\n 76 mg/dL\n 03:26 AM\n Hematocrit:\n 28.5 %\n 03:26 AM\n Finger Stick Glucose:\n 102\n 08:00 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: Micu6\n Transferred to: CC702\n Date & time of Transfer: @ 1130\n" }, { "category": "Nursing", "chartdate": "2152-04-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 447061, "text": "H/O altered mental status (not Delirium)\n Assessment:\n PATIENT received on propofol at28 mics/kg/mt, gets agitated very \n requiring bolus sedation. Pupil equal and reactive.\n Action:\n Bolused with sedation, Propofol ^ upto 40 mics gtt, MAE not following\n commands attempting to get OOB. MRI on hold pt has a screw on his\n left elbow not sure its compatible for MRI\n Response:\n Porpofol at 40mics/hr,requitring bolus sedation an dgiven Versed 1mg\n PRN\n Plan:\n Continue to follow neuro exam/daily wake up. Cont sedation,follow up\n with MRI Plan\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient received on ac 50%/18x500 /5, lungs a little rhonchus to clear\n sx for thin whitte secretion,Sating upper 90\ns RR in 18-22\n Action:\n Cont same vent setting, retaped ETT.\n Response:\n Plan:\n Cont ventr setting, extuate if MRI delayed.\n" }, { "category": "Nursing", "chartdate": "2152-04-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 447113, "text": "Mr. is a 71 year-old man with no known past medical history of\n than prior alcohol abuse who presents with altered mental status.\n Per the daughter, patient has been having tooth pain for some time but\n he has not seen a physician in years. Has been taking a bottle of\n aspirin over the course of a month (up to 2grams per day). Went to OSH\n two days PTA. Was given prescription for percocet and PenV. On the\n morning PTA, daughter noted he had taken 2 percocet. Around noon, went\n to outpatient physician and was given prescription for percocet. Upon\n returning home, noted to be delirious (banging on front door). Appears\n that he took 3 percocet after filling prescription.\n At the OSH, T101 (per report; could not find documented); labs showed\n WBC 10.6, sodium 129, normal LFTs and negative alcohol. Initial\n lactate 2.4. UA showed hematuria and ketosis. Tox showed oxycodone,\n tylenol of 31.6, ASA of 10.3.\n After becoming increasingly agitated, was intubated with 7.5 tube.\n Some bloody oral secretions were noted. LP perfomed CT head and CXR\n were reportedly normal.\n In our ED, initially intubated/sedated/paralyzed and hemodynamically\n stable. Tmax of 99.2. He was given a banana bag.\n Daughter also reports that he has complained of some headache for a\n few weeks. No fevers. No tick bites noted.\n Events: Pt getting 20 mEQ Pottasium replacement for K of 3.7 and needs\n Mag 2 gm.\n H/O altered mental status (not Delirium)\n Assessment:\n PATIENT received on propofol at28 mics/kg/mt, requiring bolus sedation.\n Pupil equal and reactive.\n Action:\n Bolused with sedation, Propofol ^ upto 40 mics gtt, MAE, not\n following commands attempting to get OOB. MRI on hold pt has a\n screw on his left elbow not sure its compatible for MRI\n Response:\n Porpofol at 50mics/hr,requitring bolus sedation and given Versed PRN\n total of 4mg last dose was at 0505\n Plan:\n Continue to follow neuro exam/daily wake up. Cont sedation, follow up\n with MRI Plan\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient received on ac 50%/18x500 /5, lungs a little rhonchus to clear\n sx for thin whitte secretion, Sats 94-96% RR in 18-22\n Action:\n Cont same vent setting, retaped ETT. MRI postponed Elbow X ray\n showed metal, couldn\nt get any records from outside hospital regarding\n metal screw.\n Response:\n Plan:\n Cont vent setting, Possible extubation if MRI gets delayed. Prezedex\n before extubation for agitation.\n" }, { "category": "Physician ", "chartdate": "2152-04-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 447123, "text": "TITLE:\n Chief Complaint: toothache, AMS, fever\n 24 Hour Events:\n - OSH Contact. HSV PCR sent on CSF sample but will add it on and\n will fax results to us if any Cx are positive.\n - CT Neck: No abscess.\n - CT Head: (Prelim) No evidence for abscess. Fluid level in the left\n maxillary sinus and mild mucosal thickening in bilateral frontal and\n ethmoid sinuses as well as the sphenoid sinus. This may be related to\n intubation.\n - Panorex performed, read pending\n - Per ID: Continue unasyn/doxy and d/c other antibiotics.\n - MRI, MRA, MRV head ordered\n - per family, pt. with hx of dysphagia & difficulty with even soft\n solids prior to admission, past hx of reflux\n - Lyme titers sent; blood smear for parasites neg x 1, need repeat x 2\n for greater sensitivity per CDC recs\n - Per family: has h/o repair to L elbow w/ metal. Plain films obtained\n showing 2 screws in L elbow. Per Rads, cannot clear for MRI until\n manufaturing specifics of screws are known. Hold on MRI for now until\n more infomation can be obtained.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:52 AM\n Ceftriaxone - 10:53 AM\n Acyclovir - 11:50 AM\n Doxycycline - 12:00 AM\n Ampicillin - 06:10 AM\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 10:53 AM\n Heparin Sodium (Prophylaxis) - 01:56 AM\n Midazolam (Versed) - 05:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 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: 35.8\nC (96.5\n HR: 83 (77 - 107) bpm\n BP: 121/69(80) {111/57(70) - 198/105(118)} mmHg\n RR: 18 (10 - 19) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,844 mL\n 1,526 mL\n PO:\n TF:\n IVF:\n 2,844 mL\n 1,526 mL\n Blood products:\n Total out:\n 1,510 mL\n 300 mL\n Urine:\n 1,510 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,334 mL\n 1,226 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 43\n PIP: 27 cmH2O\n Plateau: 18 cmH2O\n SpO2: 97%\n ABG: 7.37/49/140/27/2\n Ve: 8.6 L/min\n PaO2 / FiO2: 280\n Physical Examination\n GEN: Intubated/sedated.\n HEENT: Pupils 4mm->3mm\n CV: Regular. No obvious murmurs.\n PULM: Clear anteriorly.\n ABD: Soft; no apparent tenderness\n EXT: Warm. No edema. No lesions; right BKA\n SKIN: No rash noted.\n NEURO: Pupils as above; sedated so unable to assess further\n Labs / Radiology\n 266 K/uL\n 9.9 g/dL\n 77 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 100 mEq/L\n 136 mEq/L\n 31.1 %\n 9.5 K/uL\n [image002.jpg]\n 11:04 AM\n 04:34 PM\n 10:11 PM\n 03:16 AM\n WBC\n 10.0\n 7.7\n 9.5\n Hct\n 30.5\n 29.9\n 31.1\n Plt\n 298\n 282\n 266\n Cr\n 0.9\n 0.9\n TCO2\n 29\n Glucose\n 72\n 77\n Other labs: PT / PTT / INR:12.9/29.8/1.1, ALT / AST:15/17, Alk Phos / T\n Bili:52/0.3, Lactic Acid:0.6 mmol/L, Albumin:3.5 g/dL, LDH:138 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.7 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 71M with history of alcohol abuse, presenting with mental status change\n and fever.\n 1. Mental status change: be due to medication effect (percocet)\n though this seems unlikely given total intake. In the setting of\n fever, meningoencephalitis is of concern. LP at OSH was not consistent\n with meningitis.\n - Start IV acyclovir; given possibility of partially treated bacterial\n meningitis, will start CTX/vanco\n - Obtain CT neck\n - Consider MRI brain\n - ID consult\n 2. Fever: Other than change in mental status only localizing symptom is\n tooth pain.\n - Obtain CT neck\n - Cover for oral anaerobes with unasyn\n - CXR\n - UA\n 3. Hematuria: Unclear etiology.\n - Send urine culture\n - Consider urology consult\n FEN: NPO for possible extubation\n PPX: SC heparin; PPI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 06:11 AM\n 18 Gauge - 07:13 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2152-04-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 447111, "text": "Events: Pt getting 20 mEQ Pottasium replacement for K of 3.7 and needs\n Mag 2 gm.\n H/O altered mental status (not Delirium)\n Assessment:\n PATIENT received on propofol at28 mics/kg/mt, requiring bolus sedation.\n Pupil equal and reactive.\n Action:\n Bolused with sedation, Propofol ^ upto 40 mics gtt, MAE, not\n following commands attempting to get OOB. MRI on hold pt has a\n screw on his left elbow not sure its compatible for MRI\n Response:\n Porpofol at 50mics/hr,requitring bolus sedation and given Versed PRN\n total of 4mg last dose was at 0505\n Plan:\n Continue to follow neuro exam/daily wake up. Cont sedation, follow up\n with MRI Plan\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient received on ac 50%/18x500 /5, lungs a little rhonchus to clear\n sx for thin whitte secretion, Sats 94-96% RR in 18-22\n Action:\n Cont same vent setting, retaped ETT. MRI postponed Elbow X ray\n showed metal ,couldn\nt get any records from outside hospital regarding\n metal screw.\n Response:\n Plan:\n Cont vent setting, extubate if MRI delayed. Prezedex before\n extubation for agitation.\n" }, { "category": "Nursing", "chartdate": "2152-04-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 447218, "text": "Mr. is a 71 year-old man from with no known past\n medical history other than prior alcohol abuse who presents with\n altered mental status.\n Per the daughter, patient has been having tooth pain for some time but\n he has not seen a physician in years. He has been taking a bottle of\n aspirin over the course of a month (up to 2grams per day). Went to OSH\n two days PTA and was given prescription for percocet and Pen V. On the\n morning PTA, daughter noted he had taken 2 percocet. Around noon, went\n to outpatient physician and was given prescription for percocet. Upon\n returning home, noted to be delirious (banging on front door). Appears\n that he took 3 percocet after filling prescription.\n At the OSH, T101 (per report; could not find documented); labs showed\n WBC 10.6, sodium 129, normal LFTs and negative alcohol. Initial\n lactate 2.4. Tox showed oxycodone, tylenol of 31.6, ASA of 10.3,\n intubated at OSH with 7.5 tube for extreme agitation. LP perfomed CT\n head and CXR were reportedly normal also performed at OSH prior to\n transfer..medflighted to \n Repeat head ct/xrs teeth gums performed at , no\n abnormalities seen\n EVENTS OVERNIGHT....patient went for MRI scan to evaluate head [ recent\n hx of toothache/headcahe ? abcess/encepahlitis], patient would not\n remain still for procedure despite total 1.5mgs lorazepam therefore\n procedure abandoned\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient successfully extubated yesterday and received on 3l n/c ,\n lungs sound course upper, sats > 93%..patient is known pack a day\n smoker for years\n Action:\n Encouraged to cough/deep breath/expectorate\n Response:\n Now mobilizing secretions, expectorating thick tan secretions [ sample\n was sent prior to extubation], sats maintained > 94%\n Plan:\n Chest PT , encourage cough/deep breath IS, wean fio2 as tolerated [\n patient needs nicotine patch prescribing]\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Patient admitted for possible infection process with fever at OSH, has\n been afebrile since admission, no lactate, no WBC, previous BCS\n pending/sputum pending, all tests to date negative but does have recent\n HX toothache with acute mental status changes..ID team following\n Action:\n MRI attempted to R/O abcess/encepahlitis\n Response:\n Unable to perform as patient non-compliant\n Plan:\n Continue to monitor fever curve, ABS as ordered , for repeat bcs if\n patient spikes ?? for another attempt of MRI scan\n .H/O altered mental status (not Delirium)\n Assessment:\n Patient received much improved orientated x2/3, aware in /\n hospital/date/name, occasionally patients speech becomes less clear ?\n related to having no teeth/dry mouth but is able to make his needs\n known..he follows all commands with purposeful movement , pupils\n equal/reactive\n Action:\n MRI head attempted but despite improving MS he was unable to lie still\n for the test despite receiving sedation\n Response:\n Abandoned MRI, patient slept for long periods overnight and neuro exam\n remains unchanged\n Plan:\n Continue to follow neuro exam\n Patient has recnt HX of dyshagia, patient is in for swallow eval..NPO\n at this time as patient pulled out NG yesterday post extuabtion\n" }, { "category": "Physician ", "chartdate": "2152-04-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 447147, "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 71 yo man, traumatic R BKA, COPD, fever, recent detnal pain. Presented\n with altered MS, and intubated at OSH at . LP with 3 WBC. ID\n consulted, and recommended stopping antbiotics except for unasyn and\n doxy.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:52 AM\n Ceftriaxone - 10:53 AM\n Acyclovir - 11:50 AM\n Doxycycline - 12:00 AM\n Ampicillin - 06:10 AM\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:56 AM\n Pantoprazole (Protonix) - 08:31 AM\n Midazolam (Versed) - 08:50 AM\n Other medications:\n doxycycline\n unasyn\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36\nC (96.8\n HR: 97 (76 - 97) bpm\n BP: 169/94(105) {111/57(70) - 169/105(118)} mmHg\n RR: 16 (14 - 19) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,844 mL\n 1,773 mL\n PO:\n TF:\n IVF:\n 2,844 mL\n 1,773 mL\n Blood products:\n Total out:\n 1,510 mL\n 625 mL\n Urine:\n 1,510 mL\n 625 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,334 mL\n 1,148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 43\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 98%\n ABG: 7.37/49/140/27/2\n Ve: 11.2 L/min\n PaO2 / FiO2: 280\n Physical Examination\n General Appearance: Well nourished\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: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Verbal stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.9 g/dL\n 266 K/uL\n 77 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 100 mEq/L\n 136 mEq/L\n 31.1 %\n 9.5 K/uL\n [image002.jpg]\n 11:04 AM\n 04:34 PM\n 10:11 PM\n 03:16 AM\n WBC\n 10.0\n 7.7\n 9.5\n Hct\n 30.5\n 29.9\n 31.1\n Plt\n 298\n 282\n 266\n Cr\n 0.9\n 0.9\n TCO2\n 29\n Glucose\n 72\n 77\n Other labs: PT / PTT / INR:12.9/29.8/1.1, ALT / AST:15/17, Alk Phos / T\n Bili:52/0.3, Lactic Acid:0.6 mmol/L, Albumin:3.5 g/dL, LDH:138 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.7 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Will try SBT. If does\n well will try to extubate.\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA): No further\n fevers.\n H/O ALTERED MENTAL STATUS (NOT DELIRIUM): Unclear cause. LP largely\n negative. WBC is normal and has been afebrile here making infection\n less likely. Unable to get MRI, as he has screws in an elbow, and we\n haven't gotten records to confirm that they are compatible. Unclear\n where he is in terms of his mental status given need for sedation to\n control agitation in setting of intubation. If he does well wil SBT,\n will try extubation and see if MS clears with stoppage of sedation.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 06:11 AM\n 18 Gauge - 07:13 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: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2152-04-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 447155, "text": "TITLE:\n Chief Complaint: toothache, AMS, fever\n 24 Hour Events:\n - OSH Contact. HSV PCR sent on CSF sample but will add it on and\n will fax results to us if any Cx are positive.\n - CT Neck: No abscess.\n - CT Head: (Prelim) No evidence for abscess. Fluid level in the left\n maxillary sinus and mild mucosal thickening in bilateral frontal and\n ethmoid sinuses as well as the sphenoid sinus. This may be related to\n intubation.\n - Panorex performed, read pending\n - Per ID: Continue unasyn/doxy and d/c other antibiotics.\n - MRI, MRA, MRV head ordered\n - per family, pt. with hx of dysphagia & difficulty with even soft\n solids prior to admission, past hx of reflux\n - Lyme titers sent; blood smear for parasites neg x 1, need repeat x 2\n for greater sensitivity per CDC recs\n - Per family: has h/o repair to L elbow w/ metal. Plain films obtained\n showing 2 screws in L elbow. Per Rads, cannot clear for MRI until\n manufaturing specifics of screws are known. Hold on MRI for now until\n more infomation can be obtained.\n - pt. required increasing amounts of propofol for sedation overnight\n and also received versed boluses due to agitation.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:52 AM\n Ceftriaxone - 10:53 AM\n Acyclovir - 11:50 AM\n Doxycycline - 12:00 AM\n Ampicillin - 06:10 AM\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 10:53 AM\n Heparin Sodium (Prophylaxis) - 01:56 AM\n Midazolam (Versed) - 05:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 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: 35.8\nC (96.5\n HR: 83 (77 - 107) bpm\n BP: 121/69(80) {111/57(70) - 198/105(118)} mmHg\n RR: 18 (10 - 19) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,844 mL\n 1,526 mL\n PO:\n TF:\n IVF:\n 2,844 mL\n 1,526 mL\n Blood products:\n Total out:\n 1,510 mL\n 300 mL\n Urine:\n 1,510 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,334 mL\n 1,226 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 43\n PIP: 27 cmH2O\n Plateau: 18 cmH2O\n SpO2: 97%\n ABG: 7.37/49/140/27/2\n Ve: 8.6 L/min\n PaO2 / FiO2: 280\n Physical Examination\n GEN: Intubated/sedated.\n HEENT: Pupils 4mm->3mm\n CV: Regular. No obvious murmurs.\n PULM: Clear anteriorly.\n ABD: Soft; no apparent tenderness\n EXT: Warm. No edema. No lesions; right BKA\n SKIN: No rash noted.\n NEURO: Pupils as above; sedated so unable to assess further\n Labs / Radiology\n 266 K/uL\n 9.9 g/dL\n 77 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 100 mEq/L\n 136 mEq/L\n 31.1 %\n 9.5 K/uL\n [image002.jpg]\n 11:04 AM\n 04:34 PM\n 10:11 PM\n 03:16 AM\n WBC\n 10.0\n 7.7\n 9.5\n Hct\n 30.5\n 29.9\n 31.1\n Plt\n 298\n 282\n 266\n Cr\n 0.9\n 0.9\n TCO2\n 29\n Glucose\n 72\n 77\n Other labs: PT / PTT / INR:12.9/29.8/1.1, ALT / AST:15/17, Alk Phos / T\n Bili:52/0.3, Lactic Acid:0.6 mmol/L, Albumin:3.5 g/dL, LDH:138 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.7 mg/dL, PO4:3.0 mg/dL\n CT Head & Neck\n no evidence of abscess; fluid levels in ethmoid,\n sphenoid, and frontal sinuses.\n Assessment and Plan\n 71M with history of alcohol abuse, but no recent use, presenting with\n toothache, mental status change, and fever.\n 1. Mental status change, fever: be due simply to medication effect\n (percocet) in an elderly male, though does not explain initial fever.\n Initially, suspicion for infection high, though patient afebrile here\n and WBC count not elevated. LP at OSH was not consistent with\n meningitis. CT head & neck here without evidence of odontogenic or\n soft tissue neck abscess. Unable to obtain MRI overnight due to metal\n screws in left elbow and inability to clear patient for MRI scanner as\n unable to obtain OSH records regarding placement.\n - cont. doxycycline and unasyn for empiric coverage of ricketsial\n disease and oral flora\n - f/u ID recs\n - repeat thick & thin smear for parasites today & tomorrow for total of\n 3\n - Try to obtain records on left elbow screws to potentially clear pt\n for MRI scanner\n 2. Respiratory failure\n Patient initially intubated only for LP per\n report. Had good RSBI this morning. Continues to become agitated with\n lifting of sedation. Question regarding weaning from vent does not\n currently seem to be secondary to respiratory issues, but more due to\n mental status.\n - spontaneous breathing trial this morning\n - attempt extubation and try to better assess mental status once\n propofol clear\n - may need haldol or zyprexa prn\n .\n 3. Hematuria: Unclear etiology, may be related to foley placement. Has\n now resolved.\n .\n 4. ?Coffee grounds aspirated from NGT\n appears less red this morning.\n Will continue to monitor NGT output.\n FEN: NPO for possible extubation\n PPX: SC heparin; PPI\n Code: presumed full\n Communication: Spokesperson is patient\ns daughter who requests\n no info be given to daughter ; also communicate with\n patient\ns wife. Phone numbers on board in room.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 06:11 AM\n 18 Gauge - 07:13 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2152-04-21 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 446969, "text": "Chief Complaint: Altered mental status; fever\n HPI:\n Mr. is a 71 year-old man with no known past medical history of\n than prior alcohol abuse who presents with altered mental status.\n Per the daughter, patient has been having tooth pain for some time but\n he has not seen a physician in years. Has been taking a bottle of\n aspirin over the course of a month (up to 2grams per day). Went to OSH\n two days PTA. Was given prescription for percocet and PenV. On the\n morning PTA, daughter noted he had taken 2 percocet. Around noon, went\n to outpatient physician and was given prescription for percocet. Upon\n returning home, noted to be delirious (banging on front door). Appears\n that he took 3 percocet after filling prescription.\n Per EMG report, glucose 99, GCS 12. At the OSH, T101 (per report;\n could not find documented); labs showed WBC 10.6, sodium 129, normal\n LFTs and negative alcohol. Initial lactate 2.4. UA showed hematuria\n and ketosis. Tox showed oxycodone, tylenol of 31.6, ASA of 10.3.\n After becoming increasingly agitated, was intubated with 7.5 tube.\n Some bloody oral secretions were noted. LP perfomed with 3 WBC and\n RBC, glucose 59, protein 53 and negative gram stain. CT head and CXR\n were reportedly normal. Cephtriaxone 1g was given before the LP.\n In our ED, initially intubated/sedated/paralyzed and hemodynamically\n stable. Tmax of 99.2. He was given a banana bag.\n On ROS, daughter reports that he has complained of some headache for a\n few weeks. No fevers. No tick bites noted.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:52 AM\n Ceftriaxone - 10:53 AM\n Acyclovir - 11:50 AM\n Doxycycline - 11:50 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:53 AM\n Heparin Sodium (Prophylaxis) - 10:53 AM\n Home medications: None\n Past medical history:\n Family history:\n Social History:\n History of alcohol abuse, last drink 3 years ago (per wife).\n BKA and jaw trauma secondary to MVA ()\n Occupation:\n Drugs: None\n Tobacco: 1ppd\n Alcohol: Prior history of tobacco abuse; 3 years sober\n Other:\n Review of systems:\n Constitutional: Fever\n Neurologic: Headache\n Flowsheet Data as of 12:53 PM\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: 36.4\nC (97.5\n HR: 87 (84 - 107) bpm\n BP: 154/75(94) {136/72(87) - 198/100(118)} mmHg\n RR: 19 (10 - 19) insp/min\n SpO2: 97%\n Total In:\n 911 mL\n PO:\n TF:\n IVF:\n 911 mL\n Blood products:\n Total out:\n 0 mL\n 565 mL\n Urine:\n 565 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 346 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): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 26 cmH2O\n Plateau: 15 cmH2O\n SpO2: 97%\n ABG: ///27/\n Ve: 8.2 L/min\n Physical Examination\n GEN: Intubated/sedated.\n HEENT: Pupils 4mm->3mm\n CV: Regular. No obvious murmurs.\n PULM: Clear anteriorly.\n ABD: Soft; no apparent tenderness\n EXT: Warm. No edema. No lesions; right BKA\n SKIN: No rash noted.\n NEURO: Pupils as above; sedated so unable to assess further\n Labs / Radiology\n 298 K/uL\n 9.9 g/dL\n 72 mg/dL\n 0.9 mg/dL\n 15 mg/dL\n 27 mEq/L\n 101 mEq/L\n 3.8 mEq/L\n 135 mEq/L\n 30.5 %\n 10.0 K/uL\n [image002.jpg]\n \n 2:33 A3/13/ 11:04 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 WBC\n 10.0\n Hct\n 30.5\n Plt\n 298\n Cr\n 0.9\n Glucose\n 72\n Other labs: Ca++:7.9 mg/dL, Mg++:1.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 71M with history of alcohol abuse, presenting with mental status change\n and fever.\n 1. Mental status change: be due to medication effect (percocet)\n though this seems unlikely given total intake. In the setting of\n fever, meningoencephalitis is of concern. LP at OSH was not consistent\n with meningitis.\n - Start IV acyclovir; given possibility of partially treated bacterial\n meningitis, will start CTX/vanco\n - Obtain CT neck\n - Consider MRI brain\n - ID consult\n 2. Fever: Other than change in mental status only localizing symptom is\n tooth pain.\n - Obtain CT neck\n - Cover for oral anaerobes with unasyn\n - CXR\n - UA\n 3. Hematuria: Unclear etiology.\n - Send urine culture\n - Consider urology consult\n FEN: NPO for possible extubation\n PPX: SC heparin; PPI\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 16 Gauge - 06:11 AM\n 18 Gauge - 06:11 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2152-04-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 447042, "text": "H/O altered mental status (not Delirium)\n Assessment:\n PATIENT received from ED on fent/versed drips, very agitated upon\n arrival requiring a bolus sedation\n Action:\n Bolused with sedation, required again at 12md for extreme agitation,\n not following commands attempting to get OOB, patient switched to\n propofol\n Response:\n Settled with propofol at 28mks/hr, did require bolus wneh CT perfomed\n of 1-2cc, pupils remain equal/reactive\n Plan:\n Continue to follow neuro exam/daily wake up..MRI tonight\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient received on ac 18x500 peep @ 5 50%, lungs a little rhonchus sx\n for thin whitte\n Action:\n Attempted to flip to p/s but patients RR tv low\n Response:\n Placed back on AC with satisfactory abg\n Plan:\n Continue AC until post MRI\n" }, { "category": "Nursing", "chartdate": "2152-04-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 447214, "text": "Mr. is a 71 year-old man from with no known past\n medical history other than prior alcohol abuse who presents with\n altered mental status.\n Per the daughter, patient has been having tooth pain for some time but\n he has not seen a physician in years. He has been taking a bottle of\n aspirin over the course of a month (up to 2grams per day). Went to OSH\n two days PTA and was given prescription for percocet and Pen V. On the\n morning PTA, daughter noted he had taken 2 percocet. Around noon, went\n to outpatient physician and was given prescription for percocet. Upon\n returning home, noted to be delirious (banging on front door). Appears\n that he took 3 percocet after filling prescription.\n At the OSH, T101 (per report; could not find documented); labs showed\n WBC 10.6, sodium 129, normal LFTs and negative alcohol. Initial\n lactate 2.4. Tox showed oxycodone, tylenol of 31.6, ASA of 10.3,\n intubated at OSH with 7.5 tube for extreme agitation. LP perfomed CT\n head and CXR were reportedly normal also performed at OSH prior to\n transfer..medflighted to \n Repeat head ct/xrs teeth gums performed at , no\n abnormalities seen\n EVENTS OVERNIGHT....patient went for MRI scan to evaluate head [ recent\n hx of toothache/headcahe ? abcess/encepahlitis], patient would not\n remain still for procedure despite total 1.5mgs lorazepam therefore\n procedure abandoned\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient successfully extubated yesterday and received on 3l n/c ,\n lungs sound course upper, sats > 93%..patient is known pack a day\n smoker for years\n Action:\n Encouraged to cough/deep breath/expectorate\n Response:\n Now mobilizing secretions, expectorating thick tan secretions [ sample\n was sent prior to extubation], sats maintained > 94%\n Plan:\n Chest PT , encourage cough/deep breath IS, wean fio2 as tolerated [\n patient needs nicotine patch prescribing]\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Patient admitted for possible infection process with fever at OSH, has\n been afebrile since admission, no lactate, no WBC, previous BCS\n pending/sputum pending, all tests to date negative but does have recent\n HX toothache with acute mental status changes..ID team following\n Action:\n MRI attempted to R/O abcess/encepahlitis\n Response:\n Unable to perform as patient non-compliant\n Plan:\n Continue to monitor fever curve, ABS as ordered , for repeat bcs if\n patient spikes ?? for another attempt of MRI scan\n .H/O altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2152-04-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 447213, "text": "Mr. is a 71 year-old man with no known past medical history other\n than prior alcohol abuse who presents with altered mental status.\n Per the daughter, patient has been having tooth pain for some time but\n he has not seen a physician in years. He has been taking a bottle of\n aspirin over the course of a month (up to 2grams per day). Went to OSH\n two days PTA and was given prescription for percocet and Pen V. On the\n morning PTA, daughter noted he had taken 2 percocet. Around noon, went\n to outpatient physician and was given prescription for percocet. Upon\n returning home, noted to be delirious (banging on front door). Appears\n that he took 3 percocet after filling prescription.\n At the OSH, T101 (per report; could not find documented); labs showed\n WBC 10.6, sodium 129, normal LFTs and negative alcohol. Initial\n lactate 2.4. Tox showed oxycodone, tylenol of 31.6, ASA of 10.3,\n intubated with 7.5 tube as very agitated. LP perfomed CT head and\n CXR were reportedly normal.\n EVENTS OVERNIGHT....patient went for MRI scan to evaluate head [ recent\n hx of toothache/headcahe ? abcess/encepahlitis], patient would not\n remain still for procedure despite total 1.5mgs lorazepam therefore\n procedure abandoned\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2152-04-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 447098, "text": "Demographics\n Day of intubation: 2\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: Unknown\n Procedure location: Outside hospital\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 Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thin\n Sputum source/amount: Suctioned / Copious\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Pending procedure / OR\n" }, { "category": "Nursing", "chartdate": "2152-04-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 447195, "text": "Mr. is a 71 year-old man with no known past medical history other\n than prior alcohol abuse who presents with altered mental status.\n Per the daughter, patient has been having tooth pain for some time but\n he has not seen a physician in years. He has been taking a bottle of\n aspirin over the course of a month (up to 2grams per day). Went to OSH\n two days PTA and was given prescription for percocet and PenV. On the\n morning PTA, daughter noted he had taken 2 percocet. Around noon, went\n to outpatient physician and was given prescription for percocet. Upon\n returning home, noted to be delirious (banging on front door). Appears\n that he took 3 percocet after filling prescription.\n At the OSH, T101 (per report; could not find documented); labs showed\n WBC 10.6, sodium 129, normal LFTs and negative alcohol. Initial\n lactate 2.4. UA showed hematuria and ketosis. Tox showed oxycodone,\n tylenol of 31.6, ASA of 10.3, intubated with 7.5 tube. Some bloody\n oral secretions were noted. LP perfomed CT head and CXR were\n reportedly normal.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received today on AC/500x18/+5/50%. LSCTA bilat, AM RSBI 43.\n Action:\n Pt was sedated on propofol but easily arousable. On propofol pt with\n spontaneous breaths. Pt tried on SBT which was successful, sedation\n turned off and pt extubated. Prior to extubation pt had sputum culture\n sent.\n Response:\n Currently pt with aerosol face mask at FiO2 50%. RR 12-24 with sats\n 97-99%. When pt takes off his O2, sats as low as 91% on RA. LSCTA\n bilat. Pt able to cough up and clear secretions.\n Plan:\n Continue to monitor resp status, wean O2 as pt tolerates, encourage\n cough and deep breathing, f/u sputum culture data.\n .H/O altered mental status (not Delirium)\n Assessment:\n Pt received on propofol at 50mcg/kg/min. When propofol turned off for\n neuro assessment pt became very restless, tachypneic, tachycardic, and\n hypertensive. Initially he was unable to follow any commands and\n making non-purposeful movements, PERL brisk.\n Action:\n In setting of pt\ns altered mental status and likely difficult to wean\n from vent and sedation pt was given a short SBT which was successful,\n sedation turned off and pt extubated. When pt first extubated speech\n was garbled, inconsistently followed commands and was oriented x1.\n Response:\n At present time, pt is alert and oriented x2-3 (knows name,\n\n, and\nhospital\n). Follows all commands at that time, but continues to take\n O2 off and is apologetic about it. Movements are purposeful and PERL\n brisk.\n Plan:\n Continue to monitor MS/neuros, orient pt as needed, hold all sedating\n medications. No MRI for now unknown metal in pt\ns arm s/p MVA 7\n years ago. f/u culture data.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with Tmax 99.3 Axillary.\n Action:\n Pt given IV unasyn and doxycycline.\n Response:\n n/a\n Plan:\n Continue to monitor temp, admin IV Abx per order, culture is pt spikes.\n" }, { "category": "Nursing", "chartdate": "2152-04-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 447018, "text": "Mr. is a 71 year-old man with no known past medical history of\n than prior alcohol abuse who presents with altered mental status.\n Per the daughter, patient has been having tooth pain for some time but\n he has not seen a physician in years. Has been taking a bottle of\n aspirin over the course of a month (up to 2grams per day). Went to OSH\n two days PTA. Was given prescription for percocet and PenV. On the\n morning PTA, daughter noted he had taken 2 percocet. Around noon, went\n to outpatient physician and was given prescription for percocet. Upon\n returning home, noted to be delirious (banging on front door). Appears\n that he took 3 percocet after filling prescription.\n At the OSH, T101 (per report; could not find documented); labs showed\n WBC 10.6, sodium 129, normal LFTs and negative alcohol. Initial\n lactate 2.4. UA showed hematuria and ketosis. Tox showed oxycodone,\n tylenol of 31.6, ASA of 10.3.\n After becoming increasingly agitated, was intubated with 7.5 tube.\n Some bloody oral secretions were noted. LP perfomed CT head and CXR\n were reportedly normal.\n In our ED, initially intubated/sedated/paralyzed and hemodynamically\n stable. Tmax of 99.2. He was given a banana bag.\n Daughter also reports that he has complained of some headache for a\n few weeks. No fevers. No tick bites noted.\n" }, { "category": "Nursing", "chartdate": "2152-04-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 447023, "text": "Mr. is a 71 year-old man with no known past medical history of\n than prior alcohol abuse who presents with altered mental status.\n Per the daughter, patient has been having tooth pain for some time but\n he has not seen a physician in years. Has been taking a bottle of\n aspirin over the course of a month (up to 2grams per day). Went to OSH\n two days PTA. Was given prescription for percocet and PenV. On the\n morning PTA, daughter noted he had taken 2 percocet. Around noon, went\n to outpatient physician and was given prescription for percocet. Upon\n returning home, noted to be delirious (banging on front door). Appears\n that he took 3 percocet after filling prescription.\n At the OSH, T101 (per report; could not find documented); labs showed\n WBC 10.6, sodium 129, normal LFTs and negative alcohol. Initial\n lactate 2.4. UA showed hematuria and ketosis. Tox showed oxycodone,\n tylenol of 31.6, ASA of 10.3.\n After becoming increasingly agitated, was intubated with 7.5 tube.\n Some bloody oral secretions were noted. LP perfomed CT head and CXR\n were reportedly normal.\n In our ED, initially intubated/sedated/paralyzed and hemodynamically\n stable. Tmax of 99.2. He was given a banana bag.\n Daughter also reports that he has complained of some headache for a\n few weeks. No fevers. No tick bites noted.\n EVENTS\nlabs sent for lyme disease, CT done head/neck for possible\n abcess, dental XRS taken again looking for abcess, ID following, IV abs\n commenced\n.for MRI TONIGHT\n .H/O altered mental status (not Delirium)\n Assessment:\n PATIENT received from ED on fent/versed drips, very agitated upon\n arrival requiring a bolus sedation\n Action:\n Bolused with sedation, required again at 12md for extreme agitation,\n not following commands attempting to get OOB, patient switched to\n propofol\n Response:\n Settled with propofol at 28mks/hr, did require bolus wneh CT perfomed\n of 1-2cc, pupils remain equal/reactive\n Plan:\n Continue to follow neuro exam/daily wake up..MRI tonight\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Patient came in with fever to 101\n Action:\n ABS commenced, ID following\n Response:\n Afebrile since admission\n Plan:\n Continue to follow fever curve, abs as ordered, culture as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient received on ac 18x500 peep @ 5 50%, lungs a little rhonchus sx\n for thin whitte\n Action:\n Attempted to flip to p/s but patients RR tv low\n Response:\n Placed back on AC with satisfactory abg\n Plan:\n Continue AC until post MRI\n Of note, patient has had small amount of coffee ground noted in OG,\n placed to LWS hcts stable, active Type screen, placed on PPI\n" }, { "category": "Respiratory ", "chartdate": "2152-04-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 447190, "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: Unknown\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: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Moderate\n Respiratory Care Service: Pt extubated today to a 50 % aerosol mask\n after a successful SBT and an RSBI of 43 in the AM. Doing well\n w/improved mental status. RR 18-22 and SPO2 96 %. Will encourage C+\n DBing and monitor closely.\n" }, { "category": "Nursing", "chartdate": "2152-04-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 447180, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2152-04-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 447252, "text": "Chief Complaint:\n 24 Hour Events:\n - Extubated. Was initially hypertensive and tachycardic but normalized.\n Was given 500cc NS bolus.\n - Alert and oriented x 3 but unable to provide good history of what\n prompted his hospitalization\n - MRI attempted(hardware in left elbow okay per radiology tech) - pt\n wouldn't stay still despite 2 mg Ativan IV.\n MAGNETIC RESONANCE IMAGING - At 09:52 PM\n head but patient non compliant therefore not finished\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:52 AM\n Ceftriaxone - 10:53 AM\n Acyclovir - 11:50 AM\n Ampicillin - 12:00 AM\n Doxycycline - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:31 AM\n Midazolam (Versed) - 08:50 AM\n Lorazepam (Ativan) - 09:53 PM\n Heparin Sodium (Prophylaxis) - 01:49 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 05:38 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: 36.4\nC (97.5\n HR: 78 (76 - 124) bpm\n BP: 123/54(71) {114/54(71) - 182/100(112)} mmHg\n RR: 12 (10 - 23) insp/min\n SpO2: 95% on O2 NC\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,254 mL\n 256 mL\n PO:\n TF:\n IVF:\n 3,254 mL\n 256 mL\n Blood products:\n Total out:\n 3,280 mL\n 345 mL\n Urine:\n 2,630 mL\n 345 mL\n NG:\n 650 mL\n Stool:\n Drains:\n Balance:\n -26 mL\n -89 mL\n Physical Examination\n GEN: sleeping\n HEENT: Pupils 4mm->3mm\n CV: Regular. No obvious murmurs.\n PULM: Clear anteriorly.\n ABD: Soft; no apparent tenderness\n EXT: Warm. No edema. No lesions; right BKA\n SKIN: No rash noted.\n NEURO: Pupils as above; sedated so unable to assess further\n Labs / Radiology\n 308 K/uL\n 9.4 g/dL\n 76 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 10 mg/dL\n 102 mEq/L\n 139 mEq/L\n 28.5 %\n 10.0 K/uL\n [image002.jpg]\n 11:04 AM\n 04:34 PM\n 10:11 PM\n 03:16 AM\n 03:26 AM\n WBC\n 10.0\n 7.7\n 9.5\n 10.0\n Hct\n 30.5\n 29.9\n 31.1\n 28.5\n Plt\n 298\n 282\n 266\n 308\n Cr\n 0.9\n 0.9\n 0.9\n TCO2\n 29\n Glucose\n 72\n 77\n 76\n Other labs: PT / PTT / INR:14.0/39.5/1.2, ALT / AST:15/17, Alk Phos / T\n Bili:52/0.3, Lactic Acid:0.6 mmol/L, Albumin:3.5 g/dL, LDH:138 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 71M with history of alcohol abuse, but no recent use, presenting with\n toothache, mental status change, and fever.\n 1. Mental status change, fever: be due simply to medication effect\n (percocet) in an elderly male, though does not explain initial fever.\n Initially, suspicion for infection high, though patient afebrile here\n and WBC count not elevated. LP at OSH was not consistent with\n meningitis. CT head & neck here without evidence of odontogenic or\n soft tissue neck abscess. Attempted MRI of head however pt was able to\n tolerate it (cleared the issue of hardware in left elbow s/p ORIF in\n at pt ok for MRI)\n - cont. doxycycline and unasyn for empiric coverage of ricketsial\n disease and oral flora\n - f/u ID recs\n - repeat thick & thin smear for parasites today & tomorrow for total of\n 3 (so far negative)\n - f/u microbio studies that were sent at OSH\n 2. Respiratory failure\n Patient initially intubated only for LP per\n report. Was successfully extubated yesterday. Was hypertensive and\n tachycardic post-intubation but both HR and BP normalized after 500cc\n NS bolus. Now satting well on O2 NC\n .\n 3. AMS\n was noted to be altered on presentation to OSH. Pt now alert\n and oriented x 3 after discontinuation of sedation and extubation.\n However unable to give good history of presentation.\n - Ask family about pt\ns baseline mental status\n - f/u MRI head (although incomplete)\n .\n FEN: speech and swallow (on soft solids at home) study then PO diet .\n PPX: SC heparin; d/c PPI as pt no longer intubated\n Code: presumed full\n Communication: Spokesperson is patient\ns daughter who requests\n no info be given to daughter ; also communicate with\n patient\ns wife. Phone numbers on board in room.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 06:11 AM\n 20 Gauge - 12:36 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2152-04-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 447183, "text": "Mr. is a 71 year-old man with no known past medical history of\n than prior alcohol abuse who presents with altered mental status.\n Per the daughter, patient has been having tooth pain for some time but\n he has not seen a physician in years. He has been taking a bottle of\n aspirin over the course of a month (up to 2grams per day). Went to OSH\n two days PTA. Was given prescription for percocet and PenV. On the\n morning PTA, daughter noted he had taken 2 percocet. Around noon, went\n to outpatient physician and was given prescription for percocet. Upon\n returning home, noted to be delirious (banging on front door). Appears\n that he took 3 percocet after filling prescription.\n At the OSH, T101 (per report; could not find documented); labs showed\n WBC 10.6, sodium 129, normal LFTs and negative alcohol. Initial\n lactate 2.4. UA showed hematuria and ketosis. Tox showed oxycodone,\n tylenol of 31.6, ASA of 10.3, intubated with 7.5 tube. Some bloody\n oral secretions were noted. LP perfomed CT head and CXR were\n reportedly normal.\n In our ED, initially intubated/sedated/paralyzed and hemodynamically\n stable. Tmax of 99.2. He was given a banana bag.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received today on AC/500x18/+5/50%. LSCTA bilat, AM RSBI 43.\n Action:\n Pt was sedated on propofol but easily arousable. On propofol pt with\n spontaneous breaths. Pt tried on SBT which was successful, sedation\n turned off and pt extubated. Prior to extubation pt had sputum culture\n sent.\n Response:\n Currently pt with aerosol face mask at FiO2 50%. RR 12-24 with sats\n 97-99%. When pt takes off his O2, sats as low as 91% on RA. LSCTA\n bilat. Pt able to cough up and clear secretions.\n Plan:\n Continue to monitor resp status, wean O2 as pt tolerates, encourage\n cough and deep breathing, f/u sputum culture data.\n .H/O altered mental status (not Delirium)\n Assessment:\n Pt received on propofol at 50mcg/kg/min. When propofol turned off for\n neuro assessment pt became very restless, tachypneic, tachycardic, and\n hypertensive. Initially he was unable to follow any commands and\n making non-purposeful movements, PERL brisk.\n Action:\n In setting of pt\ns altered mental status and likely difficult to wean\n from vent and sedation pt was given a short SBT which was successful,\n sedation turned off and pt extubated. When pt first extubated speech\n was garbled, inconsistently followed commands and was oriented x1.\n Response:\n At present time, pt is alert and oriented x2-3 (knows name,\n\n, and\nhospital\n). Follows all commands at that time, but continues to take\n O2 off and is apologetic about it. Movements are purposeful and PERL\n brisk.\n Plan:\n Continue to monitor MS/neuros, orient pt as needed, hold all sedating\n medications. No MRI for now unknown metal in pt\ns arm s/p MVA 7\n years ago. f/u culture data.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with Tmax 99.3 Axillary.\n Action:\n Pt given IV unasyn and doxycycline.\n Response:\n n/a\n Plan:\n Continue to monitor temp, admin IV Abx per order, culture is pt spikes.\n" }, { "category": "Physician ", "chartdate": "2152-04-21 00:00:00.000", "description": "Physician Resident/Attending Admission Note - MICU", "row_id": 447004, "text": "Chief Complaint: Altered mental status; fever\n HPI:\n Mr. is a 71 year-old man with no known past medical history of\n than prior alcohol abuse who presents with altered mental status.\n Per the daughter, patient has been having tooth pain for some time but\n he has not seen a physician in years. Has been taking a bottle of\n aspirin over the course of a month (up to 2grams per day). Went to OSH\n two days PTA. Was given prescription for percocet and PenV. On the\n morning PTA, daughter noted he had taken 2 percocet. Around noon, went\n to outpatient physician and was given prescription for percocet. Upon\n returning home, noted to be delirious (banging on front door). Appears\n that he took 3 percocet after filling prescription.\n Per EMG report, glucose 99, GCS 12. At the OSH, T101 (per report;\n could not find documented); labs showed WBC 10.6, sodium 129, normal\n LFTs and negative alcohol. Initial lactate 2.4. UA showed hematuria\n and ketosis. Tox showed oxycodone, tylenol of 31.6, ASA of 10.3.\n After becoming increasingly agitated, was intubated with 7.5 tube.\n Some bloody oral secretions were noted. LP perfomed with 3 WBC and\n RBC, glucose 59, protein 53 and negative gram stain. CT head and CXR\n were reportedly normal. Cephtriaxone 1g was given before the LP.\n In our ED, initially intubated/sedated/paralyzed and hemodynamically\n stable. Tmax of 99.2. He was given a banana bag.\n On ROS, daughter reports that he has complained of some headache for a\n few weeks. No fevers. No tick bites noted.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:52 AM\n Ceftriaxone - 10:53 AM\n Acyclovir - 11:50 AM\n Doxycycline - 11:50 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:53 AM\n Heparin Sodium (Prophylaxis) - 10:53 AM\n Home medications: None\n Past medical history:\n Family history:\n Social History:\n History of alcohol abuse, last drink 3 years ago (per wife).\n BKA and jaw trauma secondary to MVA ()\n Occupation:\n Drugs: None\n Tobacco: 1ppd\n Alcohol: Prior history of tobacco abuse; 3 years sober\n Other:\n Review of systems:\n Constitutional: Fever\n Neurologic: Headache\n Flowsheet Data as of 12:53 PM\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: 36.4\nC (97.5\n HR: 87 (84 - 107) bpm\n BP: 154/75(94) {136/72(87) - 198/100(118)} mmHg\n RR: 19 (10 - 19) insp/min\n SpO2: 97%\n Total In:\n 911 mL\n PO:\n TF:\n IVF:\n 911 mL\n Blood products:\n Total out:\n 0 mL\n 565 mL\n Urine:\n 565 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 346 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): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 26 cmH2O\n Plateau: 15 cmH2O\n SpO2: 97%\n ABG: ///27/\n Ve: 8.2 L/min\n Physical Examination\n GEN: Intubated/sedated.\n HEENT: Pupils 4mm->3mm\n CV: Regular. No obvious murmurs.\n PULM: Clear anteriorly.\n ABD: Soft; no apparent tenderness\n EXT: Warm. No edema. No lesions; right BKA\n SKIN: No rash noted.\n NEURO: Pupils as above; sedated so unable to assess further\n Labs / Radiology\n 298 K/uL\n 9.9 g/dL\n 72 mg/dL\n 0.9 mg/dL\n 15 mg/dL\n 27 mEq/L\n 101 mEq/L\n 3.8 mEq/L\n 135 mEq/L\n 30.5 %\n 10.0 K/uL\n [image002.jpg]\n \n 2:33 A3/13/ 11:04 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 WBC\n 10.0\n Hct\n 30.5\n Plt\n 298\n Cr\n 0.9\n Glucose\n 72\n Other labs: Ca++:7.9 mg/dL, Mg++:1.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 71M with history of alcohol abuse, presenting with mental status change\n and fever.\n 1. Mental status change: be due to medication effect (percocet)\n though this seems unlikely given total intake. In the setting of\n fever, meningoencephalitis is of concern. LP at OSH was not consistent\n with meningitis.\n - Start IV acyclovir; given possibility of partially treated bacterial\n meningitis, will start CTX/vanco\n - Obtain CT neck\n - Consider MRI brain\n - ID consult\n 2. Fever: Other than change in mental status only localizing symptom is\n tooth pain.\n - Obtain CT neck\n - Cover for oral anaerobes with unasyn\n - CXR\n - UA\n 3. Hematuria: Unclear etiology.\n - Send urine culture\n - Consider urology consult\n FEN: NPO for possible extubation\n PPX: SC heparin; PPI\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 16 Gauge - 06:11 AM\n 18 Gauge - 06:11 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\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: 71M prior EtOH, recent tooth pain treated\n with PCN, high dose ASA, and percocet, developed altered mental status.\n + fevers, elevated WBCs at OSH, LP 3wbcs, xferred for further\n management.\n Exam notable for Tm 101 BP 153/88 HR 84 RR 18 with sat 100 on PSV. No\n LAD, poor dentition. No nuchal rigidity. CTA B. RRR s1s2. Soft +BS. No\n edema or rash. Labs notable for WBC 10K, HCT 32, K+ 4.0, Cr 0.9,\n lactate 1.0. CXR pending.\n Agree with plan to manage altered mental status with transition from\n fent/midaz to propofol given need for serial exams. Concern exists for\n ongoing infection given fever; will confirm HSV sent from OSH and will\n treat for possible meningitis with acyclovir and high dose CTX, while\n adding unasyn for possible odontogenic / soft tissue infection. Will\n check for lyme, erlichia, and babesia and cover with doxy for now. Need\n to check OSH records and d/w ID. Given tooth pain, will check contrast\n CT neck CT, as well as MRI for possible leptomeningeal enhancement in\n the setting of meningoencephalitis. Will continue AC vent for now until\n imaging completed. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:26 PM ------\n" }, { "category": "Physician ", "chartdate": "2152-04-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 447237, "text": "Chief Complaint:\n 24 Hour Events:\n - Extubated. Was initially hypertensive and tachycardic but normalized.\n Was given 500cc NS bolus.\n - Alert and oriented x 3 but unable to provide good history of what\n prompted his hospitalization\n - MRI/A attempted(hardware in left elbow okay per radiology tech) - pt\n wouldn't stay still despite 2 mg Ativan IV.\n MAGNETIC RESONANCE IMAGING - At 09:52 PM\n head but patient non compliant therefore not finished\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:52 AM\n Ceftriaxone - 10:53 AM\n Acyclovir - 11:50 AM\n Ampicillin - 12:00 AM\n Doxycycline - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:31 AM\n Midazolam (Versed) - 08:50 AM\n Lorazepam (Ativan) - 09:53 PM\n Heparin Sodium (Prophylaxis) - 01:49 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 05:38 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: 36.4\nC (97.5\n HR: 78 (76 - 124) bpm\n BP: 123/54(71) {114/54(71) - 182/100(112)} mmHg\n RR: 12 (10 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,254 mL\n 256 mL\n PO:\n TF:\n IVF:\n 3,254 mL\n 256 mL\n Blood products:\n Total out:\n 3,280 mL\n 345 mL\n Urine:\n 2,630 mL\n 345 mL\n NG:\n 650 mL\n Stool:\n Drains:\n Balance:\n -26 mL\n -89 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 95%\n ABG: ///27/\n Ve: 12.4 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 308 K/uL\n 9.4 g/dL\n 76 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 10 mg/dL\n 102 mEq/L\n 139 mEq/L\n 28.5 %\n 10.0 K/uL\n [image002.jpg]\n 11:04 AM\n 04:34 PM\n 10:11 PM\n 03:16 AM\n 03:26 AM\n WBC\n 10.0\n 7.7\n 9.5\n 10.0\n Hct\n 30.5\n 29.9\n 31.1\n 28.5\n Plt\n 298\n 282\n 266\n 308\n Cr\n 0.9\n 0.9\n 0.9\n TCO2\n 29\n Glucose\n 72\n 77\n 76\n Other labs: PT / PTT / INR:14.0/39.5/1.2, ALT / AST:15/17, Alk Phos / T\n Bili:52/0.3, Lactic Acid:0.6 mmol/L, Albumin:3.5 g/dL, LDH:138 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 06:11 AM\n 20 Gauge - 12:36 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2152-04-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 447238, "text": "Chief Complaint:\n 24 Hour Events:\n - Extubated. Was initially hypertensive and tachycardic but normalized.\n Was given 500cc NS bolus.\n - Alert and oriented x 3 but unable to provide good history of what\n prompted his hospitalization\n - MRI/A attempted(hardware in left elbow okay per radiology tech) - pt\n wouldn't stay still despite 2 mg Ativan IV.\n MAGNETIC RESONANCE IMAGING - At 09:52 PM\n head but patient non compliant therefore not finished\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:52 AM\n Ceftriaxone - 10:53 AM\n Acyclovir - 11:50 AM\n Ampicillin - 12:00 AM\n Doxycycline - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:31 AM\n Midazolam (Versed) - 08:50 AM\n Lorazepam (Ativan) - 09:53 PM\n Heparin Sodium (Prophylaxis) - 01:49 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 05:38 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: 36.4\nC (97.5\n HR: 78 (76 - 124) bpm\n BP: 123/54(71) {114/54(71) - 182/100(112)} mmHg\n RR: 12 (10 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,254 mL\n 256 mL\n PO:\n TF:\n IVF:\n 3,254 mL\n 256 mL\n Blood products:\n Total out:\n 3,280 mL\n 345 mL\n Urine:\n 2,630 mL\n 345 mL\n NG:\n 650 mL\n Stool:\n Drains:\n Balance:\n -26 mL\n -89 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 95%\n ABG: ///27/\n Ve: 12.4 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 308 K/uL\n 9.4 g/dL\n 76 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 10 mg/dL\n 102 mEq/L\n 139 mEq/L\n 28.5 %\n 10.0 K/uL\n [image002.jpg]\n 11:04 AM\n 04:34 PM\n 10:11 PM\n 03:16 AM\n 03:26 AM\n WBC\n 10.0\n 7.7\n 9.5\n 10.0\n Hct\n 30.5\n 29.9\n 31.1\n 28.5\n Plt\n 298\n 282\n 266\n 308\n Cr\n 0.9\n 0.9\n 0.9\n TCO2\n 29\n Glucose\n 72\n 77\n 76\n Other labs: PT / PTT / INR:14.0/39.5/1.2, ALT / AST:15/17, Alk Phos / T\n Bili:52/0.3, Lactic Acid:0.6 mmol/L, Albumin:3.5 g/dL, LDH:138 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 71M with history of alcohol abuse, but no recent use, presenting with\n toothache, mental status change, and fever.\n 1. Mental status change, fever: be due simply to medication effect\n (percocet) in an elderly male, though does not explain initial fever.\n Initially, suspicion for infection high, though patient afebrile here\n and WBC count not elevated. LP at OSH was not consistent with\n meningitis. CT head & neck here without evidence of odontogenic or\n soft tissue neck abscess. Unable to obtain MRI overnight due to metal\n screws in left elbow and inability to clear patient for MRI scanner as\n unable to obtain OSH records regarding placement.\n - cont. doxycycline and unasyn for empiric coverage of ricketsial\n disease and oral flora\n - f/u ID recs\n - repeat thick & thin smear for parasites today & tomorrow for total of\n 3\n - Try to obtain records on left elbow screws to potentially clear pt\n for MRI scanner\n 2. Respiratory failure\n Patient initially intubated only for LP per\n report. Had good RSBI this morning. Continues to become agitated with\n lifting of sedation. Question regarding weaning from vent does not\n currently seem to be secondary to respiratory issues, but more due to\n mental status.\n - spontaneous breathing trial this morning\n - attempt extubation and try to better assess mental status once\n propofol clear\n - may need haldol or zyprexa prn\n .\n 3. Hematuria: Unclear etiology, may be related to foley placement. Has\n now resolved.\n .\n 4. ?Coffee grounds aspirated from NGT\n appears less red this morning.\n Will continue to monitor NGT output.\n FEN: NPO for possible extubation\n PPX: SC heparin; PPI\n Code: presumed full\n Communication: Spokesperson is patient\ns daughter who requests\n no info be given to daughter ; also communicate with\n patient\ns wife. Phone numbers on board in room.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 06:11 AM\n 20 Gauge - 12:36 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2152-04-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 447239, "text": "Chief Complaint:\n 24 Hour Events:\n - Extubated. Was initially hypertensive and tachycardic but normalized.\n Was given 500cc NS bolus.\n - Alert and oriented x 3 but unable to provide good history of what\n prompted his hospitalization\n - MRI/A attempted(hardware in left elbow okay per radiology tech) - pt\n wouldn't stay still despite 2 mg Ativan IV.\n MAGNETIC RESONANCE IMAGING - At 09:52 PM\n head but patient non compliant therefore not finished\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:52 AM\n Ceftriaxone - 10:53 AM\n Acyclovir - 11:50 AM\n Ampicillin - 12:00 AM\n Doxycycline - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:31 AM\n Midazolam (Versed) - 08:50 AM\n Lorazepam (Ativan) - 09:53 PM\n Heparin Sodium (Prophylaxis) - 01:49 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 05:38 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: 36.4\nC (97.5\n HR: 78 (76 - 124) bpm\n BP: 123/54(71) {114/54(71) - 182/100(112)} mmHg\n RR: 12 (10 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,254 mL\n 256 mL\n PO:\n TF:\n IVF:\n 3,254 mL\n 256 mL\n Blood products:\n Total out:\n 3,280 mL\n 345 mL\n Urine:\n 2,630 mL\n 345 mL\n NG:\n 650 mL\n Stool:\n Drains:\n Balance:\n -26 mL\n -89 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 95%\n ABG: ///27/\n Ve: 12.4 L/min\n Physical Examination\n GEN: Intubated/sedated.\n HEENT: Pupils 4mm->3mm\n CV: Regular. No obvious murmurs.\n PULM: Clear anteriorly.\n ABD: Soft; no apparent tenderness\n EXT: Warm. No edema. No lesions; right BKA\n SKIN: No rash noted.\n NEURO: Pupils as above; sedated so unable to assess further\n Labs / Radiology\n 308 K/uL\n 9.4 g/dL\n 76 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 10 mg/dL\n 102 mEq/L\n 139 mEq/L\n 28.5 %\n 10.0 K/uL\n [image002.jpg]\n 11:04 AM\n 04:34 PM\n 10:11 PM\n 03:16 AM\n 03:26 AM\n WBC\n 10.0\n 7.7\n 9.5\n 10.0\n Hct\n 30.5\n 29.9\n 31.1\n 28.5\n Plt\n 298\n 282\n 266\n 308\n Cr\n 0.9\n 0.9\n 0.9\n TCO2\n 29\n Glucose\n 72\n 77\n 76\n Other labs: PT / PTT / INR:14.0/39.5/1.2, ALT / AST:15/17, Alk Phos / T\n Bili:52/0.3, Lactic Acid:0.6 mmol/L, Albumin:3.5 g/dL, LDH:138 IU/L,\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 71M with history of alcohol abuse, but no recent use, presenting with\n toothache, mental status change, and fever.\n 1. Mental status change, fever: be due simply to medication effect\n (percocet) in an elderly male, though does not explain initial fever.\n Initially, suspicion for infection high, though patient afebrile here\n and WBC count not elevated. LP at OSH was not consistent with\n meningitis. CT head & neck here without evidence of odontogenic or\n soft tissue neck abscess. Unable to obtain MRI overnight due to metal\n screws in left elbow and inability to clear patient for MRI scanner as\n unable to obtain OSH records regarding placement.\n - cont. doxycycline and unasyn for empiric coverage of ricketsial\n disease and oral flora\n - f/u ID recs\n - repeat thick & thin smear for parasites today & tomorrow for total of\n 3\n - Try to obtain records on left elbow screws to potentially clear pt\n for MRI scanner\n 2. Respiratory failure\n Patient initially intubated only for LP per\n report. Had good RSBI this morning. Continues to become agitated with\n lifting of sedation. Question regarding weaning from vent does not\n currently seem to be secondary to respiratory issues, but more due to\n mental status.\n - spontaneous breathing trial this morning\n - attempt extubation and try to better assess mental status once\n propofol clear\n - may need haldol or zyprexa prn\n .\n 3. Hematuria: Unclear etiology, may be related to foley placement. Has\n now resolved.\n .\n 4. ?Coffee grounds aspirated from NGT\n appears less red this morning.\n Will continue to monitor NGT output.\n FEN: NPO for possible extubation\n PPX: SC heparin; PPI\n Code: presumed full\n Communication: Spokesperson is patient\ns daughter who requests\n no info be given to daughter ; also communicate with\n patient\ns wife. Phone numbers on board in room.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 06:11 AM\n 20 Gauge - 12:36 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Radiology", "chartdate": "2152-04-21 00:00:00.000", "description": "MANDIBLE (PA, TOWNES & BOTH OBLS)", "row_id": 1067702, "text": " 2:58 PM\n MANDIBLE (PA, & BOTH OBLS) Clip # \n Reason: looking for odontogenic abscess or other cause\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with tooth pain and fever\n REASON FOR THIS EXAMINATION:\n looking for odontogenic abscess or other cause\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Mandible series, .\n\n HISTORY: 71-year-old man with tooth pain and fever. Evaluate for odontogenic\n abscess or other cause.\n\n FINDINGS: There is hardware in the right mandibular rami. No hardware-\n related complications are seen. The patient is edentulous. There is no \n bony destruction on these limited images. Endotracheal and nasogastric tubes\n are identified. If there is high clinical concern for subtle cortical\n abnormalities of the facial bones, dedicated CT mandibular series is\n recommended.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1067887, "text": " 3:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please check interval change\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fever of unknown etiology, respiratory failure\n REASON FOR THIS EXAMINATION:\n please check interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fever of unknown origin, respiratory failure.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip has been removed in the interim as well as the NG tube. The\n current study demonstrates significant interval worsening of the aeration of\n the left base with newly developed atelectasis and increase in pleural\n effusion. In addition to atelectasis this consolidation might represent\n progression of infection. Minimal faint opacity seen at the right base, new\n and most likely represents atelectasis. There is no appreciable right pleural\n effusion. There is no pneumothorax.\n\n IMPRESSION: Worsening of the left basal aeration with signs of volume loss\n suggesting atelectasis but the progression of infection can also not be\n excluded. Increase in left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-21 00:00:00.000", "description": "BP ELBOW, AP & LAT VIEWS BILAT PORT", "row_id": 1067769, "text": " 9:24 PM\n ELBOW, AP & LAT VIEWS BILAT PORT Clip # \n Reason: please evaluate for any evidence of metal - would like to MR\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with altered mental status, would like to get MRA/MRV but per\n daughter, patient had elbow recontructions post-MVA with some sort of metal\n placement (no records available)\n REASON FOR THIS EXAMINATION:\n please evaluate for any evidence of metal - would like to MR head\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT ELBOW\n\n HISTORY: Altered mental status, evaluate for placement of metal.\n\n Three views of each elbow. There is deformity of the medial epicondyle of the\n left elbow consistent with an old healed fracture. This is traversed by two\n metallic screws that extend into the distal humeral diametaphysis, one\n extending through the posterior cortex. Visualized cortical margins are\n intact. There is no evidence of dislocation. Mild degenerative arthritic\n changes are present bilaterally. Soft tissues are unremarkable.\n\n Impression: Old post-traumatic deformity of the distal left humerus. Two\n metallic screws are present at that site.\n\n" }, { "category": "Radiology", "chartdate": "2152-04-21 00:00:00.000", "description": "CT HEAD W/ CONTRAST", "row_id": 1067699, "text": ", F. MED MICU 2:34 PM\n CT HEAD W/ CONTRAST Clip # \n Reason: Please check for foci of infection such as odontogenic absce\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fever and AMS\n REASON FOR THIS EXAMINATION:\n Please check for foci of infection such as odontogenic abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No evidence for abscess. Fluid level in the left maxillary sinus and mild\n mucosal thickening in bilateral frontal and ethmoid sinuses as well as the\n sphenoid sinus. This may be related to intubation.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-21 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 1067697, "text": ", F. MED MICU 2:33 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: Please check for foci of infection such as abscesses\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fever and AMS\n REASON FOR THIS EXAMINATION:\n Please check for foci of infection such as abscesses\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No evidence of abscess.\n\n" }, { "category": "Radiology", "chartdate": "2152-04-22 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1067868, "text": " 8:07 PM\n MR HEAD W/O CONTRAST; MRV HEAD W/O CONTRAST Clip # \n -52 REDUCED SERVICES\n Reason: please evaluate for potential causes of AMS\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fever, altered mental status, and toothache\n REASON FOR THIS EXAMINATION:\n please evaluate for potential causes of AMS\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n LIMITED MRI SCAN OF THE BRAIN AND MR VENOGRAPHY\n\n HISTORY: Fever and altered mental status as well as toothache. Evaluate for\n potential causes of acute mental status.\n\n TECHNIQUE: As per orders of Dr. , a very limited MR protocol of the\n brain was obtained, consisting of sagittal T1- and axial FLAIR scans, followed\n by an MR venogram.\n\n COMPARISON STUDY ON PACS ARCHIVE: CT scan of the head with intravenous\n contrast enhancement from .\n\n FINDINGS: Diffusion-weighted images of the brain are normal.\n\n Axial FLAIR scans reveal only a miniscule quantity of elevated T2 signal\n within the periventricular white matter of both cerebral hemispheres. While\n nonspecific in etiology, given the absence of commensurate contrast\n enhancement on the prior CT scan, a minimal degree of chronic small vessel\n infarction appears the most likely diagnosis. There is no shift of normally\n midline structures or overt mass effect.\n\n The MR venogram is degraded by patient motion artifacts. Within these\n limitations, there is no overt abnormality of the major venous drainage\n structures of the brain. However, please note, that this study cannot provide\n reliable imaging of the cavernous sinuses. Based upon the single available\n axial FLAIR scan series, no abnormality of this region is appreciated.\n When reviewing the prior contrast-enhanced head CT scan, no definite asymmetry\n of either the degree of opacification or morphology of the cavernous sinuses\n is appreciated. There is moderate mucosal thickening within the ethmoid\n sinuses, and to a milder degree within the maxillary sinuses, similar to that\n seen on the prior CT scan, likely indicating a chronic inflammatory process.\n Please note that this study does not encompass the mandible in its entirety,\n except on the motion-degraded sagittal T1-weighted scans. Thus, it is\n impossible to comprehensively evaluate for potential odontogenic infections.\n\n CONCLUSION: Suboptimal study. Please see above report for additional\n discussion.\n\n (Over)\n\n 8:07 PM\n MR HEAD W/O CONTRAST; MRV HEAD W/O CONTRAST Clip # \n -52 REDUCED SERVICES\n Reason: please evaluate for potential causes of AMS\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2152-04-21 00:00:00.000", "description": "CT HEAD W/ CONTRAST", "row_id": 1067698, "text": " 2:34 PM\n CT HEAD W/ CONTRAST Clip # \n Reason: Please check for foci of infection such as odontogenic absce\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fever and AMS\n REASON FOR THIS EXAMINATION:\n Please check for foci of infection such as odontogenic abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMdb FRI 4:27 PM\n No evidence for abscess. Fluid level in the left maxillary sinus and mild\n mucosal thickening in bilateral frontal and ethmoid sinuses as well as the\n sphenoid sinus. This may be related to intubation.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD WITH CONTRAST\n\n HISTORY: Mental status change.\n\n There is no intracranial mass, mass effect or midline shift. There is no\n evidence for abscess.\n\n There is mild small vessel ischemic sequela in the subcortical white matter.\n\n There is intracranial vascular calcification.\n\n There are fluid levels in the left maxillary sinus, which may be related to\n intubation. Mild mucosal thickening in the sphenoid and ethmoid sinuses is\n also noted. There is mild mucosal thickening in the frontal sinuses.\n\n IMPRESSION:\n\n No evidence for intracranial abscess.\n\n Fluid level in the left maxillary sinus and mild mucosal thickening in\n bilateral ethmoid, sphenoid and frontal sinuses.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-21 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 1067696, "text": " 2:33 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: Please check for foci of infection such as abscesses\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fever and AMS\n REASON FOR THIS EXAMINATION:\n Please check for foci of infection such as abscesses\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMdb FRI 4:09 PM\n No evidence of abscess.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE NECK WITH CONTRAST\n\n HISTORY: Fever and mental status change, assess for abscess.\n\n The patient is intubated.\n\n The proximal portion of an NG tube can also be seen. There is effacement of\n the oropharyngeal and nasopharyngeal lumen from secretions. Within limits of\n the examination, no fluid collection is seen to suggest an abscess. There are\n a few scattered neck nodes in level 2 which are not pathologic by size\n criteria.\n\n The upper lung fields are clear.\n\n The thyroid gland enhances homogeneously.\n\n Bilateral apical bullous changes are seen in the lung.\n\n Evaluation of the larynx is limited due to presence of ET tube.\n\n There are degenerative changes in the cervical spine.\n\n IMPRESSION:\n\n No evidence for abscess.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1067582, "text": " 3:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for ett placement / effusion / consolidation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with altered mental status intubated xfr from osh\n REASON FOR THIS EXAMINATION:\n please eval for ett placement / effusion / consolidation\n ______________________________________________________________________________\n FINAL REPORT\n 72-year-old man with altered mental status, intubated from outside hospital,\n please evaluate for ETT placement.\n\n COMPARISON: None.\n\n CHEST, SINGLE VIEWS: An ET tube is noted with its tip 6 cm from the carina.\n An orogastric tube projects below the diaphragm and out of the field of view.\n The side port is below the diaphragm. There is mild elevation of the left\n hemidiaphragm. There is no focal parenchymal opacification. There is no\n large pleural effusion or pneumothorax. Osseous structures are grossly normal\n excepting for some degenerative changes at numerous spinal levels.\n\n IMPRESSION:\n\n 1. ETT tip 6 cm from the carina; standard position of OG tube.\n\n 2. No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2152-04-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1067781, "text": " 3:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval changes, ETT position.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with AMS, fever, now intubated\n REASON FOR THIS EXAMINATION:\n please eval for interval changes, ETT position.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 71-year-old man with mental status change, fever, now intubated.\n\n COMPARISONS: None.\n\n CHEST, AP SEMI-UPRIGHT: The endotracheal tube terminates about 6 cm above the\n carina. A nasogastric tube terminates in the stomach. The heart size is\n within normal limits. The aorta is tortuous. The mediastinum is not widened.\n There is minor volume loss and probable atelectasis in the left lower lobe,\n and perhaps a small effusion, but elsewhere the lungs are clear.\n\n" }, { "category": "ECG", "chartdate": "2152-04-21 00:00:00.000", "description": "Report", "row_id": 279404, "text": "Sinus rhythm. The axis is indeterminate. There are non-diagnostic Q waves in\nthe inferior leads. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2183-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703998, "text": "59 y.o. male with h/o polysubstance abuse and alcoholism who has had\n multiple presentations to ED with chest pain after sustaining a fall\n from a 2^nd story building , in the beginning of . He\n presented to the EW on with alcohol intoxication as well as the\n chest pain and underwent CXR which showed ol left sided rib\n fracdtures. He represented the\n Following day with back pain and intoxication. He ws discharged the\n afternoon of and was found by the fire department on the floor\n rolling around in pain and was taken back to the ED.\n He underwent CTA of the chest which showed acute fractures of the ribs\n laterally on the left and old left 5^th fx. CXR confirmed\n muplitple left sided rib fractures.\n" }, { "category": "Physician ", "chartdate": "2183-10-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 704091, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 06:09 AM\n Allergies:\n Oxycodone\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: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 75 (75 - 81) bpm\n BP: 106/66(76) {100/63(72) - 119/66(78)} mmHg\n RR: 21 (14 - 21) insp/min\n SpO2: 97%\n Total In:\n 321 mL\n PO:\n TF:\n IVF:\n 321 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 321 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n GENERAL: Awake, alert and oriented, agitated.\n HEENT: No scleral icterus. PERRL.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or .\n LUNGS: CTAB, good air movement biaterally. No chest wall tenderness.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n BACK: Patient had tenderness to palpation of inferior ribs\n posterolateral on both sides.\n EXTREMITIES: No edema, WWP.\n SKIN: No rashes.\n NEURO: Alert, oriented x3. CN 2-12 intact. No tremor or asterixis.\n Strength grossly intact.\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 59M with a history of polysubstance abuse, admitted due decreased level\n of consciousness and seizures concerning for alcohol withdrawal.\n .\n # AMA: Patient insists on leaving against medical advice. Is alert and\n oriented and is able to state risks of leaving the hospital, including\n seizures, delirium tremens, and death. Says he has a court appointment\n that he has to keep. Nurses, residents, fellow, and attending all tried\n to convince patient to stay and warned him of the dangers of leaving.\n Offered to write patient a note and/or make a phone call on his behalf\n to excuse him from his court appearance. Nonetheless patient insisted\n on leaving AMA. Patient aware that he can return anytime.\n .\n # EtOH withdrawal, hypertension, depression, diabetes mellitus:\n Recommended that the patient stay in the ICU for treatment of these\n problems. However, he insisted on leaving AMA.\n ICU Care\n Nutrition:\n Comments: NPO (occasional sips okay with RN supervision)\n Glycemic Control:\n Lines:\n 18 Gauge - 04:34 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Patient leaving AMA\n" }, { "category": "Physician ", "chartdate": "2183-10-20 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 704124, "text": "Chief Complaint: Acute ethanol withdrawal\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 59 yom polysubstance abuse, reportedly recently discharged from\n Hospital after a fall, later found down and brought to the\n ED by EMS.\n Pt. admits to consuming 1 pint of vodka on day of admission.\n Experienced vomiting and syncope , and possible seizure (although\n denies loss of continence, tongue biting.\n ER evaluation revealed HR=89 BP=134/95 RR=18 SaO2=99% RA. Pt.\n became unresponsive and had witnessed generalized tonic clonic seizure\n x2. He received naloxone and lorazepam, with improvement in mental\n status within 5 mins. Head CT, CXR, and EKG were normal. He was\n afebrile with a normal white count, tox screen positive for benzos, and\n EtOH level of 56. Received iv fluids NS x 1 L, and transferred to MICU\n fro further evaluation and mangement of acute ethanol withdrawal.\n On review of systems, he confirms left-sided chest wall pain (unclear\n if reported fall is different from fall resulting in left-sided rib\n fractures and pain noted in OMR occurring ~2 months ago).\n Denies HA, dyspnea, fevers, chills, chest pain, abdominal pain,\n although became agitated and continually repeated \"no\" with further\n questioning.\n Per ED report, he also took morphine prior to admission, although he\n denies this in the ICU.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Oxycodone\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 Polysubstance abuse\n EtOH abuse\n h/o Pseudoseizures\n Diabetes Mellitus\n HTN\n Denies\n Occupation: Unemployed\n Drugs:\n Tobacco: active smoker\n Alcohol: active EtOH\n Other: Homeless\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, 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, Appropriate\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 08:52 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: 68 (68 - 81) bpm\n BP: 127/77(90) {100/63(72) - 127/77(90)} mmHg\n RR: 22 (14 - 22) insp/min\n SpO2: 98%\n Total In:\n 694 mL\n PO:\n TF:\n IVF:\n 694 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 694 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: 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: 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: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, 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): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 0.0\n 0.0\n 0.0\n 0.0\n 0.0\n 0.0\n 0.0\n [image002.jpg]\n Other labs: Lactic Acid:0.0, Ca++:0.0, Mg++:0.0, PO4:0.0\n Assessment and Plan\n 59M with a history of polysubstance abuse, admitted due decreased level\n of consciousness and seizures concerning for alcohol withdrawal.\n ACUTE ETOH WITHDRAWAL -- Exhibiting early signs of acute withdrawal\n (seizure) and at risk for DTs. Continue monitor, benzodiazapines per\n CIWA scale. Monitor for seizures. Hold anticonvulsant for now.\n Social Work consult once more alert.\n FLUIDS\n hypovolemia. Monitor I/O. Provide iv fluid.\n NUTRITIONAL SUPPORT\n MVI, folate, micronutrients.\n HTN\n Unclear outpatient regimen. Elevated BP may represent untreated\n HTN, or signs of Etoh withdrawal. Monitor BP.\n DEPRESSION -- Reportedly on citalopram as outpatient. Hold for now,\n especially given his somnolence, and verify in am.\n DIABETES MELLITUS -- Unclear diagnosis as glucose values have been\n relatively low in past few months. Monitor glucose.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 04:34 AM\n Comments:\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: 65 minutes\n" }, { "category": "Physician ", "chartdate": "2183-10-20 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 704125, "text": "Chief Complaint: Acute ethanol withdrawal\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 59 yom polysubstance abuse, reportedly recently discharged from\n Hospital after a fall, later found down and brought to the\n ED by EMS.\n Pt. admits to consuming 1 pint of vodka on day of admission.\n Experienced vomiting and syncope , and possible seizure (although\n denies loss of continence, tongue biting.\n ER evaluation revealed HR=89 BP=134/95 RR=18 SaO2=99% RA. Pt.\n became unresponsive and had witnessed generalized tonic clonic seizure\n x2. He received naloxone and lorazepam, with improvement in mental\n status within 5 mins. Head CT, CXR, and EKG were normal. He was\n afebrile with a normal white count, tox screen positive for benzos, and\n EtOH level of 56. Received iv fluids NS x 1 L, and transferred to MICU\n fro further evaluation and mangement of acute ethanol withdrawal.\n On review of systems, he confirms left-sided chest wall pain (unclear\n if reported fall is different from fall resulting in left-sided rib\n fractures and pain noted in OMR occurring ~2 months ago).\n Denies HA, dyspnea, fevers, chills, chest pain, abdominal pain,\n although became agitated and continually repeated \"no\" with further\n questioning.\n Per ED report, he also took morphine prior to admission, although he\n denies this in the ICU.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Oxycodone\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 Polysubstance abuse\n EtOH abuse\n h/o Pseudoseizures\n Diabetes Mellitus\n HTN\n Denies\n Occupation: Unemployed\n Drugs:\n Tobacco: active smoker\n Alcohol: active EtOH\n Other: Homeless\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, 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, Appropriate\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 08:52 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: 68 (68 - 81) bpm\n BP: 127/77(90) {100/63(72) - 127/77(90)} mmHg\n RR: 22 (14 - 22) insp/min\n SpO2: 98%\n Total In:\n 694 mL\n PO:\n TF:\n IVF:\n 694 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 694 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: 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: 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: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, 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): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 0.0\n 0.0\n 0.0\n 0.0\n 0.0\n 0.0\n 0.0\n [image002.jpg]\n Other labs: Lactic Acid:0.0, Ca++:0.0, Mg++:0.0, PO4:0.0\n Assessment and Plan\n 59M with a history of polysubstance abuse, admitted due decreased level\n of consciousness and seizures concerning for alcohol withdrawal.\n ACUTE ETOH WITHDRAWAL -- Exhibiting early signs of acute withdrawal\n (seizure) and at risk for DTs. Continue monitor, benzodiazapines per\n CIWA scale. Monitor for seizures. Hold anticonvulsant for now.\n Social Work consult once more alert.\n FLUIDS\n hypovolemia. Monitor I/O. Provide iv fluid.\n NUTRITIONAL SUPPORT\n MVI, folate, micronutrients.\n HTN\n Unclear outpatient regimen. Elevated BP may represent untreated\n HTN, or signs of Etoh withdrawal. Monitor BP.\n DEPRESSION -- Reportedly on citalopram as outpatient. Hold for now,\n especially given his somnolence, and verify in am.\n DIABETES MELLITUS -- Unclear diagnosis as glucose values have been\n relatively low in past few months. Monitor glucose.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 04:34 AM\n Comments:\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: 65 minutes\n ------ Protected Section ------\n MICU Attending Addendum:\n Pt. more awake, now insisting on leaving hospital to deal with personal\n finance issues and regarding court date. Pt. oriented to person,\n place, date. Understands recommendation to remain in hospital to\n monitor while experiencing EtOH withdrawal, and understands risk for\n clinical deterioration and possible death if leaves hospital at this\n time. Understands consequences of decision to leave against medical\n advice. Competent. Pt. insists to sign out AMA.\n ------ Protected Section Addendum Entered By: , MD\n on: 20:12 ------\n" }, { "category": "Physician ", "chartdate": "2183-10-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 704020, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 06:09 AM\n Allergies:\n Oxycodone\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: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 75 (75 - 81) bpm\n BP: 106/66(76) {100/63(72) - 119/66(78)} mmHg\n RR: 21 (14 - 21) insp/min\n SpO2: 97%\n Total In:\n 321 mL\n PO:\n TF:\n IVF:\n 321 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 321 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n GENERAL: Somnolent male, NAD, awakens and responds to voice, easily\n agitated\n HEENT: No scleral icterus. PERRLA/EOMI. MM dry.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or .\n LUNGS: CTAB, good air movement biaterally. No chest wall tenderness.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema, WWP, 2+ radial and posterior tibial pulses.\n SKIN: No rashes.\n NEURO: Somnolent, oriented x3. CN 2-12 grossly intact. 5/5 strength\n throughout.\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 59M with a history of polysubstance abuse, admitted due decreased level\n of consciousness and seizures concerning for alcohol withdrawal.\n .\n #. Alcohol intoxication/withdrawal: Patient is somnolent although\n easily arousable and agitated. No current airway compromise. He is not\n hypertensive or tachycardic, and appears to be resting comfortably.\n Head CT and CXR negative. Suspect that his current appearance is\n related to continued intoxication (EtOH, possible coadministered\n narcotics) as improvement was noted with naloxone in the ED. Less\n likely a postictal state due to withdrawal seizures. Expect that with\n observation, he will become more alert and likely more agitated given\n history of withdrawal and leaving AMA.\n - CIWA scale q2h with diazepam prn\n - Banana bag\n - UA and urine culture to further r/o infectious cause\n - Urine tox\n - Blood cultures if spikes\n - SW consult once more alert\n - Hold dilantin for now as it is unclear if he has previously been\n taking this. Will need to verify meds in am.\n .\n #. Hypertension: Treated with verapamil. Also carrying rx for\n metoprolol and lisinopril. Currently normotensive, but BP will likely\n increase if he starts to undergo EtOH withdrawal.\n - Hold antihypertensives for now. Will confirm meds in am, and add them\n on prn.\n .\n #. Depression: Reportedly on citalopram as outpatient.\n - Will hold for now, especially given his somnolence, and verify in am.\n .\n #. DM: Unclear diagnosis as glucose values have been relatively low in\n past few months.\n - Humalog sliding scale for now.\n ICU Care\n Nutrition:\n Comments: NPO (occasional sips okay with RN supervision)\n Glycemic Control:\n Lines:\n 18 Gauge - 04:34 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2183-10-20 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 704007, "text": "Chief Complaint: Altered mental status\n HPI:\n History very limited by patient's somnolence and largely per report.\n This is a 59M with a history of polysubstance abuse, who was reportedly\n just discharged from Hospital after a fall, later found down\n and brought to the ED. It is unclear if the reported fall is\n different than the fall resulting in left-sided rib fractures and pain\n noted in OMR occurring ~2 months ago. He notes drinking 1 pint of vodka\n on day of presentation, followed by vomiting and a syncopal episode\n that he relates as a seizure, but denied loss of continence, tongue\n biting. Per ED report, he also took morphine prior to admission,\n although he denies this in the ICU.\n .\n In the ED, initial vitals were: HR89 BP134/95 RR18 O299%RA. He became\n unresponsive and had generalized tonic clonic seizure x2. He received\n naloxone and lorazepam, with improvement to A&Ox2 five minutes later.\n Also given 1L NS. Head CT, CXR, and EKG were normal. He was afebrile\n with a normal white count, tox screen positive for benzos, and EtOH\n level of 56. He is admitted to the ICU due to concern for EtOH\n withdrawal. Prior to transfer, his vital signs were: 98.0 72 110/77 18\n 99%,2L.\n .\n On review of systems, he confirms left-sided chest wall pain, although\n denies HA, blurry vision, fevers, chills, dyspnea. Patient became\n agitated and continually repeated \"no\" with further ROS.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Oxycodone\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n (1,2 per OMR. 3-7 per rx found on patient dated \"\")\n 1. Verapamil 180 mg daily\n 2. Citalopram 20 mg daily\n 3. Dilantin 50mg daily\n 4. Dilantin XL 400mg daily\n 5. Lisinopril 10mg \n 6. Thiamine 100mg daily\n 7. Metoprolol 50mg \n Past medical history:\n Family history:\n Social History:\n (per OMR, patient cannot confirm)\n Alcoholism - ongoing\n Polysubstance abuse\n Intravenous drug abuse.\n Chronic HCV infection\n Remote history of vertebral osteomyelitis\n Low Back Pain / Degenerative disease\n Vertebral compression fractures.\n Diabetes mellitus type II\n Pseudo-seizures\n Hypertension\n Depression\n Left parietal bone lesion NOS - ?atypical hemangioma\n Calf injury with left gluteal transplant to left calf.\n (per OMR) Positive for diabetes\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: (per OMR, patient uncooperative with confirming) He drinks 1/2-1\n pint of vodka per day. Also uses cocaine. Positive tobacco with one\n half of a pack per week. He used intravenous heroin 30 years ago. He is\n unemployed, on disability. Emigrated from in . Pt is a\n veteran, homeless. He has a sister in but does not know where\n she lives. Also one sister in . Not in contact with his\n family. No friends. Wife died last spring.\n Review of systems:\n Flowsheet Data as of 05:51 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: 75 (75 - 81) bpm\n BP: 106/66(76) {100/63(72) - 119/66(78)} mmHg\n RR: 21 (14 - 21) insp/min\n SpO2: 97%\n Total In:\n 163 mL\n PO:\n TF:\n IVF:\n 163 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 165 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GENERAL: Somnolent male, NAD, awakens and responds to voice, easily\n agitated\n HEENT: No scleral icterus. PERRLA/EOMI. MM dry.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or .\n LUNGS: CTAB, good air movement biaterally. No chest wall tenderness.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema, WWP, 2+ radial and posterior tibial pulses.\n SKIN: No rashes.\n NEURO: Somnolent, oriented x3. CN 2-12 grossly intact. 5/5 strength\n throughout.\n Labs / Radiology\n 296\n 80\n 0.7\n 11\n 27\n 104\n 3.4\n 143\n 36.4\n 8.2\n [image002.jpg]\n Imaging: CT head (, prelim): no acute intracranial process.\n .\n CXR (, my read): no acute process.\n ECG: Sinus rhythm at 65bpm, possible LVH\n Assessment and Plan\n 59M with a history of polysubstance abuse, admitted due decreased level\n of consciousness and seizures concerning for alcohol withdrawal.\n .\n #. Alcohol intoxication/withdrawal: Patient is somnolent although\n easily arousable and agitated. No current airway compromise. He is not\n hypertensive or tachycardic, and appears to be resting comfortably.\n Head CT and CXR negative. Suspect that his current appearance is\n related to continued intoxication (EtOH, possible coadministered\n narcotics) as improvement was noted with naloxone in the ED. Less\n likely a postictal state due to withdrawal seizures. Expect that with\n observation, he will become more alert and likely more agitated given\n history of withdrawal and leaving AMA.\n - CIWA scale q2h with diazepam prn\n - Banana bag\n - UA and urine culture to further r/o infectious cause\n - Urine tox\n - Blood cultures if spikes\n - SW consult once more alert\n - Hold dilantin for now as it is unclear if he has previously been\n taking this. Will need to verify meds in am.\n .\n #. Hypertension: Treated with verapamil. Also carrying rx for\n metoprolol and lisinopril. Currently normotensive, but BP will likely\n increase if he starts to undergo EtOH withdrawal.\n - Hold antihypertensives for now. Will confirm meds in am, and add them\n on prn.\n .\n #. Depression: Reportedly on citalopram as outpatient.\n - Will hold for now, especially given his somnolence, and verify in am.\n .\n #. DM: Unclear diagnosis as glucose values have been relatively low in\n past few months.\n - Humalog sliding scale for now.\n ICU Care\n Nutrition:\n Comments: NPO (occasional sips okay with RN supervision)\n Glycemic Control:\n Lines:\n 18 Gauge - 04:34 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2183-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704008, "text": "59 y.o. male with h/o polysubstance abuse and alcoholism who has had\n multiple presentations to ED with chest pain after sustaining a fall\n from a 2^nd story building , in the beginning of . He\n presented to the EW on with alcohol intoxication as well as the\n chest pain and underwent CXR which showed old left sided rib\n fractures. He presented the\n Following day with back pain and intoxication. He ws discharged the\n afternoon of and was found by the fire department on the floor\n rolling around in pain and was taken back to the ED.\n He underwent CTA of the chest which showed acute fractures of the ribs\n laterally on the left and old left 5^th fx. CXR confirmed multiple\n left sided rib fractures. Surgery was consulted and felt there were no\n acute surgical issues. Serum toxicology screens showed an ETOH level\n of 327, pain controlled with MS Contin 15 mg and Morphine Sulfate\n IR 15mg for breakthrough pain.\n Today pt took morphine, last ETOH yesterday, pt c/o left rib\n pain, has history of fall from 2^nd or 3^rd story building and had\n admission for rib fractures/pain control. Declining MS and\n pt has witnessed tonic/clonic seizures. No resp drive placed on\n 100% NRB, received 0.4 Narcan, 1 mg IV Ativan, post ictal\n received\n 2^nd dose of Narcan. Blood sugar 86, CXR WNL, CT scan head normal.\n Pt transferred to ICU for further care\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt arrived to MICU in stable condition, no seizure activity noted. Pt\n lethargic, easily arousable to voice, will answer questions with one\n word answers. Oriented to person, place, knew year. Pupils 3 mm react\n to light\n CIWA scale 2 - valium not given. Pt sleeping in long naps.\n Action:\n Ongoing monitoring\n Response:\n No seizure activity noted\n Plan:\n Continue to monitor CIWA Scale. Safety precautions, seizure\n precautions. Seizure pads on bed.\n Rib fracture\n Assessment:\n Pt with old rib fractures. Upon arrival to MICU\n pt without any\n complaints of rib pain. Pt states took morphine at home for pain, and\n drinks one pint of Vodka a day.\n Action:\n Ongoing monitoring\n Response:\n Pt without complaints of rib pain currently\n Plan:\n Continue to monitor pt closely for pain. Hold off on pain meds for now\n pt lethargic\n GI: sips of water\n supervised. Pt drank a glass of water without\n difficutly\n GU: has not voided yet need urine toxic screen when available.\n CV: bp stable 114/72 HR 68 SR no vea noted afebrilie receiving\n d5W with thiamine, folate, MVI @ 200 cc/hr x 1 liter.\n RESP: on 2 liters n/c, rr~16, O2 sats 99% lungs with decrease breath\n sounds at bases. Strong DP\n SOCIAL: pt states has no friends and no family that he keeps in contact\n with. he is homeless. Pt upset that\n The EW cut his clothing in\n when he was in the EW. They explained\n to him that he was unresponsive when he was in ,\n And they had to immed. Assess him\n contact social service consult\n today.\n" }, { "category": "Nursing", "chartdate": "2183-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704006, "text": "59 y.o. male with h/o polysubstance abuse and alcoholism who has had\n multiple presentations to ED with chest pain after sustaining a fall\n from a 2^nd story building , in the beginning of . He\n presented to the EW on with alcohol intoxication as well as the\n chest pain and underwent CXR which showed ol left sided rib\n fracdtures. He represented the\n Following day with back pain and intoxication. He ws discharged the\n afternoon of and was found by the fire department on the floor\n rolling around in pain and was taken back to the ED.\n He underwent CTA of the chest which showed acute fractures of the ribs\n laterally on the left and old left 5^th fx. CXR confirmed\n muplitple left sided rib fractures. Surgery was consulted and felt\n there were no actue surgical issues. Serum screens showed an ETOH level\n of 327, pain controlled with MS Contin 15 mg and Morphine Sulfate\n IR 15mg for breakthrough pain.\n" }, { "category": "Nursing", "chartdate": "2183-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704064, "text": "Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt awoke attempted to get OOB stating he had to go to court today. Pt\n oriented x 3, ICU team at bedside attempting to convince patient to\n stay however, while self d/cing monitoring equipment patient attempted\n to pull out IVs, which were removed by this RN. Pt dressed, signed self\n out AMA and left clothes that were apparently cut off of patient in ED\n and his upper dentures. Clothes placed in bag w/label and on\n shelf behind unit coordinator\ns desk.\n Action:\n Tried to convince patient to stay for medical work up of apparent\n seizure.\n Response:\n Pt adamant that he had to appear in court today and left AMA at approx\n 0900.\n Plan:\n Retain clothes and then submit to security after 2 days.\n" }, { "category": "Physician ", "chartdate": "2183-10-20 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 704049, "text": "Chief Complaint: Acute ethanol withdrawal\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Oxycodone\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 Polysubstance abuse\n EtOH abuse\n h/o Pseudoseizures\n Diabetes Mellitus\n HTN\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\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, 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, Appropriate\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 08:52 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: 68 (68 - 81) bpm\n BP: 127/77(90) {100/63(72) - 127/77(90)} mmHg\n RR: 22 (14 - 22) insp/min\n SpO2: 98%\n Total In:\n 694 mL\n PO:\n TF:\n IVF:\n 694 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 694 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: 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: 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: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, 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): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 0.0\n 0.0\n 0.0\n 0.0\n 0.0\n 0.0\n 0.0\n [image002.jpg]\n Other labs: Lactic Acid:0.0, Ca++:0.0, Mg++:0.0, PO4:0.0\n Assessment and Plan\n 59M with a history of polysubstance abuse, admitted due decreased level\n of consciousness and seizures concerning for alcohol withdrawal.\n .\n #. Alcohol intoxication/withdrawal: Patient is somnolent although\n easily arousable and agitated. No current airway compromise. He is not\n hypertensive or tachycardic, and appears to be resting comfortably.\n Head CT and CXR negative. Suspect that his current appearance is\n related to continued intoxication (EtOH, possible coadministered\n narcotics) as improvement was noted with naloxone in the ED. Less\n likely a postictal state due to withdrawal seizures. Expect that with\n observation, he will become more alert and likely more agitated given\n history of withdrawal and leaving AMA.\n - CIWA scale q2h with diazepam prn\n - Banana bag\n - UA and urine culture to further r/o infectious cause\n - Urine tox\n - Blood cultures if spikes\n - SW consult once more alert\n - Hold dilantin for now as it is unclear if he has previously been\n taking this. Will need to verify meds in am.\n .\n #. Hypertension: Treated with verapamil. Also carrying rx for\n metoprolol and lisinopril. Currently normotensive, but BP will likely\n increase if he starts to undergo EtOH withdrawal.\n - Hold antihypertensives for now. Will confirm meds in am, and add them\n on prn.\n .\n #. Depression: Reportedly on citalopram as outpatient.\n - Will hold for now, especially given his somnolence, and verify in am.\n .\n #. DM: Unclear diagnosis as glucose values have been relatively low in\n past few months.\n - Humalog sliding scale for now.\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n DISPOSITION -- sign out AMA.\n RIB FRACTURE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 04:34 AM\n Comments:\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: 65 minutes\n" }, { "category": "Radiology", "chartdate": "2183-10-20 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 1104446, "text": " 1:04 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: pna? aspiration?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with seizure and altered mental status.\n REASON FOR THIS EXAMINATION:\n pna? aspiration?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Seizure and altered mental status.\n\n COMPARISON: .\n\n FINDINGS: A single frontal radiograph of the chest is obtained, with the\n patient in a laterally rotated position. The lungs are clear. There is no\n pleural effusion or pneumothorax. Cardiomediastinal and hilar contours appear\n unremarkable, accounting for the rotated position. Healed fracture deformities\n and multiple left ribs are similar to those depicted previously.\n\n IMPRESSION: No acute intrathoracic process.\n\n" }, { "category": "Radiology", "chartdate": "2183-10-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1104442, "text": " 12:31 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with altered mental status and seizure.\n REASON FOR THIS EXAMINATION:\n bleed?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc MON 1:22 AM\n no acute intracranial process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status and seizure.\n\n COMPARISON: .\n\n TECHNIQUE: Axial CT images were acquired through the head in the absence of\n intravenous contrast. Coronal and sagittal reformatted images were also\n reviewed.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or\n infarction. Periventricular white matter hypodensities reflect chronic\n microvascular ischemia. Small hypodensities in the left corona radiata are\n unchanged, reflecting lacunar infarctions. The included extracranial soft\n tissue structures are unremarkable. Included osseous structures reveal no\n fracture. The mastoid air cells are clear. The included paranasal sinuses\n are notable for circumferential mucosal thickening at the right maxillary\n sinus as well as the ethmoidal air cells bilaterally and involving the\n sphenoid sinus on the right.\n\n IMPRESSION: No acute intracranial process.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2191-01-05 00:00:00.000", "description": "EMBO TRANSCRANIAL", "row_id": 1223373, "text": " 1:34 PM\n CAROT/CEREB Clip # \n Reason: angio w/coiling of aneurysm and possible stent of the right\n Contrast: OMNIPAQUE Amt: 225\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT -59 DISTINCT PROCEDURAL SERVICE *\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * CAROTID/CERVICAL UNILAT -59 DISTINCT PROCEDURAL SERVICE *\n * TRANSCATH EMBO THERAPY F/U TRANS CATH THERAPY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with known aneurysm\n REASON FOR THIS EXAMINATION:\n angio w/coiling of aneurysm and possible stent of the right pcomm\n aneurysmAnesthesia has been booked for at 1pm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old woman with known right posterior communicating artery\n aneurysm, for coil embolization.\n\n COMPARISON: CTA head .\n\n ATTENDING PHYSICIAN: . .\n\n PROCEDURE PERFORMED: Left common carotid arteriogram, right vertebral\n arteriogram and right internal carotid arteriogram. Right common femoral\n artery angiogram and Angio-Seal closure of right common femoral artery\n puncture site.\n\n INTERVENTIONAL PROCEDURE PERFORMED: Coil embolization of right posterior\n communicating artery aneurysm.\n\n DETAILS OF PROCEDURE:\n\n After explaining the risks, benefits and alternatives of the procedure,\n written informed consent was obtained. The patient was brought to the\n angiography suite and placed supine on the imaging table. General anesthesia\n was induced. Both groins were prepped and draped in standard sterile fashion.\n\n Access was gained into the right common femoral artery using Seldinger\n technique and a 6 French x 25 cm arterial sheath was placed. Using a\n combination of a 5-French 2 catheter and a 0.035 glidewire, the left\n subclavian artery ostium was successfully engaged. Contrast was injected\n which revealed a hypoplastic left vertebral artery. The catheter was then\n disengaged and used to catheterize the left common carotid artery. A left\n common carotid arteriogram was then obtained in AP and lateral projections.\n Brachiocephalic artery was subsequently engaged and right vertebral and right\n internal carotid arteriograms were subsequently obtained. Rotational right\n internal carotid arteriogram was then obtained. The 2 catheter was\n (Over)\n\n 1:34 PM\n CAROT/CEREB Clip # \n Reason: angio w/coiling of aneurysm and possible stent of the right\n Contrast: OMNIPAQUE Amt: 225\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n then exchanged for a 6 French Neuron catheter over an exchange length\n glidewire. Using a combination of an SL-10 pre-shaped microcatheter and a\n Synchro standard microwire the right posterior communicating artery aneurysm\n was successfully catheterized and coiling started. 5000 units of heparin were\n given intravenously at this time. A single Target 360 Ultra 4 mm x 6 cm\n microcoil was initially deployed followed by a single 2 mm x 4 cm followed by\n two 2 mm x 3 cm microcoils. A repeat right internal carotid arteriogram was\n obtained after coil embolization showing satisfactory aneurysm occlusion.\n\n The catheters and guidewires were then removed. The right common femoral\n arteriogram was done and an Angio-Seal 6 French device was used for closure of\n the right common femoral artery puncture site.\n\n FINDINGS:\n\n 1. Left common carotid artery arteriogram shows filling of the left ICA along\n the cervical, petrous, cavernous and supraclinoid portions. Both anterior and\n middle cerebral arteries are well seen. There is no evidence of aneurysm,\n stenosis or occlusion. The left external carotid artery fills well along with\n its branches.\n\n 2. The right vertebral artery fills well and appears to be dominant with no\n evidence of stenosis, occlusion, dissection, or aneurysm formation. The\n basilar artery fills well. Both superior cerebellar and posterior cerebral\n arteries are well seen.\n\n 3. Left internal carotid artery angiogram shows filling of the ICA along with\n the cervical, petrous, cavernous and supraclinoid portions. A 6 mm x4 mm size\n multilobulated aneurysm is seen arising at the origin of the right posterior\n communicating artery from the right internal carotid artery. The right PCOM\n appears to arise from the neck of the aneurysm.\n\n 4. Successful microcoil embolization of the right posterior communicating\n artery aneurysm.\n\n 5. Post-embolization right ICA arteriogram reveals satisfactory occlusion of\n the base of the aneurysm with minimal residual flow in the neck and preserved\n flow in the right posterior communicating artery.\n\n 6. Right common femoral arteriogram shows a widely patent right common\n femoral artery.\n\n IMPRESSION:\n\n Ms. underwent cerebral angiography and microcoil embolization of\n right posterior communicating artery aneurysm. The aneurysm was successfully\n (Over)\n\n 1:34 PM\n CAROT/CEREB Clip # \n Reason: angio w/coiling of aneurysm and possible stent of the right\n Contrast: OMNIPAQUE Amt: 225\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n coiled with satisfactory obliteration of the aneurysm sac and minimal residual\n filling in the neck of the aneurysm with preserved flow in the right posterior\n communicating artery.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2102-03-13 00:00:00.000", "description": "Report", "row_id": 79099, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure.\nHeight: (in) 63\nWeight (lb): 220\nBSA (m2): 2.02 m2\nBP (mm Hg): 122/32\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 15:49\nTest: Portable 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: Normal LV wall thickness. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. No MR.\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.\n\nConclusions:\n1.The left atrium is normal in size.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. While the views are suboptimal, it appears that the overall\nleft ventricular systolic function appears normal (LVEF>55%) The images are\nsuboptimal and therefore can not exclude wall motion abnormalities.\n3.Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic valve leaflets are mildly thickened. No aortic regurgitation is\nseen.\n5.The mitral valve leaflets are mildly thickened. No mitral regurgitation is\nseen.\n6.There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2102-03-15 00:00:00.000", "description": "Report", "row_id": 191854, "text": "Baseline artifact. Sinus rhythm. Left atrial abnormality. Modest non-specific\nintraventricular conduction delay. Left ventricular hypertrophy with ST-T wave\nabnormalities. Since the previous tracing of R wave progression has\nimproved.\n\n" }, { "category": "ECG", "chartdate": "2102-03-14 00:00:00.000", "description": "Report", "row_id": 191855, "text": "Normal sinus rhythm. Left ventricular hypertrophy with secondary ST-T wave\nabnormalities. Q waves in leads V1-V2 suggest prior anteroseptal myocardial\ninfarction. Compared to the previous tracing of no diagnostic interval\nchange.\n\n" }, { "category": "ECG", "chartdate": "2102-03-13 00:00:00.000", "description": "Report", "row_id": 191856, "text": "Sinus tachycardia. Left ventricular hypertrophy with ST-T wave abnormalities.\nPoor R wave progression could be due to left ventricular hypertrophy, but\nconsider also anteroseptal myocardial infarction of indeterminate age. Clinical\ncorrelation is suggested. Since the previous tracing of no significant\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2102-03-12 00:00:00.000", "description": "Report", "row_id": 191857, "text": "Sinus tachycardia. Left ventricular hypertrophy with ST-T wave abnormalities.\nPoor R wave progression could be due in part to left ventricular hypertrophy\nbut consider also possible anteroseptal myocardial infarction, age\nindeterminate. Clinical correlation is suggested. No previous tracing available\nfor comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2102-03-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909280, "text": " 7:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pxn/chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with acute resp distress and desatcopd, dm\n REASON FOR THIS EXAMINATION:\n r/o pxn/chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute respiratory distress.\n\n COMPARISONS: None.\n\n AP CHEST RADIOGRAPH\n\n Cardiac size appears upper limits of normal. Mediastinal contour appear\n within normal limits. There is prominence of the left hilar region, probably\n representing the left pulmonary artery, however, PA and lateral films are\n recommended for further evaluation. Increased opacity over the right middle\n and right lower lobes are seen. There is evidence of bilateral pleural\n effusions.\n\n IMPRESSION:\n 1. Right middle and right lower lobe opacities consistent with pneumonia.\n 2. Left hilar prominence, probably representing left pulmonary artery,\n however, dedicated PA and lateral views are recommended for further\n evaluation.\n 3. Bilateral effusions.\n\n Discussed with Dr. at 10 p.m. .\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 909756, "text": " 3:09 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check placement of right med. cub. PICC line please\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with copd, worsening sob\n\n REASON FOR THIS EXAMINATION:\n please check placement of right med. cub. PICC line please page IV nurse wet thanks #\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PICC line placement.\n\n COMPARISON: .\n\n AP CHEST RADIOGRAPH:\n\n New right-sided PICC line is seen. It is impossible to identify the exact\n location of the tip because of overlying right middle and lower lobe\n opacities. Given the relationship of the tip to the carina, withdrawal by\n approximately 3 cm is recommended for placement in the distal SVC. There is\n no evidence of pneumothorax. Otherwise, no significant change is seen from\n prior study.\n\n IMPRESSION: New right-sided PICC line with tip likely overlying proximal\n right atrium. Withdrawal by approximately 3 cm is recommended for placement\n in the distal SVC. These findings were relayed to the PICC team at 4:45 p.m.\n on .\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-12 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 909296, "text": " 11:22 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for chf/infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with sob\n REASON FOR THIS EXAMINATION:\n eval for chf/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old woman with shortness of breath.\n\n COMPARISON: Chest x-ray from four hours earlier.\n\n PA AND LATERAL CHEST RADIOGRAPHS: Bilateral pleural effusions are again seen,\n right greater than left. Previously identified prominence of the left hilum\n is not evident on this study. Again seen is retrocardiac opacity, as well as\n atelectasis of the middle and lower right lobe, slightly worsened. Pulmonary\n vasculature appears within normal limits.\n\n IMPRESSION:\n 1. Bilateral pleural effusions, right greater than left.\n 2. Right middle and lower lobe atelectasis. Recommend followup radiographs to\n ensure resolution.\n\n" }, { "category": "Radiology", "chartdate": "2102-03-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909419, "text": " 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with copd, worsening sob\n REASON FOR THIS EXAMINATION:\n eval for chf\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:28 A.M. ON .\n\n HISTORY: COPD, worsening shortness of breath, possible CHF.\n\n IMPRESSION: AP chest compared to and 24:\n\n Opacification of the right middle and most of the right lower lobe could be\n due to atelectasis alone, though pneumonia cannot be excluded. The findings\n are unchanged since . Moderate left and small right pleural effusion\n are unchanged. The upper lungs are clear of edema, although there is mild\n vascular congestion in the left upper lobe. Heart is partially obscured by\n adjacent abnormalities in the lung and pleura but does not appear grossly\n enlarged. There is some engorgement of mediastinal veins. Overall the\n findings are mostly pleural and pulmonary, rather than cardiac. No\n pneumothorax present. No invasive cardiopulmonary support devices are\n identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909304, "text": " 5:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: recurrant desat\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with acute resp distress and desatcopd, dm\n\n REASON FOR THIS EXAMINATION:\n recurrant desat\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:09 A.M. ON .\n\n HISTORY: Acute respiratory distress. COPD.\n\n IMPRESSION: AP chest compared to :\n\n Right middle and lower lobe collapse and moderate left pleural effusion not\n appreciably changed since . Vascular congestion in the upper lungs\n has worsened. Heart is top normal size. No pneumothorax.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-03-16 00:00:00.000", "description": "Report", "row_id": 1284296, "text": "Update\nO: See carevue flowsheet for specifics....\nNeuro: aaoriented, dozing intermittently. Follows simple commands. Perl at 3mm brisk.Wheelchair dependent.\n\nCv: sr no ectopy. hr 60-70 range. Sbp 110-130 on lopressor and captopril. Captopril dosing to be ^'d today per MICU team.Distal pulses faint palp,feet cap refill. Compression sleeves on. Heparin sq tid for dvt prophylaxis.\n\nResp: Barking non prod cough. Bilat brth snds i/e wheezes bilat w upper airway rhonchi. Cpt, alb/atrov nebs q4hr and O2 via np lpm w sats 92-93% and cfm added at 40% for sats and humidification.\n\nGi: abd soft, obese, + bowel snds. NO bm yet today. Receiving senna and colace.Tol po food and flds. Gi prophylax w protonix. Glucoses wnl not req riss.\n\nGu: bdline to qs yellow urine w sediment via foley.i/o even today.\n\nHeme/Id: hct stable. tmax 97.8 today. Wbc 17 trending dwn. BC ordered unable to obtain d/t difficult stick. Will reattempt after picc line evaluation.\n\nDispo: needs picc line placed prior to transfer to rehab MACU, today if possible. paperwork in progress.\n\nA/P: RML pneumonia by cxr-> Cont aggressive resp therapy w cpt,nebs, dbc, expectorant as ordered and per team cont w ceftriax iv to total 10 days. Follow and rx glucoses per riss. ? to IR for picc line placemnt.OOB w once picc line placed.? fleets enema today vs mag citrate check w MICU team.\n" }, { "category": "Nursing/other", "chartdate": "2102-03-16 00:00:00.000", "description": "Report", "row_id": 1284297, "text": "Update\nO: picc line placed by iv team and position confirmed by pcxr per MICU HO Dr . Periph iv's dc'd. Pt ready to transfer back to rehab MACU. This nurse spoke w charge r.n. at rehab and ready to accept pt today. BLS ambulance notified and pt ready to transfer today w O2 and monitoring. Picc line capped.\n\n" }, { "category": "Nursing/other", "chartdate": "2102-03-16 00:00:00.000", "description": "Report", "row_id": 1284295, "text": "Nursing note:\n A/Ox3, slept in naps. Afebrile. SR in 60s-70s, no ectopy. SBP 120-130s. Desatting to 80s prior to being transferred to floor. SOB, wheezy and requiring more 02 while maintaining sats in low 90s on 6L NC and 40-50% FT- > decision made to keep pt. in SICU overnight to monitor oxygenation. +strong productive cough for thick tan-yellow sputum. Abdomen soft, +BS. -stool per HO after digital exam. +flatus per pt. Tolerating sips and meds. Foley patent adequate amount amber urine. Glucose stable, insulin per SS.\n\nA/P: Improving resp. status after episode desatting overnight. Continue to monitor resp. status, ? tx. to medicine in am.\n" } ]

[ { "category": "Radiology", "chartdate": "2146-12-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1173038, "text": " 7:01 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: cardiopulm\n Admitting Diagnosis: RECTAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with ett\n REASON FOR THIS EXAMINATION:\n cardiopulm\n ______________________________________________________________________________\n WET READ: MLHh 7:32 PM\n Slight improvement in diffuse interstitial + airspace pulm edema.\n ETT still 7 cm above carina, recommend advancing at least 2 cm.\n Swan-Ganz in RVOT, advance few cm.\n L subclav port in mid SVC.\n Continued retrocardiac atelectasis.\n SQ air.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:00 P.M. ON \n\n HISTORY: Check ET tube. Cardiopulmonary abnormality.\n\n IMPRESSION:\n AP chest compared to , 1:20 p.m.:\n\n Tip of the ET tube at the thoracic inlet is no less than 75 mm from the carina\n and could be advanced safely 4 cm to improved positioning. Severe pulmonary\n edema has changed in distribution but not in overall severity. New leftward\n mediastinal shift and greater opacification in the left lower lobe indicates\n new atelectasis. Severe subcutaneous emphysema involving the chest wall and\n neck is less pronounced. There is no clear evidence of pneumothorax. The\n heart is normal size. Swan-Ganz catheter tip projects over the pulmonary\n outflow tract, below the level of the pulmonic valve.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-12-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1173067, "text": " 3:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: cardiopulm\n Admitting Diagnosis: RECTAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with intubation\n REASON FOR THIS EXAMINATION:\n cardiopulm\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3:39 A.M. \n\n HISTORY: Intubated patient after cardiopulmonary arrest.\n\n IMPRESSION: AP chest compared to :\n\n ET tube is in standard placement, Swan-Ganz catheter ends in the right\n pulmonary artery, left-sided central venous line at the junction of\n brachiocephalic veins. No pneumothorax or mediastinal widening to suggest\n complications. Moderately severe pulmonary edema has improved. Small\n bilateral pleural effusions, right greater than left, have increased slightly,\n not unexpectedly. Left lower lobe atelectasis is improved. Heart size is\n normal. No pneumothorax. Subcutaneous chest wall and neck emphysema has\n improved dramatically. Nasogastric tube passes into the stomach and out of\n view.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-12-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1173238, "text": " 7:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 78 year old man with intubated. Eval for change.\n Admitting Diagnosis: RECTAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with intubated. Eval for change.\n REASON FOR THIS EXAMINATION:\n 78 year old man with intubated. Eval for change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient intubated with ST elevation\n MI.\n\n COMPARISON: Prior study from obtained at 10:35 p.m.\n\n The ET tube tip is 7 cm above the carina. The intra-aortic balloon pump tip\n is roughly at a similar position, slightly lower, 4 cm below the superior\n aspect of the aortic arch. There is no change in the cardiomediastinal\n silhouette and left retrocardiac atelectasis. Mild pulmonary edema is\n unchanged since the most recent prior radiographs. The left Port-A-Cath\n catheter tip is at the superior SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-12-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1172976, "text": " 1:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute cardiopulmonary event\n Admitting Diagnosis: RECTAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p PEA arrest.\n REASON FOR THIS EXAMINATION:\n acute cardiopulmonary event\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post pulseless electrical activity arrest. Assess for\n cardiac or pulmonary abnormalities.\n\n COMPARISON: None.\n\n FINDINGS: The ET tube ends 8.4 cm above the carina. The left venous infusion\n catheter ends in the superior SVC. An NG tube extends into the stomach and\n out of the field of view. Diffuse interstitial and airspace opacities\n predominantly in the mid and upper lungs along with \"perihilar haze\" are\n consistent with pulmonary edema. There are no pleural abnormalities. The\n cardiac and mediastinal contours are normal. Extensive subcutaneous air is\n seen along the lateral chest walls and cervical regions bilaterally.\n\n IMPRESSION:\n 1. Diffuse interstitial and airspace opacities are most consistent with\n cardiogenic pulmonary edema, given the patient's history of cardiac arrest.\n 2. Diffuse subcutaneous air as described above.\n 3. ET tube ending 8.4 cm above the carina. Recommend advancing 2-3 cm, if\n possible.\n\n These findings were reported to Dr. at 1:50 p.m. via telephone on\n the day of the study.\n\n" }, { "category": "Radiology", "chartdate": "2146-12-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1173208, "text": " 10:17 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please assess balloon pump placement, along with other tubes\n Admitting Diagnosis: RECTAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with STEMI, now on IABP\n REASON FOR THIS EXAMINATION:\n please assess balloon pump placement, along with other tubes/lines\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with ST elevation MI, on\n intraaortic balloon pump.\n\n Portable AP chest radiograph was reviewed in comparison to prior study\n obtained in the same day earlier.\n\n Intra-aortic balloon pump tip is approximately 3 cm below the roof of the\n aortic arch. There is interval improvement of pulmonary edema, currently\n mild. Cardiomediastinal silhouette is unchanged. Left and right bilateral\n retrocardiac atelectasis are unchanged. Bilateral pleural effusion is\n unchanged. The Swan-Ganz catheter tip is in the right interlobar pulmonary\n artery. The ET tube tip is 7 cm above the carina. No appreciable\n pneumothorax is demonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-12-08 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1173283, "text": " 10:49 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for pneumothorax\n Admitting Diagnosis: RECTAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p STEMI, now with L femoral HD line, attempted L IJ line\n unsuccessful\n REASON FOR THIS EXAMINATION:\n assess for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Attempted left internal jugular line placement,\n assessment for pneumothorax.\n\n Portable AP chest radiograph was compared to prior study from \n obtained 7:57 a.m.\n\n The ET tube tip is 7 cm above the carina. The Swan-Ganz catheter tip is at\n the right main pulmonary artery. There is no evidence of interval development\n of pneumothorax. The patient continues to be in pulmonary edema. Bilateral\n pleural effusions and bibasilar atelectasis are unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-12-08 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1173284, "text": " 10:50 AM\n PORTABLE ABDOMEN Clip # \n Reason: assess HD line placement\n Admitting Diagnosis: RECTAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with renal failure s/p STEMI, now with new HD catheter in L\n femoral site\n REASON FOR THIS EXAMINATION:\n assess HD line placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Assess HD catheter placement.\n\n COMPARISON: CXR .\n\n FINDINGS: A single supine portable view of the abdomen was obtained. A\n hemodialysis catheter projects over the left groin. Another catheter tip is\n coiled over the pelvis. An aortic balloon pump catheter is in place.\n Nasogastric tube tip projects over the region of the stomach. The bowel gas\n pattern is normal. Evaluation for free air is limited on this portable supine\n view, but there is no large pneumoperitoneum.\n\n IMPRESSION: HD catheter projects over the left groin.\n\n" }, { "category": "Radiology", "chartdate": "2146-12-08 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1173322, "text": " 1:42 PM\n CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # \n CHEST FLUORO WITHOUT RADIOLOGIST\n Reason: POSTION UNDER FLUORO\n Admitting Diagnosis: RECTAL CANCER/SDA\n ______________________________________________________________________________\n FINAL REPORT\n FLUOROSCOPIC STUDY, \n\n COMPARISON: Chest x-ray of earlier same day.\n\n FINDINGS: Fluoroscopic guidance was provided to Dr. for placement\n of a Swan-Ganz catheter. A single spot fluoroscopic image from that study is\n not of diagnostic quality but demonstrates a Swan-Ganz catheter with tip\n terminating lateral to the right hilum. If not performed already,\n repositioning to a more central location would be recommended for standard\n placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-12-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1173416, "text": " 7:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? placement of ET tube? acute cardiac/pulmonary process\n Admitting Diagnosis: RECTAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with intubated. Eval for change.\n REASON FOR THIS EXAMINATION:\n ? placement of ET tube? acute cardiac/pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess endotracheal tube position. Evaluate for acute cardiac or\n pulmonary process.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: The endotracheal tube ends 6.3 cm above the carina. The left IJ\n catheter ends in the high SVC. The intra-aortic balloon pump device ends just\n above the left main bronchus. The Swan-Ganz catheter ends in the right\n pulmonary artery. As the lung bases are excluded on this radiograph, the\n course of the NG tube is not fully evaluated; the NG tube passed into the\n stomach on , however. Mild pulmonary edema, left greater than\n right, is unchanged. The right pleural effusion is unchanged. There is no\n pneumothorax. Heart size is borderline enlarged.\n\n IMPRESSION:\n\n 1. ET tube in appropriate position.\n\n 2. Unchanged asymmetric mild pulmonary edema, left greater than right.\n\n 3. Unchanged small right pleural effusion.\n\n" }, { "category": "Echo", "chartdate": "2146-12-08 00:00:00.000", "description": "Report", "row_id": 89900, "text": "PATIENT/TEST INFORMATION:\nIndication: MR?\nHeight: (in) 72\nWeight (lb): 178\nBSA (m2): 2.03 m2\nBP (mm Hg): 97/42\nHR (bpm): 114\nStatus: Inpatient\nDate/Time: at 15:26\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\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.\n\nLEFT VENTRICLE: Severely depressed LVEF. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nhypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nakinetic; septal apex- akinetic; inferior apex - akinetic; lateral apex -\nakinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Focal apical hypokinesis of RV free wall.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Calcified tips of papillary muscles. No MS. Mild (1+) MR. [Due\nto acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality as the patient was difficult to position.\n\nConclusions:\nOverall left ventricular systolic function is severely depressed (LVEF= 20 %).\nThere is focal hypokinesis of the apical free wall of the right ventricle. The\nmitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is\nseen. [Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] There is no pericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2146-12-07 00:00:00.000", "description": "Report", "row_id": 89901, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. S/p cardiac arrest\nHeight: (in) 72\nWeight (lb): 178\nBSA (m2): 2.03 m2\nBP (mm Hg): 94/57\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 11:55\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Severely depressed\nLVEF. No LV mass/thrombus.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nakinetic; mid inferior - akinetic; basal inferolateral - hypo; mid\ninferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo;\nanterior apex - akinetic; septal apex- akinetic; inferior apex - akinetic;\nlateral apex - akinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Aortic valve not well seen. No 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: Tricuspid valve not well visualized. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is severely\ndepressed (LVEF= 15-20 %) with akinesis of the inferior wall and the distal\n of the left ventricle. The remaining segments are hypokinetic with\nrelative sparing of the basal septum and lateral wall. No masses or thrombi\nare seen in the left ventricle. Right ventricular chamber size and free wall\nmotion are normal. No aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. Mild (1+) mitral regurgitation is seen. There is no\npericardial effusion.\n\nCompared with the prior study (images reviewed) of /201, the findings are\nsimilar.\n\n\n" }, { "category": "Echo", "chartdate": "2146-12-06 00:00:00.000", "description": "Report", "row_id": 89902, "text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction. S/P PEA Arrest in OR\nHeight: (in) 72\nWeight (lb): 190\nBSA (m2): 2.09 m2\nBP (mm Hg): 96/71\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 13:23\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Severely depressed\nLVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function. Cannot\nassess regional RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Aortic valve not well seen.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is severely depressed with near global LV severe\nhypokinesis/akinesis; the basal septum and basal lateral wall have relatively\npreserved function (overall LVEF= ~15-20 %). Right ventricular chamber size is\nnormal with grossly normal free wall contractility. The mitral valve leaflets\nare mildly thickened. The aortic valve is not well visualized.\n\n\n" }, { "category": "ECG", "chartdate": "2146-12-10 00:00:00.000", "description": "Report", "row_id": 238713, "text": "Sinus rhythm with multifocal ventricular premature beats. Poor R wave\nprogression with persistent slight ST segment elevation in the anterior\nprecordial leads raise concern for anteroseptal myocardial ischemia/myocardial\ninfarction. Clinical correlation is suggested. Low QRS voltage in the limb\nleads. Compared to the previous tracing of ventricular premature beats\nare more frequent on the current tracing. The other findings are similar.\n\n" }, { "category": "ECG", "chartdate": "2146-12-09 00:00:00.000", "description": "Report", "row_id": 238714, "text": "Sinus rhythm with occasional premature atrial contractions and ventricular\npremature beats. Low voltage. Precordial ST-T wave changes suggestive of\nischemia. Compared to the previous tracing no definite change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2146-12-08 00:00:00.000", "description": "Report", "row_id": 238715, "text": "Probable sinus rhythm with premature atrial contractions. Underlying\nnon-specific conduction delay. Precordial ST-T wave changes. Consider\nischemia. Low limb lead voltage. Compared to the previous tracing\nof no definite change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2146-12-08 00:00:00.000", "description": "Report", "row_id": 238716, "text": "Sinus rhythm with ventricular premature depolarizations. Non-specific\nQRS widening. Low QRS voltage in the limb leads. Diffuse non-diagnostic\nrepolarization abnormalities. Compared to the previous tracing of \nmultiple abnormalities persist without major change.\n\n" }, { "category": "ECG", "chartdate": "2146-12-07 00:00:00.000", "description": "Report", "row_id": 238717, "text": "Sinus rhythm. Mild P-R interval prolongation. Inferior and anterolateral\nST segment elevation. Since the previous tracing the rate is slower. The axis\nhas normalized. The QRS width has decreased. ST-T wave abnormalities are\npresent but less prominent in the inferior leads. The Q-T interval is shorter.\nClinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2146-12-06 00:00:00.000", "description": "Report", "row_id": 238718, "text": "Probable sinus rhythm at upper limits of normal rate. P-R interval\nprolongation. Fusion of the P wave with the prior T wave. There is a\nsingle wide complex beat, probably ventricular. Low limb lead voltage.\nThere is an intraventricular conduction delay of left bundle-branch block type\nwith prominent inferior and lateral ST segment elevation. Since the previous\ntracing of the rate is faster. The axis is more vertical.\nQRS complex is wider. ST-T wave abnormalities are new. Clinical correlation\nis suggested.\nTRACING #1\n\n" } ]

[ { "category": "Nursing", "chartdate": "2180-01-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 352872, "text": "This is a 56 year-old male with a history of ETOH cirrhosis with\n esophageal varices s/p TIPS as well as active EtOH use who presents\n with hematemesis x2 yesterday per VNA report. He was brought in by his\n cousin for concern for GIB, and currently denies that he had any\n hematemesis but instead endorses hematochezia. He denies abdominal\n pain, diarrhea, melena or hematochezia. Denies\n CP/palps/SOB/lightheadedness. Per report has been eating/drinking OK\n w/o aspiration/N/V.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No vomiting or stools. Abdomen is soft, ND, NT, +BS. Hematocrit stable\n at 2300 34.2 from 35.1 in ED. VSS\n Action:\n NPO except meds for planned Endoscopy today. He reports feeling hungry\n although his albumin is low and he was hyponatremic, hypophosphatemic,\n and hypokalemic. Lytes repleted and nutritional consult ordered.\n Response:\n Am lytes pending.\n Plan:\n Monitor crit and lytes q 8hrs, replete prn.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FSBG at midnight 329.\n Action:\n Given 10units humalog insulin.\n Response:\n Am BS pending.\n Plan:\n FSBG q 6hrs, follow SSI.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n No s/sx of withdrawal but pt was awake most of the night. He reports\n not sleeping well for the past 3 nights.\n Action:\n CIWA scale q 4hrs.\n Response:\n No valium needed.\n Plan:\n Continue CIWA scale q 4hrs.\n" }, { "category": "Physician ", "chartdate": "2180-01-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 352972, "text": "Chief Complaint:\n 24 Hour Events:\n - No N/V or hematemesis\n - feels well\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Octreotide - 50 mcg/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 06:53 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: 37.1\nC (98.7\n HR: 81 (76 - 86) bpm\n BP: 101/60(70) {101/54(67) - 116/77(98)} mmHg\n RR: 12 (10 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,267 mL\n 1,425 mL\n PO:\n TF:\n IVF:\n 867 mL\n 1,425 mL\n Blood products:\n Total out:\n 0 mL\n 330 mL\n Urine:\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,267 mL\n 1,095 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n GEN: jaundiced, disheveled, no acute distress\n COR: RRR, no M/G/R, normal S1 S2, radial pulses +2\n PULM: Lungs CTAB, no W/R/R\n ABD: distended, no peripheral dullness to percussion, Soft, NT, +BS, +\n HSM, no masses\n EXT: No C/C/E, no palpable cords\n NEURO: + asterixis, alert, oriented to place,\n SKIN: +jaundice, no cyanosis, or gross dermatitis. No ecchymoses.\n Labs / Radiology\n 47 K/uL\n 10.8 g/dL\n 174 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 2.8 mEq/L\n 20 mg/dL\n 100 mEq/L\n 134 mEq/L\n 30.3 %\n 6.8 K/uL\n [image002.jpg]\n 11:03 PM\n 04:12 AM\n WBC\n 6.8\n 6.8\n Hct\n 34.2\n 30.3\n Plt\n 51\n 47\n Cr\n 1.3\n 1.1\n Glucose\n 305\n 174\n Other labs: PT / PTT / INR:16.6/32.2/1.5, ALT / AST:35/71, Alk Phos / T\n Bili:306/10.5, Albumin:2.8 g/dL, LDH:261 IU/L, Ca++:7.9 mg/dL, Mg++:3.0\n mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n .H/O ALCOHOL ABUSE\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n DIABETES MELLITUS (DM), TYPE II\n This is a 56 year-old male with a history of ETOH cirrhosis with\n esophageal varices who presents with hematemesis x2 on day PTA,\n currently Hemodynamically stable.\n .\n Plan:\n # UGIB: in setting of known grade II varices, although GI feels varices\n are less likely post-TIPS. Rectal negative for frank blood or melena\n -GI following, appreciate their recs\n -repeat Hct\n stable at 31\n - D/C Octreotide gtt, and cipro\n - PPI PO\n -plan for EGD if rebleeds\n -clears\n # EtOH cirrhosis: c/b varices, hyponatremia, thrombocytopenia\n -Cont home rifaximin and lactulose\n -Cont MVI, Thiamine, folate\n -Continue home nadolol as BP allows\n # Hyponatremia: corrected with IVF\n # Type 2 DM- Continue home Lantus and HISS at half dose while NPO\n # EtOH abuse- pt has h/o DT's\n -CIWA scale\n -SW c/s\n #H/o depression- Cont home amitriptyline\n .\n # Thrombocytopenia- chronic liver disease. Will monitor\n .\n # FEN: NPO except for meds for now\n # Access: PIVs\n # PPx: IV PPI, no heparin, pneumoboots\n # Code: FULL\n # Dispo: ICU for now\n # Comm: With pt or sister- (HCP)\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:50 PM\n 18 Gauge - 10:51 PM\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": "Social Work", "chartdate": "2180-01-05 00:00:00.000", "description": "Social Work Admission Note", "row_id": 352977, "text": "Family Information\n Next of : (sister)\n Health Proxy appointed: Yes - Copy of signed proxy form in medical\n record (Sister)\n Family Spokesperson designated: Same ()\n Communication or visitation restriction: None\n Patient Information:\n Previous living situation: Home alone\n Previous level of functioning: Independent\n Previous or other hospital admissions: Yes\nPast psychiatric history: Pt has been periodically followed as an OTP in psychot\nherapy (see \nOMR note. In addition, he is also seen\nfor continued individual psychotherapy f\nor the management of depression and anxiety, as well as alcohol relapse preventi\n by Dr. , who is a psychologist in transplant.\n Past addictions history: Pt has a HX of EtOH use but denies illicit\n drug use. Mr. said that he has not had EtOH in the past three\n years, but an OMR note from Dr. documents that pt relapsed in\n .\n Employment status: Disable--Mr. collects worker\ns comp because\n of an injury he received approximately 10 years ago when working in the\n trucking business. The door of a truck struck him in the back of his\n head causing among other things, vertigo, from which he no longer\n suffers.\n Legal involvement: Pt states\nnever having seen the inside of a jail,\n of which is\nmother would be proud.\n Additional Information:\n Patient / Family Assessment:\n This 56 y/o DWM reports having had rectal bleeding for the past two\n days. Presently, he states experiencing no physical discomfort,\n including no problems related to his compromised liver. Mr. \n reports not needing a liver transplant at this time.\n Pt is one of four sibs, two older brothers and a young sister, who is\n his HCP. Mr. said that she has been trying to get him to go to\n a nursing home, but he is not clear as to why. All of his sibs are in\n good health. He lives in HUD housing in . Mr. has\n three daughters, 17, 27, and 37 y/o. They each have a different mother;\n he was married to the first and third women. His relationships with his\n daughters are at times, but he did not elaborate.\n Pt says that his spirits are \"up and down\" every few days, which he\n attributes to his girlfriend and her behavior toward him, which\n includes her constantly talking and wanting to sleep with her leg over\n his. For approximately the past six months, they have been seeing each\n other; she lives in the building. Presently, he does not know what\n their relationship status is. Pt expressed no financial or housing\n concerns. He states that he would like to resume seeing his\n psychologist.\n Assessment:\n Mr. was speaking on the telephone with his daughter when this\n worker entered his room. He was easily engaged in conversation. At\n times, he had memory difficulties, primarily confusion and recall,\n although not consistently. Although there may be significant\n psychosocial issues, he does not report any concerns, with the\n exception of not being clear regarding the status of his intimate\n relationship.\n Communication with Team:\n Primary Nurse: \n Plan / Follow up:\n 1. Pt was told to let his nurse know should he want to further\n meet with the SW.\n 2. Mr. should resume his OTP psychotherapy TX with Dr.\n .\n Page \n" }, { "category": "Physician ", "chartdate": "2180-01-05 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 352955, "text": "Chief Complaint: Hematemesis\n GI bleed\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 56 year old history of alcoholic cirrhosis and esophageal varices s/p\n 24 Hour Events:\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:59 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Other medications:\n Med List reviewed - See \n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:19 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: 36.7\nC (98.1\n HR: 79 (72 - 86) bpm\n BP: 104/72(80) {99/47(63) - 116/77(98)} mmHg\n RR: 12 (10 - 19) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,267 mL\n 2,070 mL\n PO:\n TF:\n IVF:\n 867 mL\n 2,070 mL\n Blood products:\n Total out:\n 0 mL\n 530 mL\n Urine:\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,267 mL\n 1,540 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished\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 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 10.8 g/dL\n 47 K/uL\n 174 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 2.8 mEq/L\n 20 mg/dL\n 100 mEq/L\n 134 mEq/L\n 30.3 %\n 6.8 K/uL\n [image002.jpg]\n 11:03 PM\n 04:12 AM\n WBC\n 6.8\n 6.8\n Hct\n 34.2\n 30.3\n Plt\n 51\n 47\n Cr\n 1.3\n 1.1\n Glucose\n 305\n 174\n Other labs: PT / PTT / INR:16.6/32.2/1.5, ALT / AST:35/71, Alk Phos / T\n Bili:306/10.5, Albumin:2.8 g/dL, LDH:261 IU/L, Ca++:7.9 mg/dL, Mg++:3.0\n mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n .H/O ALCOHOL ABUSE\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n DIABETES MELLITUS (DM), TYPE II\n 1) Possible GI bleed\n - No gross blood on rectal exam at this time...\n - hematocrit decreased slowly from 35.1 to 30.3. Will re-check\n hematocrit now -> if continues to drop, then discuss with GI about\n endoscopy (currently GI does not believe necessary)...if hematocrit is\n same or improved, then will transfer to medical \n -\n 2) Hypokalemia\n - re-check after repletion\n 3) Thrombocytopenia: chronically low secondary to liver...continue to\n monitor\n 4) PPI/pneumoboots\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:50 PM\n 18 Gauge - 10:51 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Social Work", "chartdate": "2180-01-05 00:00:00.000", "description": "Social Work Admission Note", "row_id": 352956, "text": "Family Information\n Next of : (sister)\n Health Proxy appointed: Yes - Copy of signed proxy form in medical\n record (Sister)\n Family Spokesperson designated: Same ()\n Communication or visitation restriction: None\n Patient Information:\n Previous living situation: Home alone\n Previous level of functioning: Independent\n Previous or other hospital admissions: Yes\nPast psychiatric history: Pt has been periodically followed as an OTP in psychot\nherapy (see \nOMR note. In addition, he is also seen\nfor continued individual psychotherapy f\nor the management of depression and anxiety, as well as alcohol relapse preventi\n by Dr. , who is a psychologist in transplant.\n Past addictions history: Pt has a HX of EtOH use but denies illicit\n drug use. Mr. said that he has not had EtOH in the past three\n years, but an OMR note from Dr. documents that pt relapsed in\n .\n Employment status: Disable--Mr. collects worker\ns comp because\n of an injury he received approximately 10 years ago when working in the\n trucking business. The door of a truck struck him in the back of his\n head causing among other things, vertigo, from which he no longer\n suffers.\n Legal involvement: Pt states\nnever having seen the inside of a jail,\n of which is\nmother would be proud.\n Additional Information:\n Patient / Family Assessment:\n This 56 y/o DWM reports having had rectal bleeding for the past two\n days. He lives in HUD housing in . Mr. has three\n daughters, 17, 27, and 37 y/o. They each have a different mother; he\n was married to the first and third women. His relationships with his\n daughters are at times, but he did not elaborate. Pt says\n that his spirits are \"up and down\" every few days, which he attributes\n to his girlfriend and her behavior toward him, which includes her\n constantly talking and wanting to sleep with her leg over his. For\n approximately the past six months, they have been seeing each other;\n she lives in the building. Presently he does not know what their\n relationship status is. Pt expressed no financial or housing concerns.\n He states that he would like to resume seeing his psychologist.\n Assessment:\n Mr. was speaking on the telephone with his daughter, when this\n worker entered his room. He was easily engaged in conversation. At\n times, he had memory difficulties, primarily confusion and recall,\n although not consistently. Although there may be significant\n psychosocial issues, he does not report any concerns, with the\n exception of not being clear regarding the status of his intimate\n relationship.\n Communication with Team:\n Primary Nurse: \n / Follow up:\n 1. Meet with pt re the status of his transplant.\n 2. Mr. should resume his OTP psychotherapy TX with Dr.\n .\n Page \n" }, { "category": "Social Work", "chartdate": "2180-01-05 00:00:00.000", "description": "Social Work Admission Note", "row_id": 352959, "text": "Family Information\n Next of : (sister)\n Health Proxy appointed: Yes - Copy of signed proxy form in medical\n record (Sister)\n Family Spokesperson designated: Same ()\n Communication or visitation restriction: None\n Patient Information:\n Previous living situation: Home alone\n Previous level of functioning: Independent\n Previous or other hospital admissions: Yes\nPast psychiatric history: Pt has been periodically followed as an OTP in psychot\nherapy (see \nOMR note. In addition, he is also seen\nfor continued individual psychotherapy f\nor the management of depression and anxiety, as well as alcohol relapse preventi\n by Dr. , who is a psychologist in transplant.\n Past addictions history: Pt has a HX of EtOH use but denies illicit\n drug use. Mr. said that he has not had EtOH in the past three\n years, but an OMR note from Dr. documents that pt relapsed in\n .\n Employment status: Disable--Mr. collects worker\ns comp because\n of an injury he received approximately 10 years ago when working in the\n trucking business. The door of a truck struck him in the back of his\n head causing among other things, vertigo, from which he no longer\n suffers.\n Legal involvement: Pt states\nnever having seen the inside of a jail,\n of which is\nmother would be proud.\n Additional Information:\n Patient / Family Assessment:\n This 56 y/o DWM reports having had rectal bleeding for the past two\n days. Presently, he states experiencing no physical discomfort,\n including no problems related to his compromised liver. Mr. \n reports not needing a liver transplant at this time.\n Pt is one of four sibs, two older brothers and a young sister, who is\n his HCP. of them are in good health. He lives in HUD housing in\n . Mr. has three daughters, 17, 27, and 37 y/o. They\n each have a different mother; he was married to the first and third\n women. His relationships with his daughters are at times,\n but he did not elaborate.\n Pt says that his spirits are \"up and down\" every few days, which he\n attributes to his girlfriend and her behavior toward him, which\n includes her constantly talking and wanting to sleep with her leg over\n his. For approximately the past six months, they have been seeing each\n other; she lives in the building. Presently, he does not know what\n their relationship status is. Pt expressed no financial or housing\n concerns. He states that he would like to resume seeing his\n psychologist.\n Assessment:\n Mr. was speaking on the telephone with his daughter, when this\n worker entered his room. He was easily engaged in conversation. At\n times, he had memory difficulties, primarily confusion and recall,\n although not consistently. Although there may be significant\n psychosocial issues, he does not report any concerns, with the\n exception of not being clear regarding the status of his intimate\n relationship.\n Communication with Team:\n Primary Nurse: \n / Follow up:\n 1. Pt was told to let his nurse know should he want to further\n meet with the SW.\n 2. Mr. should resume his OTP psychotherapy TX with Dr.\n .\n Page \n" }, { "category": "Nutrition", "chartdate": "2180-01-05 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 352963, "text": "Subjective\n No reported problems with intake, n/v prior to admission\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 90 kg\n 27\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 81 kg\n 111\n Was 96kg on \n Diagnosis: UGIB\n PMH : etoh cirrhosis, esophageal varices, encephalopathy s/p TIPS,\n stents, esophagitis, chronic pancreatitis c/b parapancreatic cyst, DM2,\n anemia, depression, DTs\n Food allergies and intolerances: none noted\n Pertinent medications: octreotide, multivitamin, HISS, 4gm Mg,\n neutraphos, 100meq KCl, others noted\n Labs:\n Value\n Date\n Glucose\n 174 mg/dL\n 04:12 AM\n Glucose Finger Stick\n 222\n 12:00 PM\n BUN\n 20 mg/dL\n 04:12 AM\n Creatinine\n 1.1 mg/dL\n 04:12 AM\n Sodium\n 134 mEq/L\n 04:12 AM\n Potassium\n 2.8 mEq/L\n 04:12 AM\n Chloride\n 100 mEq/L\n 04:12 AM\n TCO2\n 23 mEq/L\n 04:12 AM\n Albumin\n 2.8 g/dL\n 04:12 AM\n Calcium non-ionized\n 7.9 mg/dL\n 04:12 AM\n Phosphorus\n 1.3 mg/dL\n 04:12 AM\n Magnesium\n 3.0 mg/dL\n 04:12 AM\n Current diet order / nutrition support: NPO\n GI: Abdomen soft/distended with positive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, Etoh abuse\n Estimated Nutritional Needs\n Calories: 2250-2700 (BEE x or / 25-30 cal/kg)\n Protein: 105-135 (1.2-1.5 g/kg)\n Fluid: per team\n Specifics:\n This is a 56 year-old male with a history of ETOH cirrhosis with\n esophageal varices who presents with hematemesis x2 on day PTA. Consult\n received for etoh abuse, low albumin. Would advance diet when possible\n to low sodium and encourage PO intake. Will follow for plan of care and\n add supplements once diet advanced if PO intake is low.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Advance diet when medically possible to low sodium/heart\n healthy\n 2. Encourage PO intake\n 3. If PO intake is low, would add Ensure \n 4. Will follow for plan of care\n 12:29 PM\n" }, { "category": "Physician ", "chartdate": "2180-01-04 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 352844, "text": " Resident Admission Note\n .\n Reason for MICU Admission: Monitor HCT\n .\n Primary Care Physician: , MD \n .\n CC: .\n HPI: This is a 56 year-old male with a history of ETOH cirrhosis with\n esophageal varices s/p TIPS as well as active EtOH use who presents\n with hematemesis x2 yesterday per VNA report. He was brought in by his\n cousin for concern for GIB, and currently denies that he had any\n hematemesis but instead endorses hematochezia. He Denies abdominal\n pain, diarrhea, melena or hematochezia. Denies\n CP/palps/SOB/lightheadedness. Per report has been eating/drinking OK\n w/o aspiration/N/V.\n .\n In the ED, they did not gastric lavage due to varices and risk of\n bleed. He was hemodynamically stable w/ HR 74 BP 117/74 O2sat 98%RA.\n GI was consulted and pt was started on an octreotide gtt; received\n cipro IV and IV PPI.\n .\n ROS: The patient denies any fevers, chills, weight change, nausea,\n vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia,\n chest pain, shortness of breath, orthopnea, PND, lower extremity edema,\n cough, urinary frequency, urgency, dysuria, lightheadedness, gait\n unsteadiness, focal weakness, vision changes, headache, rash or skin\n changes.\n .\n Past Medical History:\n - Alcoholic cirrhosis - hx of esophageal variceal bleed and\n hepatic encephalopathy. He has had 2 TIPS procedures with stent\n placement in and again in . Underwent TIPS revision in\n and .\n - EGD : Grade esophageal varices, Esophagitis, Portal\n hypertensive gastropathy\n - Chronic pancreatitis complicated by a parapancreatic cyst\n that was infected with enteroccocus and coagulase negative\n staph. On vancomycin from , then linezolid\n .\n - Type 2 DM on insulin\n - Anemia of chronic disease\n - Thrombocytopenia\n - Depression\n - Umbilical Hernia\n - History of delerium tremens\n .\n Medications: Per d/c Summary. Unclear of pt compliance.\n 1. Multivitamin one QD\n 2. Nadolol 20 mg Daily\n 3. Rifaximin 200 mg Tablet three tabs \n 4. Lactulose Thirty (30) ML PO QID\n 5. Omeprazole 40 mg \n 6. Spironolactone 150mg Daily\n 7. Amitriptyline 10 mg QHS\n 8. Thiamine HCl 100 mg Daily\n 9. Folic Acid 1 mg Daily\n 10. Insulin Glargine 100 unit/mL Solution Sig: 38U Subcutaneous\n at bedtime.\n .\n Allergies: NKDA\n .\n Social History: Pt lives alone with sisters in area and friends in the\n building. Unemployed. Last used ETOH \"in \". No h/o IVDU or other\n drug use. Says he smokes \"5 packs a day\".\n .\n Family Medical History: Father- cirrhosis\n .\n Physical Exam:\n Vitals: T: 98.4 BP: HR: 83 RR: 19 O2Sat: 100% RA\n GEN: jaundiced, disheveled, no acute distress\n HEENT: EOMI, PERRL, sclera icteric, no epistaxis or rhinorrhea, dryMM,\n OP Clear\n NECK: No JVD, carotid pulses brisk, no bruits, no cervical\n lymphadenopathy, trachea midline\n COR: RRR, no M/G/R, normal S1 S2, radial pulses +2\n PULM: Lungs CTAB, no W/R/R\n ABD: distended, no peripheral dullness to percussion, Soft, NT, +BS, +\n HSM, no masses\n Rectal: guiac (-)\n EXT: No C/C/E, no palpable cords\n NEURO: + asterixis, alert, oriented to place, unable to rename people,\n not oriented to time. CN II\n XII grossly intact. Moves all 4\n extremities. Strength 5/5 in upper and lower extremities. Plantar\n reflex downgoing. +dysdiadokokinesia.\n SKIN: +jaundice + ecchymoses on BL lower extremities. no cyanosis, or\n gross dermatitis.\n .\n Laboratories:\n HCT 35 platelets 49\n .\n ECG: Sinus rhythm at 69 bpm, poor R-wave progression no acute ST or\n T-wave changes compared to .\n .\n Imaging:\n CXR: Interval improvement in right basilar opacity with persistent\n small right pleural effusion. Findings are suggestive of resolving\n pneumonia. No new areas of abnormality otherwise identified.\n .\n Assessment: This is a 56 year-old male with a history of ETOH cirrhosis\n with esophageal varices who presents with hematemesis x2 on day PTA,\n currently Hemodynamically stable.\n .\n Plan:\n # UGIB: in setting of known grade II varices.\n -GI following, appreciate their recs\n -Q6 hr Hct\n -Octreotide gtt\n - IV PPI\n -Cipro IV x5 days for SBP prophylaxis\n -plan for EGD if rebleeds\n -NPO except for meds\n # EtOH cirrhosis: c/b varices, hyponatremia, thrombocytopenia\n -Cont home rifaximin and lactulose\n -Cont MVI, Thiamine, folate\n -Continue home nadolol as BP allows\n # Hyponatremia: appears hypovolemic\n - trend w/IVF boluses\n - urine lytes\n # Type 2 DM- Continue home Lantus and HISS at half dose while NPO\n # EtOH abuse- pt has h/o DT's\n -CIWA scale\n -SW c/s\n #H/o depression- Cont home amitriptyline\n .\n # Thrombocytopenia- chronic liver disease. Will monitor\n .\n # FEN: NPO except for meds for now\n # Access: PIVs\n # PPx: IV PPI, no heparin, pneumoboots\n # Code: FULL\n # Dispo: ICU for now\n # Comm: With pt or sister- (HCP)\n" }, { "category": "Physician ", "chartdate": "2180-01-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 352846, "text": " Resident Admission Note\n .\n Reason for MICU Admission: Monitor HCT\n .\n Primary Care Physician: , MD \n .\n CC: .\n HPI: This is a 56 year-old male with a history of ETOH cirrhosis with\n esophageal varices s/p TIPS as well as active EtOH use who presents\n with hematemesis x2 yesterday per VNA report. He was brought in by his\n cousin for concern for GIB, and currently denies that he had any\n hematemesis but instead endorses hematochezia. He Denies abdominal\n pain, diarrhea, melena or hematochezia. Denies\n CP/palps/SOB/lightheadedness. Per report has been eating/drinking OK\n w/o aspiration/N/V.\n .\n In the ED, they did not gastric lavage due to varices and risk of\n bleed. He was hemodynamically stable w/ HR 74 BP 117/74 O2sat 98%RA.\n GI was consulted and pt was started on an octreotide gtt; received\n cipro IV and IV PPI.\n .\n ROS: The patient denies any fevers, chills, weight change, nausea,\n vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia,\n chest pain, shortness of breath, orthopnea, PND, lower extremity edema,\n cough, urinary frequency, urgency, dysuria, lightheadedness, gait\n unsteadiness, focal weakness, vision changes, headache, rash or skin\n changes.\n .\n Past Medical History:\n - Alcoholic cirrhosis - hx of esophageal variceal bleed and\n hepatic encephalopathy. He has had 2 TIPS procedures with stent\n placement in and again in . Underwent TIPS revision in\n and .\n - EGD : Grade esophageal varices, Esophagitis, Portal\n hypertensive gastropathy\n - Chronic pancreatitis complicated by a parapancreatic cyst\n that was infected with enteroccocus and coagulase negative\n staph. On vancomycin from , then linezolid\n .\n - Type 2 DM on insulin\n - Anemia of chronic disease\n - Thrombocytopenia\n - Depression\n - Umbilical Hernia\n - History of delerium tremens\n .\n Medications: Per d/c Summary. Unclear of pt compliance.\n 1. Multivitamin one QD\n 2. Nadolol 20 mg Daily\n 3. Rifaximin 200 mg Tablet three tabs \n 4. Lactulose Thirty (30) ML PO QID\n 5. Omeprazole 40 mg \n 6. Spironolactone 150mg Daily\n 7. Amitriptyline 10 mg QHS\n 8. Thiamine HCl 100 mg Daily\n 9. Folic Acid 1 mg Daily\n 10. Insulin Glargine 100 unit/mL Solution Sig: 38U Subcutaneous\n at bedtime.\n .\n Allergies: NKDA\n .\n Social History: Pt lives alone with sisters in area and friends in the\n building. Unemployed. Last used ETOH \"in \". No h/o IVDU or other\n drug use. Says he smokes \"5 packs a day\".\n .\n Family Medical History: Father- cirrhosis\n .\n Physical Exam:\n Vitals: T: 98.4 BP: HR: 83 RR: 19 O2Sat: 100% RA\n GEN: jaundiced, disheveled, no acute distress\n HEENT: EOMI, PERRL, sclera icteric, no epistaxis or rhinorrhea, dryMM,\n OP Clear\n NECK: No JVD, carotid pulses brisk, no bruits, no cervical\n lymphadenopathy, trachea midline\n COR: RRR, no M/G/R, normal S1 S2, radial pulses +2\n PULM: Lungs CTAB, no W/R/R\n ABD: distended, no peripheral dullness to percussion, Soft, NT, +BS, +\n HSM, no masses\n Rectal: guiac (-)\n EXT: No C/C/E, no palpable cords\n NEURO: + asterixis, alert, oriented to place, unable to rename people,\n not oriented to time. CN II\n XII grossly intact. Moves all 4\n extremities. Strength 5/5 in upper and lower extremities. Plantar\n reflex downgoing. +dysdiadokokinesia.\n SKIN: +jaundice + ecchymoses on BL lower extremities. no cyanosis, or\n gross dermatitis.\n .\n Laboratories:\n HCT 35 platelets 49\n .\n ECG: Sinus rhythm at 69 bpm, poor R-wave progression no acute ST or\n T-wave changes compared to .\n .\n Imaging:\n CXR: Interval improvement in right basilar opacity with persistent\n small right pleural effusion. Findings are suggestive of resolving\n pneumonia. No new areas of abnormality otherwise identified.\n .\n Assessment: This is a 56 year-old male with a history of ETOH cirrhosis\n with esophageal varices who presents with hematemesis x2 on day PTA,\n currently Hemodynamically stable.\n .\n Plan:\n # UGIB: in setting of known grade II varices.\n -GI following, appreciate their recs\n -Q6 hr Hct\n -Octreotide gtt\n - IV PPI\n -Cipro IV x5 days for SBP prophylaxis\n -plan for EGD if rebleeds\n -NPO except for meds\n # EtOH cirrhosis: c/b varices, hyponatremia, thrombocytopenia\n -Cont home rifaximin and lactulose\n -Cont MVI, Thiamine, folate\n -Continue home nadolol as BP allows\n # Hyponatremia: appears hypovolemic\n - trend w/IVF boluses\n - urine lytes\n # Type 2 DM- Continue home Lantus and HISS at half dose while NPO\n # EtOH abuse- pt has h/o DT's\n -CIWA scale\n -SW c/s\n #H/o depression- Cont home amitriptyline\n .\n # Thrombocytopenia- chronic liver disease. Will monitor\n .\n # FEN: NPO except for meds for now\n # Access: PIVs\n # PPx: IV PPI, no heparin, pneumoboots\n # Code: FULL\n # Dispo: ICU for now\n # Comm: With pt or sister- (HCP)\n ------ Protected Section ------\n I was physically present with the resident team for evaluation of this\n patient and was present for the history, medications, ROS, Family\n History and exam on this date. I would add the following.\n Patient with history of Cirrhosis and now patient at home and\n presenting to ED with concern for hematemesis, although patient history\n equivocal as to extent and severity of bleeding. In ED\npatient with\n HR=74, HCT=35 and patient had U/S in ED showing patent TIPSS.\n He was admitted to ICU with concern for GI bleed in the setting of\n varices and significant cirrhosis, thrombocytopenia and risk for brisk\n bleeding.\n Will\n GI Bleed-\n -PPI\n -2 PIV\n -GI consulted and aware of patient\n -HCT q 6 hours\n -Monitor VS continuously\n -Will need trend in HCT to determine stability over time but initial\n ultrasound reassuring.\n Critical Care Time-35 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 00:34 ------\n" }, { "category": "Physician ", "chartdate": "2180-01-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 352913, "text": "Chief Complaint:\n 24 Hour Events:\n -\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Octreotide - 50 mcg/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 06:53 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: 37.1\nC (98.7\n HR: 81 (76 - 86) bpm\n BP: 101/60(70) {101/54(67) - 116/77(98)} mmHg\n RR: 12 (10 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,267 mL\n 1,425 mL\n PO:\n TF:\n IVF:\n 867 mL\n 1,425 mL\n Blood products:\n Total out:\n 0 mL\n 330 mL\n Urine:\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,267 mL\n 1,095 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n GEN: jaundiced, disheveled, no acute distress\n COR: RRR, no M/G/R, normal S1 S2, radial pulses +2\n PULM: Lungs CTAB, no W/R/R\n ABD: distended, no peripheral dullness to percussion, Soft, NT, +BS, +\n HSM, no masses\n EXT: No C/C/E, no palpable cords\n NEURO: + asterixis, alert, oriented to place,\n SKIN: +jaundice, cyanosis, or gross dermatitis. No ecchymoses.\n Labs / Radiology\n 47 K/uL\n 10.8 g/dL\n 174 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 2.8 mEq/L\n 20 mg/dL\n 100 mEq/L\n 134 mEq/L\n 30.3 %\n 6.8 K/uL\n [image002.jpg]\n 11:03 PM\n 04:12 AM\n WBC\n 6.8\n 6.8\n Hct\n 34.2\n 30.3\n Plt\n 51\n 47\n Cr\n 1.3\n 1.1\n Glucose\n 305\n 174\n Other labs: PT / PTT / INR:16.6/32.2/1.5, ALT / AST:35/71, Alk Phos / T\n Bili:306/10.5, Albumin:2.8 g/dL, LDH:261 IU/L, Ca++:7.9 mg/dL, Mg++:3.0\n mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n .H/O ALCOHOL ABUSE\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n DIABETES MELLITUS (DM), TYPE II\n This is a 56 year-old male with a history of ETOH cirrhosis with\n esophageal varices who presents with hematemesis x2 on day PTA,\n currently Hemodynamically stable.\n .\n Plan:\n # UGIB: in setting of known grade II varices.\n -GI following, appreciate their recs\n -Q6 hr Hct\n -Octreotide gtt\n - IV PPI\n -Cipro IV x5 days for SBP prophylaxis\n -plan for EGD if rebleeds\n -NPO except for meds\n # EtOH cirrhosis: c/b varices, hyponatremia, thrombocytopenia\n -Cont home rifaximin and lactulose\n -Cont MVI, Thiamine, folate\n -Continue home nadolol as BP allows\n # Hyponatremia: appears hypovolemic\n - trend w/IVF boluses\n - urine lytes\n # Type 2 DM- Continue home Lantus and HISS at half dose while NPO\n # EtOH abuse- pt has h/o DT's\n -CIWA scale\n -SW c/s\n #H/o depression- Cont home amitriptyline\n .\n # Thrombocytopenia- chronic liver disease. Will monitor\n .\n # FEN: NPO except for meds for now\n # Access: PIVs\n # PPx: IV PPI, no heparin, pneumoboots\n # Code: FULL\n # Dispo: ICU for now\n # Comm: With pt or sister- (HCP)\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:50 PM\n 18 Gauge - 10:51 PM\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" }, { "category": "Nursing", "chartdate": "2180-01-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 352912, "text": "This is a 56 year-old male with a history of ETOH cirrhosis with\n esophageal varices s/p TIPS as well as active EtOH use who presents\n with hematemesis x2 yesterday per VNA report. He was brought in by his\n cousin for concern for GIB, and currently denies that he had any\n hematemesis but instead endorses hematochezia. He denies abdominal\n pain, diarrhea, melena or hematochezia. Denies\n CP/palps/SOB/lightheadedness. Per report has been eating/drinking OK\n w/o aspiration/N/V.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No vomiting or stools. Abdomen is soft, ND, NT, +BS. Hematocrit stable\n at 2300 34.2 from 35.1 in ED. VSS\n Action:\n NPO except meds for planned Endoscopy today. He reports feeling hungry\n although his albumin is low and he was hyponatremic, hypophosphatemic,\n and hypokalemic. Lytes repleted and nutritional consult ordered.\n Response:\n Am lytes pending.\n Plan:\n Monitor crit and lytes q 8hrs, replete prn.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FSBG at midnight 379.\n Action:\n Given 10units humalog insulin.\n Response:\n Am BS pending.\n Plan:\n FSBG q 6hrs, follow SSI.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n No s/sx of withdrawal but pt was awake most of the night. He reports\n not sleeping well for the past 3 nights. He is A&O X2-3, sometimes\n can\nt figure out the day or date but knows month and year.\n Action:\n CIWA scale q 4hrs.\n Response:\n No valium needed.\n Plan:\n Continue CIWA scale q 4hrs.\n" }, { "category": "Nursing", "chartdate": "2180-01-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 352986, "text": "This is a 56 year-old male with a history of ETOH cirrhosis with\n esophageal varices s/p TIPS as well as active EtOH use who presents\n with hematemesis x2 yesterday per VNA report. He was brought in by his\n cousin for concern for GIB, and currently denies that he had any\n hematemesis but instead endorses hematochezia. He denies abdominal\n pain, diarrhea, melena or hematochezia. Denies\n CP/palps/SOB/lightheadedness. Per report has been eating/drinking OK\n w/o aspiration/N/V.\n Diabetes Mellitus (DM), Type II\n Assessment:\n At 1200 pt\ns blood sugar 251. At time pt NPO. Currently on humalog\n SS.\n Action:\n Given 3 units humalog SC x 1 according to SS to cover blood sugar. Pt\n currently on clear liquid diet.\n Response:\n Pt states that he is hungry. Remains on humalog SS.\n Plan:\n ? advance diet and continue to monitor blood sugar. Administer insulin\n as needed according to SS.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt with hx of bleed. Continues on Q 8 hour crit checks. AM crit\n 30.3.\n Action:\n Crit drawn at 1200 30.6. Electrolytes replaced by AM nurse.\n Response:\n Crit remains stable.\n Plan:\n Continue to monitor crit and lytes as ordered. Replace as needed.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt remains on CIWA scale Q 4 hours. Score at 1200 is 0\n Action:\n Pt does not require Diazepam at this time. Ordered for 5-10 mg for\n CIWA scale >10\n Response:\n CIWA scale 0\n Plan:\n Continue to monitor CIWA scale and monitor for signs of DT\n Pt to be transferred to 10.\n" }, { "category": "Nursing", "chartdate": "2180-01-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 352987, "text": "Demographics\n Attending MD:\n W.\n Admit diagnosis:\n UPPER GI BLEED\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 90 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, Diabetes - Insulin\n CV-PMH:\n Additional history: alcoholic cirrhosis, esophageal variceal bleed s/p\n TIPS, hepatic encephalopathy, chronic pancreatitis, thrombocytopenia,\n depression, umbilical hernia, hx of delerium tremens\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:84\n D:58\n Temperature:\n 97.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 92 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 94% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,942 mL\n 24h total out:\n 805 mL\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 11:39 AM\n Potassium:\n 3.6 mEq/L\n 11:39 AM\n Chloride:\n 103 mEq/L\n 11:39 AM\n CO2:\n 19 mEq/L\n 11:39 AM\n BUN:\n 19 mg/dL\n 11:39 AM\n Creatinine:\n 0.9 mg/dL\n 11:39 AM\n Glucose:\n 159 mg/dL\n 11:39 AM\n Hematocrit:\n 30.7 %\n 11:39 AM\n Finger Stick Glucose:\n 222\n 12:00 PM\n Valuables / Signature\n Patient valuables: sent with pt\n 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: 10\n Date & time of Transfer: 1500\n This is a 56 year-old male with a history of ETOH cirrhosis with\n esophageal varices s/p TIPS as well as active EtOH use who presents\n with hematemesis x2 yesterday per VNA report. He was brought in by his\n cousin for concern for GIB, and currently denies that he had any\n hematemesis but instead endorses hematochezia. He denies abdominal\n pain, diarrhea, melena or hematochezia. Denies\n CP/palps/SOB/lightheadedness. Per report has been eating/drinking OK\n w/o aspiration/N/V.\n Diabetes Mellitus (DM), Type II\n Assessment:\n At 1200 pt\ns blood sugar 251. At time pt NPO. Currently on humalog\n SS.\n Action:\n Given 3 units humalog SC x 1 according to SS to cover blood sugar. Pt\n currently on clear liquid diet.\n Response:\n Pt states that he is hungry. Remains on humalog SS.\n Plan:\n ? advance diet and continue to monitor blood sugar. Administer insulin\n as needed according to SS.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt with hx of bleed. Continues on Q 8 hour crit checks. AM crit\n 30.3.\n Action:\n Crit drawn at 1200 30.6. Electrolytes replaced by AM nurse.\n Response:\n Crit remains stable.\n Plan:\n Continue to monitor crit and lytes as ordered. Replace as needed.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt remains on CIWA scale Q 4 hours. Score at 1200 is 0\n Action:\n Pt does not require Diazepam at this time. Ordered for 5-10 mg for\n CIWA scale >10\n Response:\n CIWA scale 0\n Plan:\n Continue to monitor CIWA scale and monitor for signs of DT\n Pt to be transferred to 10.\n" }, { "category": "Physician ", "chartdate": "2180-01-05 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 352995, "text": "Chief Complaint: Hematemesis\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 56 year old history of alcoholic cirrhosis and esophageal varices s/p\n TIPS who presented after report of hematemesis. Patient has no other\n complaints.\n 24 Hour Events:\n Overnight, hematocrit drifted downward but no hematemesis or blood per\n rectum\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:59 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Other medications:\n Med List reviewed - See \n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:19 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: 36.7\nC (98.1\n HR: 79 (72 - 86) bpm\n BP: 104/72(80) {99/47(63) - 116/77(98)} mmHg\n RR: 12 (10 - 19) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,267 mL\n 2,070 mL\n PO:\n TF:\n IVF:\n 867 mL\n 2,070 mL\n Blood products:\n Total out:\n 0 mL\n 530 mL\n Urine:\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,267 mL\n 1,540 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished\n Chest: CTA bilaterally\n Cardiovascular: (S1: Normal), (S2: Normal)\n Extremities: warm, good pulses\n Skin: warm, dry\n Neurologic: no focal neuro findings\n Labs / Radiology\n 10.8 g/dL\n 47 K/uL\n 174 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 2.8 mEq/L\n 20 mg/dL\n 100 mEq/L\n 134 mEq/L\n 30.3 %\n 6.8 K/uL\n [image002.jpg]\n 11:03 PM\n 04:12 AM\n WBC\n 6.8\n 6.8\n Hct\n 34.2\n 30.3\n Plt\n 51\n 47\n Cr\n 1.3\n 1.1\n Glucose\n 305\n 174\n Other labs: PT / PTT / INR:16.6/32.2/1.5, ALT / AST:35/71, Alk Phos / T\n Bili:306/10.5, Albumin:2.8 g/dL, LDH:261 IU/L, Ca++:7.9 mg/dL, Mg++:3.0\n mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n .H/O ALCOHOL ABUSE\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n DIABETES MELLITUS (DM), TYPE II\n 1) Possible GI bleed\n - No gross blood on rectal exam at this time.\n - hematocrit decreased slowly from 35.1 to 30.3. Will re-check\n hematocrit now -> if continues to drop, then discuss with GI about\n endoscopy (currently GI does not believe necessary)...if hematocrit is\n same or improved, then will transfer to medical \n -\n 2) Hypokalemia\n - re-check after repletion\n 3) Thrombocytopenia: chronically low secondary to liver...continue to\n monitor\n 4) PPI/pneumoboots\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:50 PM\n 18 Gauge - 10:51 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : To floor if hematocrit stable\n Total time spent: 35\n" }, { "category": "Radiology", "chartdate": "2180-01-04 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1047982, "text": " 8:12 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: evaluate if TIPS patent\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with TIPS, here with bloody emesis, evaluate with doppler\n REASON FOR THIS EXAMINATION:\n evaluate if TIPS patent\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr TUE 10:32 PM\n Patent posterior TIPS with no interval change since .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man with TIPS and bloody emesis. Please evaluate for\n TIPS patency.\n\n Comparison is made to the prior study of .\n\n TECHNIQUE AND FINDINGS: Nodular and coarse liver parenchyma is unchanged and\n is compatible with the reported diagnosis of cirrhosis. Evaluation is limited\n somewhat by the patient body habitus and cooperation. The occluded anterior\n TIPS is unchanged. The posterior TIPS is patent and demonstrates wall-to-wall\n flow. The velocities within the proximal, mid, and distal TIPS are 99, 125,\n and 104 cm/sec, respectively, compared to the prior study when it measured 70,\n 102, and 168 cm/sec, respectively. Velocity within the main portal vein\n equals 71 which is unchanged compared to the prior study. The main portal\n vein demonstrates normal hepatopetal flow. The left portal vein demonstrates\n appropriate hepatofugal flow. The right anterior portal vein demonstrates\n appropriate hepatofugal flow towards the posterior TIPS. The hepatic veins and\n hepatic artery and IVC demonstrate normal flow pattern.\n\n Cholelithiasis with no evidence of cholecystitis again noted. No ascites is\n visualized in the interrogated regions of the right upper quadrant area.\n\n IMPRESSION:\n\n 1. Unchanged occluded anterior TIPS and unchanged patent posterior TIPS with\n normal flow in the proximal, mid and distal portions of the stent.\n\n 2. Cholelithiasis with no evidence of cholecystitis.\n\n 3. Cirrhotic liver.\n\n" }, { "category": "Radiology", "chartdate": "2180-01-04 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1047983, "text": ", W. MED 8:12 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: evaluate if TIPS patent\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with TIPS, here with bloody emesis, evaluate with doppler\n REASON FOR THIS EXAMINATION:\n evaluate if TIPS patent\n ______________________________________________________________________________\n PFI REPORT\n Patent posterior TIPS with no interval change since .\n\n" }, { "category": "Radiology", "chartdate": "2180-01-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1047979, "text": " 7:08 PM\n CHEST (PA & LAT) Clip # \n Reason: eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with hemoptysis\n REASON FOR THIS EXAMINATION:\n eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hemoptysis.\n\n COMPARISON: Chest radiograph .\n\n UPRIGHT AP AND LATERAL VIEWS OF THE CHEST: The cardiac and mediastinal\n contours are unchanged, with mild unfolding of the aorta. The heart size is\n normal. Pulmonary vascularity and hilar structures are also unchanged,\n without evidence of volume overload. The left lung is clear without pleural\n effusion, focal consolidation, or pneumothorax. There has been slight\n interval improvement in aeration of the right base, with persistent small\n right pleural effusion. No pneumothorax is seen on the right. Two TIPS\n stents are again seen within the right upper quadrant of the abdomen.\n Embolization coils are also seen within the left mid abdomen.\n\n IMPRESSION: Interval improvement in right basilar opacity with persistent\n small right pleural effusion. Findings are suggestive of resolving pneumonia.\n No new areas of abnormality otherwise identified.\n DFDdp\n\n" }, { "category": "ECG", "chartdate": "2180-01-04 00:00:00.000", "description": "Report", "row_id": 176328, "text": "Sinus rhythm. Borderline P-R interval prolongation. Q-T interval prolongation.\nSince the previous tracing of the rate has decreased. Q-T interval\nprolongation is more prominent. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Echo", "chartdate": "2165-09-27 00:00:00.000", "description": "Report", "row_id": 104142, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Congenital heart disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Myocardial infarction. Right ventricular function. Ventricular ectopy.\nStatus: Inpatient\nDate/Time: at 16:43\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 not identified.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. PFO is present.\nLeft-to-right shunt across the interatrial septum at rest.\n\nLEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Severe regional\nLV systolic dysfunction. Severely depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; basal inferolateral -\nhypo; mid inferolateral - hypo; basal anterolateral - hypo; mid anterolateral\n- hypo; anterior apex - hypo; septal apex - hypo; inferior apex - hypo;\nlateral apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets (3). No valvular AS. The increased transaortic velocity is related to\nhigh cardiac output. Trace AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate to severe\n(3+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope. No TEE\nrelated complications.\n\nConclusions:\nThe left atrium is mildly dilated. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium or left atrial appendage. The right atrium\nis markedly dilated. A patent foramen ovale is present. A left-to-right shunt\nacross the interatrial septum is seen at rest. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity is mildly dilated. There\nis severe regional left ventricular systolic dysfunction with mid-apical\ninferior and lateral alkinesis and apical akinesis. Overall left ventricular\nsystolic function is severely depressed (LVEF= 20 %). The right ventricular\ncavity is moderately dilated with moderate global free wall hypokinesis. The\nascending, transverse and descending thoracic aorta are normal in diameter and\nfree of atherosclerotic plaque to XX cm from the incisors. There are three\naortic valve leaflets. The aortic valve leaflets (3) are mildly thickened.\nThere is no valvular aortic stenosis. The increased transaortic velocity is\nlikely related to high cardiac output. Trace aortic regurgitation is seen. The\nmitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral\nregurgitation is seen. There is no pericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2165-09-14 00:00:00.000", "description": "Report", "row_id": 104143, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 72\nWeight (lb): 225\nBSA (m2): 2.24 m2\nBP (mm Hg): 124/70\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 10:42\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\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: Mildy dilated aortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: No or vegetations on aortic valve, but cannot be fully\nexcluded due to suboptimal image quality. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. or\nvegetations on mitral valve, but cannot be fully excluded due to suboptimal\nimage quality.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus. Suboptimal image quality - ventilator.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic root is mildly dilated at the sinus level. The ascending aorta is\nmildly dilated. No or vegetations are seen on the aortic valve, but\ncannot be fully excluded due to suboptimal image quality. There is no aortic\nvalve stenosis. No aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. No or\nvegetations are seen on the mitral valve, but cannot be fully excluded due to\nsuboptimal image quality. There is no pericardial effusion.\n\nIMPRESSION: No vegetations or clinically-significant regurgitant valvular\ndisease seen (suboptimal-quality study). Symmetric LVH with normal global and\nregional biventricular systolic function.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-09-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1250197, "text": " 8:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?new pna\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57yoM with history of DM, HTN, psychiatric illness who presents for fevers, new\n testicular mass and altered mental status found to be in respiratory failure\n who is doing well after extubating yesterday and off of pressors however\n continues to be delirious, now with new fever\n REASON FOR THIS EXAMINATION:\n ?new pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old man with fevers and altered mental status.\n\n COMPARISON: Chest radiographs through , CT .\n\n FINDINGS: A frontal upright view of the chest was obtained portably. There\n has been interval removal of the right internal jugular catheter. A PICC ends\n in the lower SVC. There is no focal consolidation or pneumothorax. Mild left\n basilar opacity has improved and is likely atelectasis and small pleural\n effusion as seen on chest CT. There is no pulmonary edema. Cardiac and\n mediastinal silhouettes are stable.\n\n IMPRESSION: Left basilar atelectasis and small effusion. No pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2165-09-15 00:00:00.000", "description": "GALLBLADDER SCAN", "row_id": 1249615, "text": "GALLBLADDER SCAN Clip # \n Reason: 57 YEAR OLD M W CONCERN FOR ACUTE CHOLI AND RISING TBILI. EVAL FOR ACUTE CHOLI\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 3.9 mCi Tc-m DISIDA ();\n HISTORY: Rising bilirubin. Patient on fentanyl.\n\n TECHNIQUE:\n Following the intravenous injection of tracer, serial one-minute images of\n tracer uptake into the hepatobiliary system were obtained for 60 minutes.\n\n INTERPRETATION:\n Serial images over the abdomen show delayed and diminished uptake of tracer into\n the hepatic parenchyma.\n\n At 60 minutes, neither the gallbladder or bowel are visualized.\n\n IMPRESSION: Abnormal hepatobiliary scan. The delayed tracer uptake into the\n hepatic parenchyma suggests hepatocellular dysfunction. The lack of\n visualization of the biliary collecting system may be secondary to biliary\n obstruction; however, poor hepatocellular dysfunction can also cause this\n finding.\n\n\n , M.D. Approved: MON 3:48 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": "2165-09-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1249377, "text": " 4:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ptx, pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 57M with hypoxia\n REASON FOR THIS EXAMINATION:\n ? ptx, pna\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old male with hypoxia, question pneumothorax.\n\n COMPARISON: No relevant comparisons available.\n\n ONE VIEW OF THE CHEST:\n\n The lungs are low in volume but clear. The cardiac silhouette is enlarged.\n The mediastinal silhouette is widened. The hilar contours and pleural\n surfaces are normal. No pleural effusion or pneumothorax is present. An ET\n tube and NG tube are appropriate.\n\n IMPRESSION:\n\n Mildly widened mediastinum is likely accentuated by low lung volumes. If an\n aortic injury is a clinical concern, then a CT of the chest may be obtained\n for further evaluation.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-09-13 00:00:00.000", "description": "SCROTAL U.S.", "row_id": 1249378, "text": " 7:52 AM\n SCROTAL U.S.; DUPLEX DOPP ABD/PEL Clip # \n Reason: ? mass, abscess ? torsion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 57M with swelling L testicle, now febrile with transient hypotension\n REASON FOR THIS EXAMINATION:\n ? mass, abscess ? torsion\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SVMc FRI 9:40 AM\n Heterogenous, relatively mass in the left testes. There is some\n vascularity within it, although not hypervascular. There is some peripheral\n more normal appearing testicular tissue which looks edematous. These findings\n learn towards mass, although time course history would of course be helpful in\n discerning\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57-year-old man with left testicle swelling.\n\n COMPARISON: None.\n\n TECHNIQUE: Scrotal ultrasound.\n\n FINDINGS: The right testis is unremarkable measuring 3.8 x 3.6 x 3.0 cm and\n is of normal echogenicity. The right epididymis is unremarkable as well. The\n left testis is grossly abnormal measuring up to 10.4 cm. There appears to be\n a large heterogeneous, relatively hypoechoic mass with minimal vascularity\n displacing the normal testis. Some more peripheral areas of edematous, but\n spared, testicular tissue is seen. Left epididymis is not well visualized.\n This mass also causes mass effect in the scrotum on the right testis. No\n hydrocele seen on either side.\n\n IMPRESSION: Large heterogeneous mass in the left testis enlarging and\n replacing a majority of the normal testicular tissue. These findings are\n suggestive of mass lesion.\n\n" }, { "category": "Radiology", "chartdate": "2165-09-19 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1250062, "text": " 9:04 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: ?mass, infectious process,\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: GADAVIST Amt: 14\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57yoM with history of DM, HTN, psychiatric illness who presents for fevers of\n unclear etiology, new testicular mass and altered mental status found to be in\n respiratory failure who is doing well after extubation and off of pressors\n however continues to be delirious.\n REASON FOR THIS EXAMINATION:\n ?mass, infectious process,\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:07 AM\n No acute infarct, mass effect, or enhancing brain lesion. Chronic left\n cerebellar infarct.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with diabetes, hypertension and psychiatric\n illness, presenting with fever of unclear etiology, testicular mass and\n altered mental status, found to be in respiratory failure, for further\n evaluation.\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 is no evidence of acute infarct seen on diffusion-weighted\n images. There is prominence of ventricles and sulci indicating brain atrophy.\n There is mild medial temporal atrophy seen. Brain atrophy is inappropriate\n for patient's age. There is no midline shift or hydrocephalus. A chronic\n left cerebellar infarct is identified. Following gadolinium there is no\n evidence of abnormal parenchymal, vascular or meningeal enhancement seen.\n\n IMPRESSION: No acute infarct seen. Age-inappropriate brain atrophy. Small\n chronic left cerebellar infarct. No mass effect or hydrocephalus. No\n enhancing brain lesions.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-09-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1249510, "text": " 4:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? intracranial process, ? abdominal process, ? scrotal absce\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 57M with repeat chest after central line, ? altered with fevers 106,\n testicular swelling on L with abdominalpain\n REASON FOR THIS EXAMINATION:\n ? intracranial process, ? abdominal process, ? scrotal abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Repeat chest after central line, fevers.\n\n CHEST, SINGLE AP PORTABLE VIEW\n\n Compared with at 11:12 a.m., the ET tube and NG tube are poorly\n delineated due to underpenetration and slight rotation and can therefore not\n be localized. A right IJ central line is present, tip over mid/distal SVC.\n\n There is increased retrocardiac density, consistent with left lower lobe\n collapse and/or consolidation and a small left effusion. This is similar or\n possibly slightly worse compared with at 11:12 am. There is minimal\n patchy opacity at the right lung base, which appears new. No right-sided\n effusion. Allowing for low inspiratory volumes, there is slight vascular\n plethora, but I doubt overt CHF.\n\n" }, { "category": "Radiology", "chartdate": "2165-09-13 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1249439, "text": " 1:28 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: r/o cholecystitis\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with sepsis and elevated LFTS concern for cholangitis\n REASON FOR THIS EXAMINATION:\n r/o cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old man with sepsis and elevated LFTs. Evaluate for\n cholecystitis.\n\n COMPARISON: Abdomen CT, .\n\n FINDINGS: The liver is unremarkable in appearance with no concerning liver\n lesion identified. No biliary dilatation is seen. The portal vein is patent\n with hepatopetal flow.\n\n Transverse and sagittal images were obtained of the gallbladder. A small\n gallstone is seen in the neck of the gallbladder measuring about 4 mm. The\n gallbladder wall is thickened and is edematous. Ultrasound cannot exclude\n cholecystitis.\n\n The pancreas is unremarkable but is only partially visualized due to overlying\n bowel gas. The spleen is enlarged measuring 15.8 cm. No ascites is seen in\n the abdomen.\n\n IMPRESSION: Cholelithiasis with edematous gallbladder wall. Cholecystitis\n cannot be excluded. A HIDA scan could be performed for further\n characterization.\n\n Splenomegaly.\n\n Findings of edematous gallbladder wall concerning for cholecystitis were\n discovered at 16:49 on and were conveyed by telephone to Dr.\n , at 16:52 on the same day.\n\n" }, { "category": "Radiology", "chartdate": "2165-09-21 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1250327, "text": " 11:04 AM\n PORTABLE ABDOMEN Clip # \n Reason: ?SBO\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57yoM with history of DM, HTN, psychiatric illness who presents for fevers, new\n testicular mass and altered mental status found to be in respiratory failure\n who is doing well after extubating yesterday and off of pressors however\n continues to be delirious. Now with hemetemesis\n REASON FOR THIS EXAMINATION:\n ?SBO\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN ON \n\n HISTORY: Testicular mass and altered mental status with delirium.\n\n FINDINGS: The stomach is grossly distended. Gas is seen in the colon and\n small bowel. There are scattered air-fluid levels on the decubitus film. The\n lower portion of the chest is seen on the supine film, and there is blunting\n of the CP angle suggesting an effusion, though is not visualized previously.\n Recommend dedicated chest x-ray for further assessment.\n\n IMPRESSION:\n 1. Distended stomach.\n 2. Question left effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-09-17 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1249844, "text": " 2:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: right brachial power picc 48 cm \n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with new line placement\n REASON FOR THIS EXAMINATION:\n right brachial power picc 48 cm \n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 57-year-old male patient with new line placement of right\n brachial PowerPICC. Report to cell, page .\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n semi-upright position. Comparison is made with the next preceding similar\n study of . During the interval, the patient has been extubated.\n The patient's position has improved in as much as he is not tilting any more\n towards the right as before. The previously present right-sided internal\n jugular approach central venous line remains in unchanged position, seen to\n terminate 2 cm below the level of the carina. A new right-sided PICC line has\n been placed, seen to terminate also overlying the right-sided mediastinal\n structures terminating 2 cm further down in comparison with the other line.\n Termination point is still safe above the expected entrance into the right\n atrium. No new pulmonary abnormalities are seen and no pneumothorax can be\n identified.\n\n IMPRESSION: Well positioned right-sided PICC line, no complications. Page to\n cell at was performed at 3:30 p.m.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-09-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1249387, "text": " 5:21 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? intracranial process, ? abdominal process, ? scrotal absce\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 57M with repeat chest after central line, ? altered with fevers 106,\n testicular swelling on L with abdominalpain\n REASON FOR THIS EXAMINATION:\n ? intracranial process, ? abdominal process, ? scrotal abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf FRI 6:20 AM\n No acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old male with altered mental status, question\n intracranial process.\n\n COMPARISON: No relevant comparisons available.\n\n TECHNIQUE: MDCT images were acquired through the head without contrast. Bone\n kernel reconstructions and multiplanar reformations were obtained and\n reviewed.\n\n FINDINGS:\n\n No acute intracranial hemorrhage, large vascular territory infarct, shift of\n midline structures or mass effect is present. There is an old left cerebellar\n infarct. The ventricles and sulci are normal in size and configuration. The\n visible paranasal sinuses show anterior ethmoidal secretions. Secretions are\n noted in the nasopharynx.\n\n IMPRESSION:\n\n No acute intracranial process.\n\n" }, { "category": "Radiology", "chartdate": "2165-09-13 00:00:00.000", "description": "CT ABD & PELVIS WITH CONTRAST", "row_id": 1249388, "text": " 5:22 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: ? intracranial process, ? abdominal process, ? scrotal absce\n Field of view: 50 Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 57M with repeat chest after central line, ? altered with fevers 106,\n testicular swelling on L with abdominalpain\n REASON FOR THIS EXAMINATION:\n ? intracranial process, ? abdominal process, ? scrotal abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf FRI 7:06 AM\n No acute intra-abdominal process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old male with fevers to 106 and testicular swelling,\n question abdominal process.\n\n COMPARISON: No relevant comparisons available.\n\n TECHNIQUE: MDCT images were acquired through the abdomen and pelvis with IV\n contrast. Multiplanar reformations were obtained and reviewed.\n\n The partially imaged lungs show bibasilar atelectasis. The partially imaged\n heart is unremarkable.\n\n CT OF THE ABDOMEN WITH IV CONTRAST:\n\n The liver, spleen, left adrenal, pancreas, and gallbladder are unremarkable.\n Both kidneys show multiple lobulations, which could represent scarring. No\n abdominal, retroperitoneal or mesenteric lymphadenopathy by CT size criteria\n is noted, although several nonenlarged lymph nodes are noted in the left\n retroperitoneum. The small and large bowel loops are unremarkable. The right\n adrenal has a large fatty nodule most consistent with a lipoma.\n\n CT OF THE PELVIS WITH IV CONTRAST:\n\n The rectum, sigmoid colon, collapsed bladder are unremarkable. No pelvic or\n inguinal lymphadenopathy or pelvic free fluid is present.\n\n OSSEOUS STRUCTURES:\n\n The visible osseous structures show no suspicious lytic or blastic lesions or\n fractures. Multilevel degenerative disc and joint disease with posterior disc\n osteophyte at L3-L4 is noted.\n\n IMPRESSION:\n\n No acute intra-abdominal process.\n (Over)\n\n 5:22 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: ? intracranial process, ? abdominal process, ? scrotal absce\n Field of view: 50 Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2165-09-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1249389, "text": " 5:59 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: confirm line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 57M with right IJ placed\n REASON FOR THIS EXAMINATION:\n confirm line placement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old male with right IJ placement. Please confirm line.\n\n COMPARISON: Chest radiograph from at 4:00 a.m.\n\n ONE VIEW OF THE CHEST:\n\n The lungs are low in volume but clear. The cardiac silhouette and mediastinal\n silhouettes are prominent, likely related to low lung volumes. The hilar\n contours and pleural surfaces are normal. There is mild pulmonary vascular\n congestion. There may be a small left pleural effusion. A right IJ line\n terminates appropriately in the distal SVC. High position of ET tube is at the\n level of thoracic inlet, advancement of 3 cm is appropriate. NG tube is\n appropriate. No pneumothorax is present.\n\n IMPRESSION:\n\n Mild pulmonary vascular congestion. Appropriate right IJ line. High position\n of ET tube is at the level of thoracic inlet, advancement of 3 cm is\n appropriate.\n\n Discussed with Dr over the phone by Dr at 1 pm on\n \n\n" }, { "category": "Radiology", "chartdate": "2165-09-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1249425, "text": " 11:03 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p intubated with high peak pressures\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Intubation, high peak ventilation pressure.\n\n AP radiograph of the chest was reviewed in comparison to prior study\n obtained the same day earlier.\n\n The ET tube tip is still high, 8 cm above the carina. The right internal\n jugular line tip is at the level of mid SVC. NG tube tip is in the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2165-09-22 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1250449, "text": " 7:33 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? acute intracranial process s/p fall\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with dementia, s/p fall\n REASON FOR THIS EXAMINATION:\n ? acute intracranial process s/p fall\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SJBj SUN 9:42 PM\n No acute intracranial process.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old man with dementia and fall.\n\n COMPARISONS: .\n\n TECHNIQUE: MDCT data were acquired through the head without intravenous\n contrast. Images were reconstructed using bone and soft tissue kernels and\n displayed in multiple planes.\n\n FINDINGS: There is no evidence of hemorrhage, infarction, edema, mass, or\n shift of normally midline structures. There is no evidence of fracture.\n Prominence of the ventricles and sulci is consistent with cortical atrophy.\n Basal cisterns are widely patent. An apparent 3 mm focus of air attenuation\n superior to the clivus (601B:45, 602B:41) is most likely artifactual in the\n absence of any fracture. The calvarium is intact. There is no scalp\n hematoma. The visualized paranasal sinuses, mastoid air cells, and inner ear\n cavities are clear.\n\n IMPRESSION: No evidence of hemorrhage or fracture..\n\n NOTE ADDED AT ATTENDING REVIEW: There is a small air collection at the dorsum\n sellae. This may be a consequence of recent lumbar puncture. I agree that\n there is no evidence of fracture, and the dorsum is not pneumatized. Although\n air may be seen in the cavernous sinus due to intravenous access, it would not\n be expected in this location.\n\n" }, { "category": "Radiology", "chartdate": "2165-09-20 00:00:00.000", "description": "LUMBAR SPINAL PUNCTURE", "row_id": 1250219, "text": " 10:42 AM\n LUMBAR PUNCTURE Clip # \n Reason: Please do large volume LP (20-30cc) for cytology\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ********************************* CPT Codes ********************************\n * LUMBAR SPINAL PUNCTURE FLUORO GUID FOR SPINE DIAG/THE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57yoM with history of DM, HTN, psychiatric illness who presents for fevers, new\n testicular mass and altered mental status found to be in respiratory failure\n who is doing well after extubating yesterday and off of pressors however\n continues to be delirious.\n REASON FOR THIS EXAMINATION:\n Please do large volume LP (20-30cc) for cytology\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57-year-old male with mental status change. Please perform lumbar\n puncture with large volume tap.\n\n COMPARISON: None.\n\n OPERATORS: Dr. , attending. Dr was present and\n participating in the entirety of the procedure.\n\n Dr. , resident.\n\n , nurse practitioner.\n\n TECHNIQUE: The procedure was explained to the patient, and written informed\n consent was obtained after all questions were answered. The patient was\n brought to the angiography suite and placed prone on the table. The area\n overlying the lumbar spine was prepped and draped in usual sterile fashion. A\n preprocedure timeout confirmed the patient identity and procedure to be\n performed. Under fluoroscopic guidance, an appropriate site was marked at\n L3-L4. The skin overlying this area was anesthetized with approximately 10 cc\n of 1% lidocaine. Then, under fluoroscopic guidance, an 18 gauge spinal needle\n was advanced into the subarachnoid space. The stylet was removed, yielding\n clear CSF. Approximately 22 cc of clear CSF was removed, the needle was\n removed after the stylet was replaced, and a Band-Aid was applied. The\n patient tolerated the procedure well, though did ask that we terminate the\n procedure early and therefore more CSF could not be obtained.\n\n IMPRESSION: Successful lumbar puncture, with removal of 22 cc of clear CSF,\n sent to laboratory for analysis.\n\n" }, { "category": "Radiology", "chartdate": "2165-09-14 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1249546, "text": " 1:55 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please evaluate for pneumonia\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with scrotal mass, sepsis\n REASON FOR THIS EXAMINATION:\n Please evaluate for pneumonia\n CONTRAINDICATIONS for IV CONTRAST:\n \n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: CT chest without contrast.\n\n HISTORY: 57-year-old man with scrotal mass, sepsis, please evaluate for\n pneumonia. Acute renal failure, high creatinine, no IV contrast.\n\n COMPARISON: CT abdomen and pelvis .\n\n FINDINGS: Endotracheal tube is seen terminating above the carina. Visualized\n airways are patent. No evidence of focal consolidation to suggest pneumonia.\n Mild subsegmental atelectasis bilateral lung bases. Small left greater than\n right bilateral pleural effusions. 3mm nodule right upper lobe. 4mm nodule\n right middle lobe.\n\n Visualized thyroid unremarkable. No evidence of axillary, mediastinal, or\n hilar lymphadenopathy. Mild calcific atherosclerosis of a normal caliber\n aortic arch. Coronary artery atherosclerosis. Otherwise, normal-appearing\n colon heart on non-contrast exam. Esophageal tube terminating in the gastric\n antrum. Partially visualized upper pole of bilateral kidneys appear atrophic.\n Bilateral small adrenal myelolipomas unchanged. Partially visualized upper\n abdominal viscera appear otherwise unremarkable.\n\n IMPRESSION:\n 1. No evidence of pneumonia. Bibasilar subsegmental atelectasis with small\n left greater than right pleural effusions.\n 2. Tiny pulmonary nodules <4mm as described above.\n\n" }, { "category": "ECG", "chartdate": "2165-09-21 00:00:00.000", "description": "Report", "row_id": 305905, "text": "Sinus rhythm. Left axis deviation consistent with left anterior fascicular\nblock. Delayed R wave progression which may be due to left anterior fascicular\nblock. Non-specific anteroseptal ST-T wave changes. Compared to the previous\ntracing of the heart rate has slowed and anteroseptal ST segment changes\nare slightly more pronounced.\n\n\n" }, { "category": "ECG", "chartdate": "2165-09-13 00:00:00.000", "description": "Report", "row_id": 305906, "text": "Sinus tachycardia. Left anterior hemiblock. No previous tracing available for\ncomparison.\n\n" }, { "category": "ECG", "chartdate": "2165-09-27 00:00:00.000", "description": "Report", "row_id": 305903, "text": "Possible ectopic atrial rhythm. Left axis deviation. Intraventricular\nconduction defect of left bundle-branch block type raise concern for drug\nor metabolic effect. Compared to the previous tracing of \nQRS complexes is markedly wider at a similar heart rate. The rhythm appears\nto be non-sinus in origin. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2165-09-27 00:00:00.000", "description": "Report", "row_id": 305904, "text": "Sinus rhythm. Left anterior fascicular block. Poor R wave progression.\nConsider prior anteroseptal myocardial infarction. Compared to the previous\ntracing of no diagnostic interim change.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2122-05-24 00:00:00.000", "description": "Report", "row_id": 1579093, "text": "CCU NPN\n\nS: \"I feel lighter\"\nO: Please see carevue for all objective data\nneuro: alert, oriented cooperative w/ care\ncv: hemodynamically stable w/ hr 72-79 sr no vea, bp 91-97/49-64 and MAPs > 60.\nresp: Sats 91-96% on 2.5 liters np. some exp wheezes, takes nebs at bedside.\ngi: excellent appitite, up to commode w/ assistance\ngu: CRRT continues for ultrafiltration only. Taking off 300cc/hr. Heparin ^ to 900 units/hr per renal fellow, f/u ptt pnd. Dialyzer w/ clots, however unchanged since AM. Flushed x2. Lasix gtt continues at 7 mg/hr w/ u/o 80-200cc/hr. Currently ~ 6500cc neg since mn. Wt 145.6 today down from 153.7 yessterday. foley fell out and replaced.\nid: afebrile, cont on keflex.\nskin: intact\nactivity: OOB to commode w/ assistw/ lines, moves well.\nsocial: husband in to visit\nA: tolerating ultrafiltration.\nP: continue ultrafiltration at current rate w/ lasix gtt titrated to > 100cchr. Monitor bp. Labs ( Na, K, Cl, CO2, bun/cr, ca, mg phos, PTT)\nq 12 hr.\n" }, { "category": "Nursing/other", "chartdate": "2122-05-25 00:00:00.000", "description": "Report", "row_id": 1579094, "text": "NURSING PROGRESS NOTE 7P-7A\nS: \" I DID NOT SLEEP WELL, I KEPT COUGHING\"\n\nO: NEURO: PT. ALERT AND ORIENTED X3, PLEASANT AND COOPERATIVE WITH CARE. TRANSFERS TO COMMODE WITH 1 ASSIST. SLEPT POORLY DUE TO COUGH.\n\nCV: HR 72-79 SR WITH RARE PVC. BP 91/48-111/64 MAP 64. RECEIVING HEPARIN 900 UNITS THROUGH ULTRAFILTRATION. PTT PENDING.\n\nRESP: ON 2.5L NC, O2 SAT 93-95%. DESAT TO 88% WITHOUT O2. LUNGS CLEAR, SL EXP WHEEZE NOTED IN RUL. CONGESTED, PRODUCITVE COUGH. COUGHING AND RAISING THICK WHITE SPUTUM. ALB/ATR NEBS GIVEN X2. STARTED ON FLONASE NASAL SPRAY. GIVEN ROBITUSSIN FOR COUGH WITH FAIR EFFECT. NOW ORDERED FOR ROBITUSSIN AC.\n\nGI: + BOWEL SOUNDS. NO BM OVERNIGHT. PASSING GAS. C/O NAUSEA EARLIER, GIVEN ZOFRAN WITH RELIEF FROM NAUSEA.\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE IN GOOD AMTS. HUO 100-120 CC/HR. CONT ON ULTRAFILTRATION, WEIGHT TODAY 137 KG (-8.6 KG). (-) 2L X 24 HRS. SEE CAREVUE FOR ULTRAFILTRATION DATA.\n\nID: AFEBRILE, RECIEVED LAST DOSE KEFLEX THIS AM. WBC 4\n\nSKIN: INTACT.\n\nA: ADMIT WITH CHF,COPD, EF 15%, RISING CREAT, NOW ON ULTRAFILTRATION. CREAT IMPROVING, WEIGHT DOWN.\n\nP: CONT TO FOLLOW,PTT LYTES, REPLETE AS NEEDED. MONITOR I/O, DAILY WEIGHT. UPDATE PT. AND FAMILY ON PLAN OF CARE PER CCU TEAM.\n" }, { "category": "Nursing/other", "chartdate": "2122-05-25 00:00:00.000", "description": "Report", "row_id": 1579095, "text": "CCU NPN\n\n0700-1900\n\nneuro: alert, oriented x3 cooperative w/ care\ncv: hr 71-81 sr no vea, bp 85-104/41-67. Heparin at 900 units/hr thru Prisma w/ theraputic PTT.\nresp: SATs 91-94 on 2.5 liters o2. lungs cta w/ occ exp wheezes, pt takes nebs. c/o cough, non productive, given Robitussin w/ codine w/ good effect.\ngi: no issues, no stool this shift\ngu: foley draining cyu 50-180 cc/hr on lasix gtt 7 mg/hr. Continues on CRRT, ultrafiltration only w/ fluid removal rate set at 350cc/hr. Tolerating well, Quinton cath site d/i. neg 7000cc since mn, ~ 25 kg down since crrt stqrted. Cr down to 2.1 this am.\nskin: intact\nactivity: OOB to commode w/ one assist, tolerated well\nA: tolerating agressive ultrafiltration and diuresis,\nP: Continue ultrafiltration and lasix gtt (titrated to u/o >100cc), monitor bp. Follow lytes,ca, mg, phos, BUN, Cr , ptt q 12 hr.\nEmotional support to pt.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-05-26 00:00:00.000", "description": "Report", "row_id": 1579096, "text": "NPN 7 PM-- 7 AM\n\nPT has been on CRRT since friday admitted to hospital with fluid overload on , had been on lasix drip here, and on floor, but back to CCU with ARF and CHF. We have been doing SCUF, and pt is net negative 28 liters since friday. She developed ARF on floor, ? from drug effect vs por forward flow, and creatinine has been improving. She was being concomitantly diuresed with a lasix drip and SCUF, however lasix drip was stopped last night and we went down on UF rate, as pt had dropped her BP to 70's and urine output dropped off from 80--100 cc per hr to zero. PT did respond to measures and BP came up and urine output picked up as well, and pt may again tolerate aggressive diuresis, though currently we have backed off from net negative 350 cc per hour to 150 cc per hour.\n\nneuro- Alert Ox3, OOB to commode with supervision. pt has removed her O2 at times and her BP cuff once but not confused and replaces o2 when prompted.\n\nCV-Respiratory SR on increased dose carvedolol 6.25 mg first dose at 8PM and BP did drop later to 80's then 76/51- team aware. However since we decreased UF rate BP has been 90-100 systolic. HR in the 70's pt denies any pain, edema is markedly decreased, but pt still exhibits\nDOE esp on room air. PT on home O2, here in hospital able to tolerate room air when resting and sitting up on side of bed, but with activity desats to 88-90 and appears SOB. pt alternates overnight on room air and 2L NC. Pt has non productive nagging cough seems to occur at night\n( or not noted early in shift), pt experienced relief with cough med\nguaifenesin codeine.\n\nGU/renal- pt U/O dropped off last night from 100 per hr to 40 then 15 and then zero, but improved as BP increased when we backed off on CVVH. last few hours 25-40 cc per hr. Urine is amber in color. creatinine has been coming down and last night was 1.8 - labs sent at 0400 and results are pending. PT on SCUF, removing 150 cc per hour ( from 350 per hr last night) and pt is tolerating this. We are checking Labs Q 12 hrs, Machine and catheter are working well, however system clotted last night and was changed arout 11 PM. System flushed this AM\nwith saline, filter is in excellent condition but the access pressure pod does have some clotting already.\n\nA: Pt with cardiomyopathy and chf, now ARF, on SCUF for aggressive fluid removal, lasix drip on hold as pt appeared dry, currently improved with decreased UF.\n\nP: re evaluate in AM for increased UF as pt tolerates, follow labs (now Q 12) I/O, BP, respiratory and CV status. Pt is anxious to get up and walk around, has been OOB to commode x 2 without incident. Pt has some unsafe habits - putting baby powder on the floor and applies lotion to feet, then forgets to put on slippers for ambulating. Pt educated and reminded about fall safety. keep pt udated on POC as discussed in CCU rounds.\n" }, { "category": "Nursing/other", "chartdate": "2122-05-26 00:00:00.000", "description": "Report", "row_id": 1579097, "text": "Nursing Progress Note (0700-1900)\n56 y.o. female w/ CHF admitted for diuresis after p/w worsening SOB, DOE, bil. LE edema;(recent admit w. 40 lbs removed by diuresis) to F3 from ED where diuresed w/lasix gtt, became somnolent required CCU trxfr, rec'd PICC line, returned to F3: transfered back to CCU for management of ARF, UTI and SCUF v. lasix only for aggressive diuresis. Continues on SCUF today (off lasix gtt) and has diursed approx. 32 L since admit.\n\nS: \" How many more days on this machine?\"\nO: Please see careview for all objective data.\nA:\nCV: SR w.freq. PAC's/SA; rate 73-80. Carvedilol dose decreased for this pm to 3.125 mg from 6.25 mg. BP 81-108/50-70 maintained MAP's > 60. Hemodynamically tolerating progressive increases in UF rate over this shift. Goal to remove 5 liters by midnight (ultimate goal - 15-20 more liters this admission). Bilateral lower extremity edema noted, but decreasing per patient. pedal pulses palpable; denies any c/o CP.\n\nRESP: LS CTA bilaterally, slightly diminished evenly throughout lung fields body habitus. Wearing and intermittently removing 2 l O2 via NC.; provided education and reinforcement regarding importance of maintaining NC. Sats 91-96%; drop rapidly to 88% on RA. Still w/ slight DOE to commode. Medicated w/ 10 mg guiafenesin w/ codeine at early onset of \"coughing fit\" which seems to have prevented any episodes of coughing.\n\nNEURO: alert and oriented x 3. notable exopthalmus.reports \"feeling better\". while pleasant in demeanor, pt. does engage in potentially unsafe behaviors and requires frequent limit setting in these arenas: removing O2 tubing and BP cuff, declining to wear skid-free stockings, sitting at edge of bed/ standing up at bedside w/o assistance. pt. has been educated and reminded of the hazards of these behaviors. Is not confused but continues to state that she is \"always watching her lines\". Bed alarm activated for safety.\n\nGI: Abdomen softly obese, NT, ND, active bs x4. No bm this shift; colace as ordered. Non-diabetic.\n\nGU/RENAL: Foley removed at 5 pm. UO 5-45 cc's/hour. SCUF w/ goal neg 5 liters by midnight; on-track to reach goal. please see following RN note regarding further details of ultrafiltration.\n\nSKIN: Warm, dry and intact; patient frequently applies personal lotion to LE's.\n\nACCESS: Right IJ Quinton cath; right brachiocephalic PICC-is midline not central by xray.\n\nSOCIAL: Husband and cousin in to visit today. Discussed need for VNA when ready for d/c to home; patient amenable at this time.\n\nPLAN: continue to monitor tele and vs. closely monitor I and O to reach goal -5 L w/ SCUF by midnight as BP allows. continue to monitor respiratory status; encourage pt. to wear o2. encourage safety w/ assist to commode. continue to update patient w/ plan of care per team.\n" }, { "category": "Nursing/other", "chartdate": "2122-05-26 00:00:00.000", "description": "Report", "row_id": 1579098, "text": "CCU NSG NOTE: \nADDENDUM TO PRIOR NOTE: \nPt remains on SCUF, tolerating it well and will likely reach todays goal of 5 liters neg as she is now >3800cc neg. The line site is clean with no signs of reddness. The filter pressure have been elevated in low 200s with no alarms or problems in . The line has been flushed a number of times. Her PTT was 45.3 and with higher parameter written her dose was increased from 900 to 1000u at 1700. Other labs, her K+ is 4.9 and creat increased to 2.2.\n" }, { "category": "Nursing/other", "chartdate": "2122-05-27 00:00:00.000", "description": "Report", "row_id": 1579099, "text": "NPN 7 PM- 7 Am\n\nPT stable overnight, continues on SCUF therapy for fuid overload and renal failure, tolerated well, without drop in BP. Reached goal of net negative 5 liters at midnight and this morning pt is additionally net negative 1.7 liters . She is breathing easier and her edema is markedly decreased. Pt able to tolerate room air overnight, 02 sats on room air 93-98 percent, continues to have some DOE when getting out of bed to commode and back. Morning labs PTT within range, lytes OK, Phos is high and creatinine continues to climb, pt put out only 200 cc last night voiding. She took her cough med and ambien last night and was able to sleep , she did however remove BP cuff and o2 sat probe at one point and stated that she could not sleep with them on. SHe states she is anxious to get rid of all these wires and would like to remove the heart monitor as well.\n\nPrisma machine is running well and catheter functions ok, however clots continue to appear in the access pressure pod and system was changed after several filter is clotting alarms. We are also flushing the filter Q4-6 hours with saline, but without replacement fluid system is prone to clotting.\n\nA: Pt with cardiomyopathy and copd, fluid overload, now down 77 lbs\nsince , feeling better but continues to have ARF.\n\nP: Continue SCUF therapy as tolerated by pt hemodynamics, follow Labs,\nI/O, consider phosphate binders, OOB to chair.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-05-27 00:00:00.000", "description": "Report", "row_id": 1579100, "text": "Nursing Progress Note (0700-1900)\n56 yo female w/CM EF 30-30%; p/w CHF exacerbation; admit since between CCU and F3 for diuresis. Now in ARF on SCUF for aggressive diuresis.\n\nS: \"I know that I can watch my sodium at home\"\nO: Please see careview for all objective data.\nA:\nCV: SR rate 73-83 w/o notable ectopy. Carvedilol 3.125 mg . BP 89-100/62-70 while maintaining MAP's 62-75. Continues to hemodynamically tolerate aggressive rate of fluid removal w/ SCUF. Exceeding fluid removal goal 5 liters per day. Improving LE edema. Continues to deny CP. K+ 4.8.\n\nRESP: LS CTAB; ls remain slightly diminished body habitus. Maintianed O2 sats 94-100% on RA today. Slightly dyspneic when OOB to commode but no drop in O2 sat. Medicated this afternoon with guiafenesin w/codeine to prevent \"coughing fit\"; no coughing noted this shift. Denies feeling SOB.\n\nNEURO: Alert and oriented x 3. pleasant; exopthalmus. no unsafe behaviors today; no attempts oob w/o RN.\n\nGI: Abdomen soflty obese, active BS x4; no bm today; continues on colace. TID Tums started today for phos. binding (Phos:5.5). 2 episodes of acute LUQ pain this afternoon completely relieved w/application of warm pack and emotional support. MD 'd; likely r/t fluid shifts SCUF; rate then slightly decreased w/ good effect.\n\nGU: Patient making little urine today. voids amber colored into the commode. Afternoon CR 2.8, BUN 84 (both levels rising) team aware, plan per team to decrease SCUF rate. phosp binding as above w/ tid tums.please see following RN note for details on SCUF.\n\nSKIN: warm, dry and intact. pt. c/o severe itching to bil. LE's; is not scratching. she is liberally applying lotion. sarna lotion ordered. rec'd 25 mg benadryl this afternoon w/ excellent relief.\n\nMSKLT: c/o leg cramping this afternoon (again, likely fluid removal/fluid shifts). given 50 mg ultram w/ complete relief of pain.\n\nACCESS: right IJ dialysis catheter; site wnl. Right AC mid-line PICC; double -lumen. slow to flush but remains patent.\n\nDISPO: nutrition consulted and initiated dietary teching w/ pt.; espeically re: 2 gm sodium. patient receptive to teaching and appeared to understand concept of noting not only sodium but serving size. case management notified that pt. will require vna services when approp. for discharge.\n\nSOCIAL: Husband in to visit today.\n\nPLAN: continue to monitor tele and vs. monitor I and O and daily weight; SCUF as ordered. continue to monitor for effects of diuresis; monitor for pain/discomfort. closely monitor labs esp. renal function. continue to provide emotional support and dietary teaching. await further team plans for care.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-05-23 00:00:00.000", "description": "Report", "row_id": 1579091, "text": "CCU NPN\n\n0700-1900\n\nneuro: alert, oriented x3, cooperative w/ care\ncv: hr 69-74 nsr w/ no vea. bp 88-110/51-64\nresp: SATs 91-96 on 2lnp, coarse lung sounds w/ some bibasilar crackles and occ exp wheezes. Non productive cough, given guaifenesin w/ good effect.\ngi: given ducolax this am w/ good effect, 2 med brn formed stool\ngood appitite\ngu; continues on crrt, ultrafiltration only rate ^ to 300 tolerating well. Dialyzer clotted at 1300, restarted at 1545. lasix gtt started at 10 mg/hr at 1300, now putting out ~ 200cchr. Net negative 4500cc since mn. Heparin ^ to 500 units/hr for ptt 38, at 1100.\nid: afebrile, cont on abx\nskin: intact\nactivity: OOB to commode MD. Tolerated well. Pt moves well but requires assistance w/ lines.\nA: Tolerating increased ultrafiltration rate and lasix gtt.\nP: Continue CRRT and lasix gtt w/ goal fluid removal per hr 400-500cc.\nMonitor bp. Up to commode w/ assistance to maintain line integrity.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-05-24 00:00:00.000", "description": "Report", "row_id": 1579092, "text": "ccu npn\n\ns:\" When do you think I can go home?\"\n\ncv\" remains in nsr w hr 68-78. sbp 90-105 w mean pressures > 61. able to receive carvedilol 3.125mg, tol well by pt.\n\nresp: periods of coughing. raising thick white secretions. bs cl/diminished. 0300 awoke coughing. bs course exp wheezes no chg in sats. sats 95-97% on 2.5l. received robitussin, pt had own albuterol inhaler at bedside. took 2 puffs. more comfortable/cough controlled. rr -16-20\n\ngi: appetite good. tol po's/meds obese abd + bs. up to commode x2 had bm's x2 brown formed. guiac neg. up to commode w assist/supervision.\n\ngu: con't on cvvhdf pfr rates remain @ 300cc. u/o on lasix 7mg 100-110cc/hr. currently 12 L. filter pressures wnl. ptt 34.8. heparin dose increased to 600u (concentration in syringe chg to 1000u/ml heparin) rate now 0.6ml/hr. am wt 145.6 creat 2.1\n\nskin; intact. noted on back of l leg just below buttock small open area, superficial (? old scab area) small ooz. dsd applied\n\nid: afebrile wbc 3.9 con't on keflex for uti\n\nneuro: a/o x3. follows all commands. intact\n\nsocial: pt spoke to husband and family friends via phone. no inquieres \n\nlabs: per flow\n\na/p: con't aggressive diuresis/ lasix/crrt. follow lytes. support pt /family. review poc. con't pewr nsg judgement\n" }, { "category": "Nursing/other", "chartdate": "2122-05-05 00:00:00.000", "description": "Report", "row_id": 1579087, "text": "Nursing Note 7a-7p\nNeuro- A+Ox3, cooperative w/ care. No c/o sob or c-pain.\nCV- SR no vea, HR 70s-80s. NBPs 84->107/40s-50s (baseline). DL PICC dsg changed, hep flushed.\nResp- LS diminished in bases, occ insp/exp wheezing. Sats on 2L NC 94-98%. Conts on Lasix gtt @ 5mg/hr, diuresing >120cc/hr (goal).\nGI/GU- Obese +bs no bm, appetite good. Voiding qs cyu via foley.\nSkin- Intact, no issues. Using a Shuttle bed @ bedside.\nA/P- 56yo female w/ CHF exacerbation. Tnsf to CCU p having periods of somnulence on 3 d/t ? lasix boluses->hypotension. Cont lasix gtt, monitor hemodynamics & MS. Daughter @ bedside, is a call-out when bed available.\n" }, { "category": "Nursing/other", "chartdate": "2122-05-05 00:00:00.000", "description": "Report", "row_id": 1579088, "text": "Update\nO: hemodynamically stable in sr no ectopy. sbp 90-110.bbs clear but diminish bibas O2 sats 97-100% on 2lpm nc, no desats w pt removing O2 from time to time sats > 95%. Continues on lasix gtt @ 10mg /hr & meeting goal uop 120cc/hr.Labs drawn at 2200 Bun/Cr,Mg+,K+ and glucose,all wnl(see carevue flowsheet).\nA/P: Stable c/o to floor.Report to primary rn . Pt transf to 309 @ 2315 in shuttle chair monitored-> telemetry.\n" }, { "category": "Nursing/other", "chartdate": "2122-05-22 00:00:00.000", "description": "Report", "row_id": 1579089, "text": "Nursing Note 1p-7p\nThis is a 56yo female who was admitted to 6 on for acute on chronic CHF. Please see admit note for PMH. After receiving iv bolus lasix in EW, was started on lasix gtt. Had become somnolent & hypotensive into 80s on floor, triggered to CCU for poss inotropic support. MS improved & BPs stablized, baseline 80s-90s. Cont'd on lasix gtt w/o adding pressor. Called-out to 3 on . Pt spent last several days on 3 diuresing on Lasix gtt & spironolactone. Cre cont'd slowly rising from 1.7-> 3.0, both drugs stopped. Her uop dropped & I+O +1.5L w/ Cre still rising. Renal cx'd & recommended CVVHD. R SC Dialysis line placed by IR & tnsf back to CCU on for CVVHDF.\nNeuro- A+Ox3, cooperative. No c/o sob, c-pain. Pt is obese, has a big-boy bed in room though not using. Asking approp questions & follows commands. Needs assistance w/ moving LEs.\nCV- SR no vea, HR 70s-80s. NBPs 83-96/50s. R PICC reported in subclavian by CXR, HO aware. Hickman cath in R SC. +DP/PTs by doppler.\nCRRT- Started on CVVHDF doing ultrafiltration only. PFR started @ 150cc, BP tol well so ^ PFR to 200cc & conts to tol. Goal 250cc, blood flow rate @ 120cc & anticoag rate @ 4ml/hr. Access/ filter & return line pressures all wnls.\nResp- LS diminished in bases, sats >95% on 2L nc. Has prn guaifenosen for dry unprod cough.\nGI/GU- Obese, appetite good, not on FR, no bm. Lasix gtt d/c'd, uop improved ?, voided approx 2L since tnsf from floor. Balance -2300 @ 6pm. Last Cre 2.8\nID- Afeb, conts on Keflex for UTI.\nSkin- No issues.\nSocial- Daughter is HCP. w/ known ETOH abuse, visited today.\nA/P- 56yo w/ acute on chronic CHF, tx w/ lasix gtt, now rising Cre. Tnsf to CCU for CVVHDF. Pt tol ultrafiltration on CRRT. Goal PFR to 250cc/hr if BP will tol . Support pt/ family.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-05-23 00:00:00.000", "description": "Report", "row_id": 1579090, "text": "ccu npn\n\n56 yr old female w h/o chf ef 30-40% non ischemic cardiomyopathy substance abuse cocaine/etho. (hx of neg cath). non compliance @ home w meds and diet. copd, htn, gout, obesity (baseline wt 312 lbs) recent adm in for chf which she diuresised off 30lbs. adm for sob,doe, bilat LE edema. started on iv lasix on floor. c/b hypotension, somulance. abg 7.34,61,49 transfered to ccu for lasix gtt. picc placed. sent back to 3 but had ^ creat 1.7-3.0 renal consulted. crrt recommended. transfered back to ccu for ultrafiltration started on \n\ncv: remains in nsr w hr 74-80. sbp 92-100 w mean pressures 60-70. had droppped in bp @ 0300 88/50. pfr rate decreased to 150cc/hr w improving bp's. bilat lower ext edema. pulses palp bilat. ext wrm\n\nresp; O2 @ 2l np. bs cl/diminished bilat. hx of copd on advair. has occassional cough. robitussin w relief. 0230 pt awoke c&r thick yellow secretions. bs course w exp wheezes. alb/atv nebs w good effect. sats 95-97%. denies sob, but clearly sob w activity. vbg ( no a-line) drawn (pt on crrt) results per flow. address line status w team. team in to draw abg. 7.35,,57,113,33,4 md aware. pt states she has bipap machine 2 home but doesn't use it. offered here refused by pt. no apnic periods noted.\n\ngu: on crrt for ultrafiltration only. dialysate/repletion rates @ 0. able to maintain goal of 200cc/hr till 0230 when bp drop to 88/50 pfr rate decreased to 150cc/hr w good recovery in bp. creat 2.8 now 2.5 u/o 90-160cc/hr 5468. @ mn -3600cc. renal goal is 10kg neg. filter pressures wnl. anticoagulation via pump syringe @ 400u/hr (4ml/hr)\n\ngi/activity: appetite fair. very little po fluids . obese. am wt 153.7kg. + bs passing gas, but c/o constipation. received senna @ hs. pt asking to get oob to commode. nusring reviewed reasons w pt why she could not get oob. pt refuses bedpan. states she will only get aggrevated w it. md in to explain reasons to maintain br. pt refusing to use bp. risk reviewed w pt by md's and nursing. pt states she understands but demanding to get oob to commode. verbal order given by md . bld flow rates and pfr slowed while getting oob. pt ^ commode. passing gas but no stool. up to commode this am. no stool. senna given @ hs. will need dulcolax tabs today. steady on ft w assists.\n\nskin: intact\n\naccess: picc r ac, dialysis line r subclavian\n\nid: afebrile. kelflex-uti, wbc 3.5\n\nneuro; a/o x3 follows all commands. mae steady on ft w guidance\n\nlabs: wnl for renal orders. hct 34\n k+ 4.8, 4.7\n I ca 1.13/1.14\n mg 2.5\n\nsocial: daughter is pt's hcp. husband in to visit yesterday (intoxicated) husband also has hx of polysubstance abuse.\n\na/p; diuresis as pt tolerates. goal is 10kg neg. follow bld values. support pt and family. con't per nsg judgement\n" }, { "category": "Nursing/other", "chartdate": "2122-05-27 00:00:00.000", "description": "Report", "row_id": 1579101, "text": "CCU NSG NOTE ADDEDUM: \nPt has remained on today receiving only UF with goal being 300cc/hr off. She has tolerated this well with stable BPs and maps over 60. However in the afternoon she had 2 episodes of abdominal cramping that seemed to decrease with decrease in rate of fluid removal. Afternoon labs showed her renal failure was worsening with BUN/creat now 84/2.8 with K+ 4.8 and phos 5.5. As pt was already 5 liters neg for the day pt goal was decreased to 100cc/hr. Present cassette has been functioning for 20hrs. It has clots, but filter pressure has actually decreased from 300 down to 267. She has had NS flushes from rescue line ~Q4hr. Heparin was increased to 1100u/hr at 1700. Pt now comfortable and pain free.\n" }, { "category": "Nursing/other", "chartdate": "2122-05-28 00:00:00.000", "description": "Report", "row_id": 1579102, "text": "NPN 7 PM - 7 AM\n\nS: \" Those terrible cramps come and go!\"\n\nO: please see careview for vitals labs and other objective data\n\nPt has been here in CCU receiving agressive SCUF therapy and has lost over 100 lbs of fluid since admission and we have removed 30 liters over last 6-7 days. Pt has been tolerating fluid removal, however yesterday as they were removing 300 CC per hour pt developed muscle cramping of legs and abdomen, thought to be similar to dialysis cramping R/T fluid removal. Initially treated with heat packs with fair effect. Last night pt had intermittent severe cramping, We decreased fluid removal to 50-100 cc per hour, gave fluid bolus of 200 cc when she complained of severe cramping, and started quinine. Pt did respond to measures, and overnight no further cramping after 11 PM. we also decreased the blood flow raate from 150ML per hr to 110 ( which may or may not help) And pt was allowed to get OOB and bear weight\non affected foot. Renal was updated by house staff.\n\nOtherwise pt was stable overnight, BP has been very good 93/54--101/67\n MAP 62- 65, HR 70-84 tolerating her carvedolol 3.25 BP meds on hold to give room for fluid removal. Pt edema is very much decreased, she was net negative 5.4 liters yesterday, and is net negative 500 cc this AM. Her creatinine is still high, and urine out put has been low- 610 cc yesterday . SHe has been tolerating room air and o2 sats 95-98 percent. She still has DOE, when getting oob to commode but much improved over last few days. Pt has been calm and cooperative, no longer getting out of bed without supervision, but is emotional and appears fustrated with all the equiptment and would really like to \"get up and walk around some\".\n\nPrisma machine and pt catheter working well, filter was changed last night as I had taken her off briefly for severe cramping and access\npressure pod was very clotted and I felt that it wouldnt last, and pt needed a good night sleep.\n\nA: pt with cardiomyopathy, fluid overload, now ARF and SCUF, fluid balance negative. DC planning started, nutrition came to see pt regarding low NA diet teaching.\n\nP: Continue to follow labs ( Q 12 hours on SCUF), continue attempt fluid removal if pt tolerates, to new dry weight ( to be determined),\n? recall PT/OT pt should get OOB if able, keep pt and family updated on POC as discussed in CCU rounds. Pt asking lots of questions regarding renal failure, neprology fellow should talk to pt today\nregarding this.\n" }, { "category": "Nursing/other", "chartdate": "2122-05-28 00:00:00.000", "description": "Report", "row_id": 1579103, "text": "addendum to NPN 7P-7AM\n\nPt awoken this Am and denies any complaints, no further cramping and SCUF fluid removal rate titrated up to cover PO intake and flushing\nof filter. PT labs came back, Pt may have to go on renal diet, vs have dialysis /CVVH .\n" }, { "category": "Nursing/other", "chartdate": "2122-05-05 00:00:00.000", "description": "Report", "row_id": 1579086, "text": "CCU NPN 1900-0700\nS: \"Is that lasix working good enough?\"\n\nO: 56 y/o female on 6 for diuresis transferred last eve after becoming somnolent with SBP 80's, ABG 7.34/49 PO2/PCO2 61. Pt lost IV access-PICC placed in IR and pt to CCU for lasix gtt with possible inotropic support if needed during diuresis(pt baseline BP 80-90 per notes). Pt with 2-3+ BLE. Please see careview for VS and additional data.\n\nCV: Pt HR 70-74 NSR with rare PVC's noted, NBP 83-100/40-55. Pt continues on lasix gtt 10 mg/hr with effect. Bilat pedal pulses palp. No c/o CP. AM labs pending.\n\nResp: Pt LS CTA, RR 15-19, O2 sats 95-100% on 2L n.c. Pt has OSA but repportedly does not wear CPAP/Bipap at home. Pt easily arousable to voice. No c/o SOB.\n\nNeuro: Pt A&Ox3, cooperative with care, MAE (BLE with assistance r/t LE edema). Pt denies pain. Pt asking appropriate questions re. POC.\n\nGI/GU: Pt abd soft, obese, +BS x4, no stool this shift. Foley cath draining clear light yellow u/o 100-240 cc's/hr, pt - at midnoc (goal -2L at midnoc on lasix gtt).\n\nSkin: Intact, no breakdown noted.\n\nSocial: Pt dtr in sleeping at bedside.\n\nA/P: 56 y/o female diuresing to lasix gtt close to goal, SBP maintain 80's-90's with pt mentating. As discussed with CCU MD's, cont to monitor pt hemodynamics, lasix gtt for SBP>80. Cont to monitor resp status, u/o. Cont to provide emotional support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2122-05-28 00:00:00.000", "description": "Report", "row_id": 1579104, "text": "56 yo female c cardiomyopathy EF 30% COPD, fluid overloaded, now down >80lbs since .\n\nGU:pt has minimal urin output today. ARF, SCUF dc'd this am 1000. pt will not be hemofiltrated even though pts cr is rising. Pt will be medically managed to keep volume status undercontrol. pt may have been non compliant with medical regimen in the past. If this does not work pt may need to receive dialysis as an outpt.\n\nCV:NSR hr 77, bp 100/50. pt ontinues to tolerate carvedilol. Improving back and thigh edema.\n\nResp:o2 sats 100% on room air. LSC. pt denies SOB.\n\nGI:abd soft BS + no BM today\n\nmobility:pt will get in and out of bed to commode she does not like her chair.\n\naccess:right arm midline, right IJ dialysis cath.\n\nP:pt will start lasix at some point to try to keep fluid undercontrol if pt does not respond she will most likely need to start hemodialysis as an outpt.\n" }, { "category": "Nursing/other", "chartdate": "2122-05-29 00:00:00.000", "description": "Report", "row_id": 1579105, "text": "npn 7p-7a (please also see carevue flownotes for objective data)\n\n56F w/ massive body fluid removal since mid may; developed renal failure, transferred from floor care to CCU; pt previously on HD, had SCUF in CCU--dc'd 10:00;\n\nPt w/ improvment in decrease of wt, and improvement in less SOB;\n\nSignificant is yesterday serum K+ up to 5.7, received PO Kayexelate yest approx 18:30, this a.m.'s serum K+ 5.2;\nSerum creatinine down very slightly from 3.7 to 3.6;\n\nPt using bedside commode per self;\n\nAt hs c/o itching, requested benedryl, cough syrup, ambien, pain med for head ache, received all somewhat spread apart, with good effect; pt observed sleeping later;\n\nPt has rt a.c. PICC/midline; flushed at 21:00, but unable to draw labs from either port at 02:30, therefore pt received 1 phlebotomy stick in left hand to obtain a.m. labs;\n\nPlan is for medical mx of pt's fluid status ( diuretics) for goal of euvolemia; may possibly need outpt H.D.;\n" }, { "category": "Radiology", "chartdate": "2122-05-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1016254, "text": " 6:37 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with asthma who has developed worsening cough and wheeze\n during hospitalization for acute on chronic heart failure.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n WET READ: JXKc WED 9:02 PM\n Massive cardiomegaly, similar in appearance to prior study. Perihilar\n prominence with hazy airspace opacities bilaterally. This is likely due to\n fluid overload. -jkang.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Worsening cough and wheeze. Assess heart failure.\n\n Comparison is made with prior study .\n\n Marked cardiomegaly is stable. haziness of the perihilar regions is new\n consistent with mild interstitial pulmonary edema. Right PICC tip is in the\n proximal SVC. There is no pneumothorax. If any, there is a small left\n pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-05-08 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1014726, "text": " 2:07 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: pls eval RUE for clot\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with morbid obesity, LVEF 15% a/w CHF exac. s/p PICC to RUE\n REASON FOR THIS EXAMINATION:\n pls eval RUE for clot\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old woman with morbid obesity, low ejection fraction and\n right upper extremity PICC line. Please evaluate for right upper extremity\n clot.\n\n scale, color flow and Doppler images of the right upper extremity were\n performed.\n\n No comparison is available.\n\n The right internal jugular vein, subclavian vein, axillary vein, brachial vein\n and basilic vein demonstrate normal compressibility, respiratory variation in\n venous flow and venous augmentation. The right cephalic vein was not\n visualized. The right basilic vein contains the PICC and has normal\n appearance.\n\n IMPRESSION: No DVT in the right upper extremity.\n\n" }, { "category": "Radiology", "chartdate": "2122-05-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1013916, "text": " 9:11 PM\n CHEST (PA & LAT) Clip # \n Reason: ? overload\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with severe chf dyspnea\n REASON FOR THIS EXAMINATION:\n ? overload\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, at 21:11.\n\n HISTORY: Severe dyspnea.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Massive cardiomegaly is again evident but stable from multiple\n prior examinations. The study is compromised secondary to body habitus,\n however, there is cephalization of flow, pulmonary vascular indistinctness and\n a small amount of fluid within the minor fissure. These findings suggest\n volume overload. No consolidation is seen. No pneumothorax is noted.\n\n IMPRESSION: A mild congestive failure with stable marked cardiomegaly.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-05-22 00:00:00.000", "description": "NON-TUNNELED", "row_id": 1016444, "text": " 9:38 AM\n CENTRAL LINE PLCT Clip # \n Reason: please place catheter for CVVH\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with systolic heart failure (EF 15%) and 60 pound weight\n gain; planning to use ultrafiltration for volume removal. Pursuing IR-guided\n line placement as she is very obese.\n REASON FOR THIS EXAMINATION:\n please place catheter for CVVH\n ______________________________________________________________________________\n FINAL REPORT\n\n CLINICAL HISTORY: 56-year-old female with heart failure, EF 15%, in need of\n ultrafiltration for volume removal. Please place temporary hemodialysis\n catheter.\n\n RADIOLOGISTS: Dr. and attending radiologist, Dr. , who was\n present and supervised the entire procedure.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient\n explaining the risks and benefits of the procedure, the patient was placed\n supine on the angiography table and the right neck was prepped and draped in\n standard sterile fashion. A preprocedure timeout was performed to confirm the\n patient's name, medical record number, date of birth, and the nature of the\n procedure to be performed.\n\n Using sterile technique and local anesthesia, the right internal jugular vein\n was punctured under direct ultrasound guidance using a micropuncture set. A\n 0.018 guidewire was then advanced into the SVC under fluoroscopic guidance.\n Hardcopies of the ultrasound images were obtained before and immediately after\n establishing intravenous access. The needle was exchanged for a 4.5 French\n introducer sheath and the existing 0.018 guidewire was exchanged for a 0.035\n wire, which was placed within the SVC under fluoroscopic guidance. The\n tract was then serially dilated under fluoroscopic guidance and a 20 cm\n double- lumen hemodialysis catheter was advanced over the wire and positioned\n in the right atrium. All ports were flushed and then line secured to the skin\n with 0 silk. Sterile dressing was applied. There were no immediate\n complications, and the patient tolerated the procedure well.\n\n IMPRESSION: Placement of a dual-lumen temporary hemodialysis catheter via the\n right internal jugular vein with the tip in the right atrium. The line is\n ready to use.\n (Over)\n\n 9:38 AM\n CENTRAL LINE PLCT Clip # \n Reason: please place catheter for CVVH\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2122-05-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1017659, "text": " 10:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Need to assess placement of PICC line.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with heart failure. Need to assess placement of PICC line.\n REASON FOR THIS EXAMINATION:\n Need to assess placement of PICC line.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Patient in heart failure, PICC line placed, check position.\n\n The tip of the PICC line lies in the mid to upper SVC.\n\n The heart remains markedly enlarged but failure is not currently seen.\n\n IMPRESSION: PICC line in mid to upper SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-05-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1016485, "text": " 1:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate fluid status, heart size\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with CHF and low EF, now admitted to CCU, new line placement\n REASON FOR THIS EXAMINATION:\n please evaluate fluid status, heart size\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old woman with CHF and low EF now admitted to CCU, new\n line placement, evaluate for fluid status, heart size.\n\n COMPARISON: .\n\n BEDSIDE AP UPRIGHT RADIOGRAPH OF THE CHEST AT 1:30 P.M: Severe cardiomegaly\n is unchanged. There is mild interstitial edema with prominence of the right\n horizontal fissure. There are no focal consolidations or obvious pleural\n effusions. There is no pneumothorax. Right IJ catheter is terminating in the\n right atrium. The right PICC, however, is now only visualized up to the\n medial right subclavian vein and may be partially obscured by the overlying\n right IJ catheter.\n\n IMPRESSION:\n 1. Mild interstitial edema with stable severe cardiomegaly.\n\n 2. Right PICC is now only visualized up to the medial right subclavian vein\n and may be displaced, alternately course may be obscured by the overlying\n catheter.\n\n This was discussed with Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2122-05-04 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1014033, "text": " 3:37 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with CHF, OSA, morbid obesity, with CHF exacerbation\n REASON FOR THIS EXAMINATION:\n please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: IV access needed for antibiotics.\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 right basilic\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a double lumen PICC line measuring 42 cm in length (4 cm of the\n catheter is out of the skin) was then placed through the peel-away sheath with\n its tip positioned in the SVC under fluoroscopic guidance. Position of the\n catheter was confirmed by a fluoroscopic spot film of the chest.\n The peel-away sheath and guidewire were then removed. The catheter was secured\n to the skin, flushed, and a sterile dressing applied.\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French\n double lumen PICC line placement via the right basilic venous approach. Final\n internal length is 42 cm, (4cm of the catheter is out of the skin) with the\n tip positioned in SVC. The line is ready to use.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-05-03 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1013923, "text": " 10:34 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: ? DVT SWELLING, SOB,MORBIT OBESITY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with b/l LE edema, SOB\n REASON FOR THIS EXAMINATION:\n ? dvt\n ______________________________________________________________________________\n WET READ: KCLd SUN 11:41 PM\n limited body habitus; no evidence of lower extremity dvt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral lower extremity edema, shortness of breath.\n\n FINDINGS: Study is slightly limited by patient body habitus. Grayscale and\n Doppler son of the right and left common femoral, superficial femoral,\n and popliteal veins were performed. These demonstrate normal compressibility,\n augmentation, waveforms and flow. There is no evidence of intraluminal\n thrombus.\n\n IMPRESSION: Slightly limited study secondary to patient body habitus. No\n evidence of lower extremity DVT.\n\n\n" }, { "category": "Echo", "chartdate": "2122-05-21 00:00:00.000", "description": "Report", "row_id": 102666, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. CMP\nHeight: (in) 66\nWeight (lb): 350\nBSA (m2): 2.54 m2\nBP (mm Hg): 100/59\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 15:20\nTest: Portable TTE (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: Markedly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV cavity. Moderate\nglobal LV hypokinesis. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. Severe global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Partial mitral leaflet\nflail. Mild mitral annular calcification. Mild thickening of mitral valve\nchordae. Calcified tips of papillary muscles. No MS. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Moderate [2+] TR. Severe PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is markedly dilated. The right atrium is markedly dilated.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity is\nseverely dilated. There is moderate global left ventricular hypokinesis (LVEF\n= 30-40 %). There is no ventricular septal defect. The right ventricular free\nwall is hypertrophied. The right ventricular cavity is dilated with severe\nglobal free wall hypokinesis. 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. There is partial mitral\nleaflet flail (anterior leaflet). At least moderate (2+) mitral regurgitation\nis seen. Due to the highly eccentric (posterior) trajectory of the regurgitant\nflow, the severity of mitral regurgitation may be significantly underestimated\n(Coanda effect). The tricuspid valve leaflets are mildly thickened. At least\nmoderate [2+] tricuspid regurgitation is seen. There is severe pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , partial flail anterior mitral leaflet is now present. The mitral\nregurgitation may be increased, and may be significantly underestimated on\nthis study due to the Coanda effect. The left ventricular ejection fraction is\nincreased on the current study. The pulmonary artery pressure is now markedly\nincreased.\n\nIMPRESSION:\n\n\n" }, { "category": "ECG", "chartdate": "2122-05-31 00:00:00.000", "description": "Report", "row_id": 296061, "text": "Artifact is present. Sinus rhythm. Ventricular ectopy. The P-R interval is\nprolonged. Non-specific intraventricular conduction delay. Probable biatrial\nabnormality. Compared to the previous tracing ventricular ectopy is new.\n\n" }, { "category": "ECG", "chartdate": "2122-05-28 00:00:00.000", "description": "Report", "row_id": 296062, "text": "Sinus rhythm with borderline first degree A-V block. Possible biatrial\nabnormality. Non-specific intraventricular conduction delay. Baseline\nartifact. Compared to the previous tracing of the QRS voltage\nis decreased.\n\n" }, { "category": "ECG", "chartdate": "2122-05-28 00:00:00.000", "description": "Report", "row_id": 296063, "text": "Sinus rhythm\nBorderline first degree A-V delay\nConsider biatrial abnormality\nIntraventricular conduction delay - may be atypical left bundle branch block\nProbable left ventricular hypertrophy\nNonspecific ST-T wave changes\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2122-05-27 00:00:00.000", "description": "Report", "row_id": 296064, "text": "Sinus rhythm. Baseline artifact. Non-specific intraventricular conduction\ndelay. Poor R wave progression. Non-specific ST-T wave changes. Compared to\nthe previous tracing of the artifact is present. Ventricular premature\nbeat is absent.\n\n" }, { "category": "ECG", "chartdate": "2122-05-22 00:00:00.000", "description": "Report", "row_id": 296065, "text": "Sinus rhythm. Premature ventricular contractions. Consider left atrial\nabnormality. Non-specific intraventricular conduction delay. Low limb\nlead QRS voltage. Poor R wave progression. Non-specific low amplitude\nT wave voltage in the limb leads. Compared to the previous tracing of \nventricular premature beat is new.\n\n" }, { "category": "ECG", "chartdate": "2122-05-06 00:00:00.000", "description": "Report", "row_id": 296066, "text": "Sinus rhythm\nConsider left atrial abnormality\nModest nonspecific intraventricular conduction delay\nLow limb lead QRS voltages\nLate precordial QRS transition\nModest low amplitude T wave changes\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of , ST-T wave changes decreased\n\n" }, { "category": "ECG", "chartdate": "2122-05-04 00:00:00.000", "description": "Report", "row_id": 296067, "text": "Sinus rhythm with 1st degree A-V block\nLeft atrial abnormality\nIV conduction defect\nAnterior T wave changes are nonspecific\nLow lead voltage\nSince previous tracing of , ST-T wave abnormalities more marked\n\n" }, { "category": "ECG", "chartdate": "2122-06-01 00:00:00.000", "description": "Report", "row_id": 296060, "text": "Sinus rhythm\nAtrial premature complex\nBorderline first degree A-V delay\nLeft atrial abnormality and consider also biatrial abnormality\nNonspecific intraventricular conduction delay\nProbable left ventricular hypertrophy\nSince previous tracing of , ventricular ectopy absent\n\n" }, { "category": "ECG", "chartdate": "2122-05-03 00:00:00.000", "description": "Report", "row_id": 296305, "text": "Sinus rhythm with borderline 1st degree A-V block\nIndeterminate axis\nIntraventricular conduction delay\nLow QRS voltages in limb leads\nConsider left atrial abnormality\nST-T wave abnormalities\nSince previous tracing of , QRS width increased, ST-T wave abnormalities\nmore marked\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2185-03-02 00:00:00.000", "description": "Report", "row_id": 1514813, "text": "FOCUS; NURSING PROGRESS NOTE\nPMH- COPD ON HOME O2,AF, MVR AND CABG ,INCREASED CHOLERSTEROL,RHEUMATIC FEVER, HYPOTHYROID, AND HX OF HEPATITIS.\nALLERGIES- NKA\nRFA- INTUBATION S/P BRONCH.\nHPI- PATIENT WITH LUNG MASS SEEN ON CXR IN . REFUSING TO HAVE BRONCH. DID HAVE BRONCH TODAY AND FOUND RUL MASS EXTENDING INTO THE CARINA. RECEIVED 50MCGS FENTANYL AND 1MG VERSED FOR BRONCH. WAS STABLE S/P BRONCH AND THEN BECAME OBTUNDED MOVING LITTLE AIR. ALBUTEROL NEB TX ATTEMPTED WITHOUT SUCESS. PATIENT INUBATED AND TRANSFERRED TO MICU.\nREVIEW OF SYSTEMS-\nNEURO- PATIENT EASILY AROUSABLE ON VENT. APPEARS CALM. NODS HEAD TO ANSWER QUESTIONS. DENIES PAIN. MAE. FOLLOWS COMMANDS.\nRESP- INTUBATED AND VENTED ON 1OO% FIO2 TV 360 RATE OF 16 BREATHING 16-17 AND 5 PEEP. ON THIS ABG 7.34/71/158/40. DR MADE AWARE. TV UP TO 400. BS COARSE DIMINISHED ON THE RIGHT. SUCTIONED FOR THICK BLOODY SPUTUM.\nCARDIAC- IN AFIB RATE OF 70-80'S. SBP DOWN TO THE 80'S ON ADMISSION TO MICU. 250 NS BOLUS ORDERED AND GIVEN. SBP UP TO THE 90'S WHERE IT HAS REMAINED.\nGI- ABD DISTENDED WITH POS BS.\nGU- FOLEY PLACED ON ADMISSION AS PATIENT HAD BEEN INCONTINENT IN HER BED ON ADMISSION. PATIENT PUT OUT 30CC/HR PAST 2 HOURS.\nACCESS- HAS 2 #20 PERIPHERAL IV'S.\n HUSBAND SPOKE WITH DR PULMONOLOGIST. HUSBAND THEN IN TO SEE PATIENT. HE WAS VERY TEARY EYED. OFFERED EMOTIONAL SUPPORT. HE LEFT WILL BE BACK LATER.\nPLAN- CONSULT CT AND ONCOLOGY IN AM. LEAVE INTUBATED OVERNIGHT.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-02 00:00:00.000", "description": "Report", "row_id": 1514814, "text": "FOCUS; ADDENDUM\nCARDIAC- CK BEING CYCLED. NEXT SET DUE AT 2300\n" }, { "category": "Nursing/other", "chartdate": "2185-03-03 00:00:00.000", "description": "Report", "row_id": 1514815, "text": "NPN 19:00-07:00 MICU\n*Please refer to Carevue for additional patient information\n*Full Code\n*Pt w/ extensive med hx, MD's report tumor in .\n\nShift Events:\nReceived pt on A/C 400x16/peep 5/FiO2 40% (down from 50%.) Sxn'd q1-2 hr for small-moderate amounts of thick, bld tinged sputum, O2 sat's high-mid-90's. Pt mouthing words, and using note pad to communicate. CV: Temp spike to 102.5 PO, pan cx'd, and given Tylenol 650mg PR, temp now ~99.0. BP continues to be an issue, SBP 68/28-92/43 (110/48 when coughing/agitated.) Given NS 500cc bolus x1 w/ little effect. 2u PRBC's given for BP and falling Hct (Hct at shift change 27.2, at 23:00 hct=21.3-> after 1uPRBC's hct=24.9, in process of receiving units.) HR 63-99, A-fib/Junctional rhythm **at times HR down to 40's(Atropine on cart in room), HR quick to bounce back to mid-upper 50's (Dr. aware). GU: U/o very poor, ~5cc/hr for three consecutive hrs, Dr. aware. Access: PIV x2 R&L arm 20g.\n\n **According to Dr. , husband does not want any interventions unless \"absolutely necessary.\" *Plan is for team to meet w/ family and patient ~11:30 am, to discuss prognosis and overall treatment.\n\nROS:\nNeuro: A/O communicating through writing. No c/o pain/discomfort. Written for Ativan PRN (agitation), given 0.5mg x1 after coughing fit, w/ good effect. MAE's on bed, restraints on upper extremities for patient safety.\n\nCV: Please see above. *Pndg am labs.\n\nResp: Please see above. Currently on A/C sxn'd q1-2 hrs at begining of shift, now ~q2-4 hr (secretions becoming less). Getting Inhalers PRN.\n\nGI/GU: +BS, +Flatus, no bm, NPO (no access, husband did not want team to place OGT). U/O very poor, diminished to ~5cc/hr, Dr. aware.\nID: started on Levoflaxacin\nSkin: Intact\nAccess: PIVx2\nSocial: Husband in to visit, updated on pt's condition.\n\nPlan: Monitor BP, hct. Family meeting ~11:30 am to discuss overall plan of care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-03-03 00:00:00.000", "description": "Report", "row_id": 1514816, "text": "pt.remains on ac ventilation, mdi albuterol given q4h, bs with rhonchi, wheezes on occaision, sx for blood tinged white secretion, abg acidotic, may attempt to wean if tol.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-03 00:00:00.000", "description": "Report", "row_id": 1514817, "text": "nursing note 7a-7p\nNEURO-PT.awake,alert,with close ayes,MAE,no c/o pain,cooperative with care.\n\nRESP-ON AC,tv-350-400,rr-16-20,peep-5,fio2-40%,sat-99%,bs-expwhz & dm to lb-r & l,sx-mod thick bld secr.felt c-pap after 10\" hr-130's,rr-40's,c/o sob & sat 90%.\n\nCV-A-FIB 50-70's,same pvc's,sbp-80-110's,no c/o cp,no edema,last hct-29.7 next check at 2200.\n\nGI-abd soft dist.bs + x 4,no n/v,no bm.\n\nGU-foley ,poor uo team aware.\n\nSKIN-intact\n\nONCOLOGY-biopsy-pnd,rad-tx today well.\n\nSOCIAL-family mitting this am,pt full code\n" }, { "category": "Nursing/other", "chartdate": "2185-03-03 00:00:00.000", "description": "Report", "row_id": 1514818, "text": "Resp Care: pt remains intubated via #8 secured 20cm at lip. BS bilat E wheezes. MDI's given as ordered. Sx'd freq for thick blood tinged sputum. Team aware. Attempted on PSV. Tol poor. C/o SOB, tachycardic w/in minutes. Placed back on a/c w/ gd effect. Pt to for radiation tx w/o incident. No other vent changes made this shift. PLease see carevue for further vent inquiries.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-05 00:00:00.000", "description": "Report", "row_id": 1514821, "text": "\nPt has rested comfortabley overnight on vent.\nResp:no changes made, she cont on A/C with occas breath, O2 sats >97%. Pt without c/o SOB and secretions with less blood. Ativan .25mg for sleep given at 1am, no other sedation given nor needed.\nCV:pt with x2-4 episodes of dropping HR into the 30's and 40's with no apparent cause. She had no BP changes nor was SX or moved. Episodes brief with no interventions necessary. Digoxin held at MN and a level will be checked in the am.\nGI:pt cont on TF-Probalance- rate increased to 20cc/hr(goal rate 50cc/hr), so far tol well with no aspirates noted. Still with +BS but no stool.\nGU: u/o still min at 20cc/hr.She cont on IVF and TF rate is slowly increasing.\nID:pt remains afebrile and on IV AB.\nHeme: am hct pnd.\nSocial:family meeting with social work and MD's-reviewed plans, goals, and status, awaiting decision from family after they digest this info.\nA/P:Will reasses pt for breathing trial this am, cont with pulm toilet as needed, awaiting path results\n Cont to follow for VS changes and await dig level,replace lytes as needed\n Adv TF as tolerated, note stool amt\n Follow u/o and avoid fluid overload\n Follow hct and coags, asses for bleeding\n Note fever curve and await cx results\n" }, { "category": "Nursing/other", "chartdate": "2185-03-05 00:00:00.000", "description": "Report", "row_id": 1514822, "text": "Respiratory Care\nPT remain inbtubated and on vent support no vent setting cgange overnight, SX mod- amount thick yello some what bloody,BS coares whith some exp wheezes, MDI given with vent check.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-05 00:00:00.000", "description": "Report", "row_id": 1514823, "text": "FOCUS; NURSING PROGRESS NOTE\nREVIEW OF SYSTEMS-\nNEURO- ALERT AND COOPERATIVE WITH CARE. WRITING NOTES. ABLE TO LET HER NEEDS BE KNOWN. MAE.\nRESP- ON 40% FIO2,400CC,RATE 16 OVERBREATHING BY 2-4 BREATHS PEEP5. BS COARSE ON LEFT RHONCHOROUS ON LEFT. BBT DONE. PATIENT WITH INITIALLY HEART RATE OF 60 WHICH WENT UP TO 90 AFTER A FEW MINUTES ON TRIAL. ALSO HAD ECTOPI WITH TRIAL. UP TO 25 PVC'S PER MINUTE. PVC'S DISAPPEARED WHEN TRIAL COMPLETED. RESP RATE ON TRIAL 30-34 WITH TV 190-250. RSBI 138. SUCTIONED Q 1-2 HOURS FOR THICK YELLOW SPUTUM. PATIENT LETS YOU KNOW WHEN SHE NEEDS TO BE SUCTIONED.\nCARDIAC- HR 60'S AFIB WITH RARE PVC. RATE AS ABOVE DURING SBT. SBP 104-113. DIG LEVEL 0.6 THIS AM. DIG RESUMED. MG 1.6 REPLETED WITH 2GMS MAG.\nGI- ABD SOFT DISTENDED WITH POS BS. NO STOOL. REFUSED SUPPOSITORY TODAY. ON COLACE AND SENNA. POS FLATUS. TF PROBALANCE AT 40CC/HR WITH MIN RESIDUALS. GOAL RATE 50CC/HR.\nGU- UO VIA FOLEY 25-120CC/HR. STARTED ON BUMETANIDE 0.5MG QD. GOAL IS TO HAVE PATIENT EVEN. PRESENTLY POS 400CC SINCE RECEIVING BUMEX. WILL CALL HO IF CONT TO BE POS.\nHYERCALCEMIA- CA TOAY UP FROM 11 YESTERDAY. CONT ON CALCITRONIN. IV FLUIDS INCREASED TO NS AT 125CC/HR X 2L.\n HUSBAND IN TO VISIT. SPOKE TO INTERN.\nDISPO- REMAINS IN MICU A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-05 00:00:00.000", "description": "Report", "row_id": 1514824, "text": "FOCUS; ADDENDUM\nGU- DR INFORMED OF UO AND PATIENT BEING 400CC MORE POS FOR THE DAY SINCE RECEIVING PO BUMEX. PATIENT IS TO RECEIVE IV BUMEX ONCE AVAILABLE FROM PHARMACY.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-05 00:00:00.000", "description": "Report", "row_id": 1514825, "text": "FOCUS; ADDENDUM\nGI- PATIENT REQUESTED DUCOLAX SUPP THIS EVENING. HAD SMALL BROWN FORMED STOOL. SHE STILL FELT AS THOUGH SHE NEEDED TO GO TO THE BATHROOM. GIVEN FLEETS ENEMA WITH MED BROWN FORMED STOOL THAT WAS GUIAC POS.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-04 00:00:00.000", "description": "Report", "row_id": 1514819, "text": "NPN 19:00-07:00 MICU\n*Please refer to Carevue for additional patient information\n*Full Code\n\nROS: (No significant events o/n, VSS, no c/o pain, ?trial on PS this am.)\nNeuro: Communicating via writing tablet. Sleeping on and off throughout night; no c/o pain. MAE's.\n\nCV: VSS, HR 60-70's, A-fib, PVC's rare. SBP 88/50-104/40's. Tmax 98.9, po. No hypotension noted. Last Hct=29.9\n\nResp: Continues on A/C 400x16/peep 5/FiO2 40%, O2 sat's 99-100%. Sxn q2-3 hrs for small amounts of thick, bld tinged thick sputum. Plan for pt to be trialed on PS (yesterday trialed on PS, RR 40's, O2 sat's down to 90, HR 140's.)**Pt should not be placed on L side d/t pressure of lung growth impeding breathing/bld flow.\n\nGi/GU: OGT in place per Dr. , Abdomen slightly distended, +BS, no BM (+ flatus). U/O ~20-30cc/hr, amber in color at times slightly pinkish/red, Dr. aware.\nAccess: PIV x2, L hand intermittently working, L ant 18g placed, sites wnl.\n\nEndo: FS qid, no Insulin required.\nSocial: Husband and sister in to visit.\nSkin: Intact, pt did not want bed bath.\n\nPlan: Pt will be trialed on PS, ?when/if pt can possibly be extubated. Monitor BP,\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-03-02 00:00:00.000", "description": "Report", "row_id": 1514812, "text": "Respiratory Care Note:\n Patient admitted to MICU s/p intubation in pulmonary lab. She had a bronchoscopy done and an obstructive tumor was found in her R main stem bronchus. The RN reported that she went into resp distress several hours after the bronchoscopy was done, when she was laid flat to roll onto a bedpan. It appears that the tumor obstructed her airways and she is now intubated, sedated, ventilated and has particles of tumor being suctioned from ET tube that is 20cm at lip and in good place via bronch, per Dr. . BS absent on the R, scattered rhonchi and mild exp., wheezing noted t/o L lung. ABG pending. Plan to maintain support as needed. See Carevue flowsheet for specifics.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-04 00:00:00.000", "description": "Report", "row_id": 1514820, "text": "nsg progress note 7a-7p\nNeuro: alert and oriented. MAE's. Denies pain. Interacting with family but with flat affect. Refused bath.\n\nCV: VSS. Hr 50-80's AFib. Occ PVC this am. Repleted K+ and Mg+ this am. Pt had run of ? RAF vs VT rate 198 which resolved once placed back on AC on vent. Pt had been on breathing trial and was anxious, SOB, and HR up. No intervention needed to resolve arrythmia. Good pedal pulses No edema. Repeat HCT this eve 29.4, stable. Coumadin and heparin held d/t risk of bleeding with tumor.\n\nRESP: On AC 400 X16 Peep 5 Fio2 100%. No aline, no ABG's today. Sats 98 %. Failed breathing trial. LS with exp wheezes on right and coarse on left. Very dim on right as well. Sx' Q2hr for thick blood tinged secretions. Lg ? plug or tissue suctioned and to be to Path lab ? tumor tissue. Pt to lie ONLY on right side and back as she does not tolerate left side lying.\n\nGI: abd softly distended, + BS. Started TF's today Probalance @ 10cc/hr Goal 50cc. No stool. To start colace and senna today.\nOn PPI.\n\nGU: urine ouptu 15-30cc/hr, team aware and are satisfied with output. NS @ 100cc/hr.\n\nSkin: intact.\nAccess: Two PIV's, both patent.\nFull code. Pt had radiation tx yesterday. Started IV steroids today. Await path report from biopsy two days ago before making a decision as to plan of care. Home health services initiated and accpeted pending if pt can be extubated to go home. Family involved and spoke with team today.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-12 00:00:00.000", "description": "Report", "row_id": 1514842, "text": "Respiratory Care\nChanged overnight from pressure support to assist/control due to tachypnea. Plan is to change back to psv later this morning when pt more awake. RSBI =124. Breath sounds are decreased with scattered crackles/wheezes. Given inhalers in line with the vent. Suctioned for small amounts of thick white sputum.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-12 00:00:00.000", "description": "Report", "row_id": 1514843, "text": "NPN 7p-7a:\n Nuero: Pt awake, follows commands. MAE. received tylenol 650mg pngt x 2, and 325mg pngt x 1 with minimal relief of throat pain. PT then ordered for and received MSO4 .5mg iv x 2 with some relief. ? if throat r/r ETT or .\n RESP: vent settings changed to A/C 400 x 18/.40 peep 5 after pt received ativan 1mg at HS and had periods of apnea. (has been placed on A/c frequently at ). sats remain high 90's, sx frequently for thick white secretions in small amts.. difficult to obtain secretions, requiring bagging/lavaging, although pt frequently with sensation of needing to be sx'd. LS bronchial RUL/diminihsed RML/RLL, course LUL/LLL.\n CV: Ptt therapeutic on heparin gtt at 1200u/hr for AF. received coumadin dose as ordered. pt with hematuria which developed again o/n.. Per team will cont to follow UO, but will not shut off heparin at this time unless foley clots. HR 50's-70's junctional rythym/AF. Sbp 90's -1teens.\n FE: FB neg 1.5L at midnight (goal was 1Lneg yesterday). tf's at goal.\n GU: hematuria again. uo tapered to 15-25cc's/hr after lasix effect dwindled.\n GI: ab soft, distended, bs +. + flatus, no stool.\n Access: 2piv's.\n Social: pt's husband into visit at onset of shift. pt remains full code.\n A/P: therpeutic on hparin gtt. requiring resting mode o/n d/t tachypnea/apnea after ativan for sleep. Pt with frequent sx needs for small amts. f/u hematuria/urine output. await results am inr. ? If will d/c hepain today if Inr therapuetic? cont mso4 for throat pain. pt will need Basis soap d/t to chest. Will need family meeting to discuss plan.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-16 00:00:00.000", "description": "Report", "row_id": 1514862, "text": "Resp. Care Note\nPt remains intubated and vented on settings as per resp flowsheet. No vent changes made. Requires freq. for thick tan secretions. Plan to extub. and not reintubate. MDI's Q vent check.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-16 00:00:00.000", "description": "Report", "row_id": 1514858, "text": "Respiratory Care Note\nPt remains intubated and fully ventilated on AC settings. No vent changes made during the . pt for blood tinged secretions q30. Pt coughing secretions into flex tube. MD aware. No RSBI as of this note due to pt asleep with no spontaneous breaths. Will try again later. ETT secure and in good position.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2185-03-16 00:00:00.000", "description": "Report", "row_id": 1514859, "text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT ALERT, FOLLOWS COMMANDS. MOUTH WORDS AND WRITES ON PAPER NEEDS AND QUESTIONS. PT ANXIOUS AT TIMES, FUSTRATED. ENCOURAGEMENT AND SUPPORT GIVEN. PT ONCE AGAIN NOT ABLE TO SLEEP. PT GIVEN 10MG AMBIEN, 2MG ATIVAN TOTAL OVERNIGHT. PT STILL NOT ABLE TO SLEEP DUE TO COUGHING AND SECREATIONS.\n\nRESP: NO VENT CHANGES MADE OVERNIGHT. LS ON RIGHT DIMINSHED AND ON LEFT COARSE. PT HAS AMTS SECREATIONS. YELLOW TO BLOOD TINGED THICK SECREATIONS. Q30MIN TO 1HR PER PT REQUEST. PT IS ABLE TO COUGH SECREATIONS UP THROUGH ETT. HURRICANE SPARY USED PRN X2 FOR GAGING.\n\nCV: PT REMAINS AFIB, 60-70'S. SBP 90-120'S. LOW GRADE TEMPS. PT OFF HEPARIN GTT SINCE DAY, COUMADIN GIVEN OVERNIGHT, AM INR 2.3.\n\nGI/GU: ABD SOFT, +BS, NO BM. TF CONT AT GOAL 50CC/HR PROBALANCE VIA OGT. U/O ~40CC/HR AMBER URINE W/ SEDIMENT.\n\nDISPO: PLAN IS TO ATTEMPT PS AGAIN TODAY. ?BRONCH TO HELP CLEAR OUT SECREATIONS. ETHICS TO BE IN AGAIN TODAY AND SPEAK WITH FAMILY. HUSBAND WOULD LIKE TO SPEAK W/ CASE MGT TODAY. PT IS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-16 00:00:00.000", "description": "Report", "row_id": 1514860, "text": "MICUB 0700-1500 RN Note\n\nNeuro: Awake alert oriented x3 follows commands appropriately, MAE equal strength. Communicating by mouthing word, nodding and writting. No c/o pain. Most of the time calm and coorperative. with periods of anxiety related to need for suctioning. Medicatd with Ativan 1mg x2.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-16 00:00:00.000", "description": "Report", "row_id": 1514863, "text": "increased secretions. ativan and abien given pt. awake and uncomfortable. difficulty breathing on vent. h.o. called. orders for increase sedation. additional ativan given. report to night rn. pt. justs wants to sleep. written dnr/dni.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-17 00:00:00.000", "description": "Report", "row_id": 1514864, "text": "Resp Care,\nPt. remains on A/C overnoc. No vent changes this shift. Pt. for copious thick tan sputum. Had episode earlier in shift of gagging. Resolved with increased sedation. Pt. had a comfortable . RSBI not done this am for comfort at this time. Will check with MD in am. See carevue.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-17 00:00:00.000", "description": "Report", "row_id": 1514865, "text": "NPN 11p-7a:\n Pt much more comfortable on increased amts sedation. received 2mg ativan x 2 o/n and 1mg mso4 for anxiety/air hunger with good effect. pt wanting to sleep, wanting minimal interventions.\n review of Systems:\n Nuero: sedation as noted. pt sleeping most of . using call bell when needing sx.\n rESP: pt with large amts thick tan secretions q 2-3 hrs. Pt vented on A/c 4000 x 16/.40 peep 5. sats high 90's. LS with crackles to clavicle level. per team pt diuresed with 20mg iv lasix, with brisk uo. peak airway pressures 25 now resting, were high 30's before lasix.\n CV: HR AF 60's-80's. BP 80's-1teens.\n Access: 2 piv's.\n GU: foley intact. hematuria persists.\n GI: ab firmly distended, bs +. no stool, + flatus. tf's off for impending extubation.\n Social: pt requesting to sleep, requesting ativan. affect withdrawn. Will need sw to assist with difficult day ahead.\n A/P: pt more comfortable on higher doses ativan more frequently, and prn mso4. Plan is for husband to come in today, and for pt to be extubated. if does not tolerate extubation, pt wishes to become CMO. Currently DNR/DNI. Please notify SW of very difficult day ahead for and her family.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-17 00:00:00.000", "description": "Report", "row_id": 1514866, "text": "NSG NOTE\nDecision made with husband and pt and MICU team to extubate and be made CMO, this AM. Was extubated and started on MSO4 Gtt and Ativan Gtt for comfort. Husband @ pt's bedside when pt had no HR,BP or RR, pt was without pain. Was pronounced by MD @ 1245. PM care done.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-16 00:00:00.000", "description": "Report", "row_id": 1514861, "text": "Continuation RN Note\n\nMICUB 0700-1500\n\nCV: HR 68-123 Afib no ectopy. NIBP SBP 92-130, MAP 60-88. IV access 2 peripheral LFA d/c unable to flush. Restarted #20 LH. 2nd line RFA intact. Heparin off PT 18.7 PTT 32.7 INR 2.3 Plan to recieve Coumadin Per routine. Heme: HCT 27.2.\nPhos 2.4 repleted K phos.\n\nResp: Orally Intubated #8 19 L Lip. Vent AC % 5 peep. Rare spont Resp. Strong cough reflex requiring suctioning q30min-1hr for copious tan blood tinged secretions. orally for mod amt clear secretions. Lungs: RUL Exp wheezes dim RMand Lower lobe, Left Lung Coarse with crackles @ base. @1100 Lasix 40mg IV with diuresis +1L. O2 sat 95-98%. HOB Maintained elevated. recieving MDI Atrovent/albuterol q4-5hrs/\n\nGU: Foley u/o 25-650cc/hr amber to dilute. BUN 24 creat 0.4\n\nGI: Abd soft distended. + BS sm brown BM. Pasing flatus. Sump orally placed recieving Probalance FS TF @ 50cc/hr.\n\nDerm: jaundice warm occassionally moist skin. Low grade temp T-max 100.4 PO\n\nSocial: Husband visited met with team and Case Management. Discussed options with patient. Plan to extubate and pt request to not be reintubated. to be referred for hospice. Husband will plan to be with pt.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-03-09 00:00:00.000", "description": "Report", "row_id": 1514835, "text": "MICU-B NPN 1900-0700\nPT. 62 Y/O FEMALE W/ (R)LUNG MASS; (R)LL LUNG COLLAPSE . INTUBATED FOR RESP. DISTRESS FOLLOWING BRONCH. UNDERWENT XRT IN ATTEMPT TO DECREASE LUNG MASS, TO UNDERGO SECOND XRT TODAY @ 0915 ON (AMBULANCE BOOKED) W/GOAL DECREASE MASS SO THAT PT. BE EXTUBATED AND SENT HOME W/HOSPICE. DISCUSSED W/FAMILY LUNG BX; BUT FAMILY DECLINED. FAMILY MEETING YEST. ADDRESSED XRT/LUNG BX. AND CODE STATUS. PT. TO REMAIN FULL-CODE AT PRESENT.\n\nNEURO - PT. INTUBATED ON NO SEDATION. X2 .5MG ATIVAN FOR ANXIETY W/GOOD EFFECT. PT. ALERT, INTERACTING EFFECTIVELY W/MOUTHING WORDS; DOES WRITE AS WELL. +MAE. DENIES PAIN.\n\nRESP - NO VENT CHANGES OVER/ PT. REMAIN ON A/C .40/400X18 WITH PT. OVERBREATHING /PEEP 5. O2SATS 94-97%. LS COURSE T/O W/ABSENT RLL BREATH SOUNDS. SX. T/O SHIFT FOR MOD. AMTS. RUST COLORED, THICK, SPUTUM. CONT. ON STEROIDS; AND NEBS FOR COPD. LEVOQUIN FOR ?OBSTRUCTIVE PNA YEST DAY . AS ABOVE TO UNDERGO XRT THIS AM FOR LUNG MASS ON .\n\nC/V - PT. W/CHRONIC A-FIB. STARTED ON HEP GTT. FOR A-FIB/MVR. PRESENTLY OFF (OFF @ 0200 FOR PTT 150) HAD BEEN RUNNING @900U/HR. CONT. Q6HR PTT DRAWS. HAS BEEN RATE CONTROLLED OFF DIG. HR 50-60'S, IRREG. W/NO ECTOPY NOTED. COUMADIN RESTART OVER/ SINCE PT. DECLINED LUNG BX. NBP 100'S-ONE-TEENS/40'S-60'S. PERIPHERAL PULSES PALPABLE. EDEMA NOTED TO EXTREM.\n\nID - AFEBRILE.\n\nGI/GU - OGT IN PLACE; PATENT PER AUSCULTATION. DELIVERING GOAL TF(PROBALANCE) @ 50CC/HR W/ MIN. RESIDUALS. ABD. SOFT, DISTENDED, W+BS. NO STOOL OVER/. +FLATUS. ATTEMPT. BEDPAN W/NO RESULTS. ON BOWEL REGIME. INDWELLING FOLEY IN PLACE; PATENT W/ MARGINAL U/O. 20-50/HR PINK>RED, URINE.\n\nSKIN - GROSSLY INTACT.\n\nACCESS - PT. W/2 PIV TO (L)ARM. LAC W/+DRAW. NEED TO BE CHANGED, BUT PT. W/ EXTREMELY POOR ACCESS. TO ADDRESS TODAY W/ROUNDS.\n\nSOCIAL - FAMILY MEETING YEST. W/COURSE TX. AND CODE STATUS DISCUSSED AS ABOVE. REMAINS FULL-CODE. XRT THIS AM; NO LUNG BX. GOAL TO DECREASE LUNG MASS>TO RE-INFLATE LUNG IN HOPES TO BE ABLE TO EXTUBATE PT. SO THAT SHE GO HOME ON HOSPICE. CONT. SUPPORTIVE CARE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-03-11 00:00:00.000", "description": "Report", "row_id": 1514840, "text": "MICU NPN 7P-7A\nNEURO: ALERT AND ORIENTED. COMMUNICATING VIA MANY FORMS. MOVING ALL EXTREMITIES. COMPLAIN OF THROAT PAIN AND MEDICATED WITH 650MG TYLENOL PO. REQUESTED A PILL FOR SLEEP, MEDICATED WITH 1MG ATIVAN IV WITH EFFECT.\n\nCARDIAC: HR 63-73 ?AFIB/?JUNCTIONAL WITH RARE ECTOPY. BP 101-122/45-61 PEDAL PULSES PRESENT. RECEIVED ON 1300U/HR OF HEPARIN. PTT WAS 109 SO GTT DECREASED TO 1200U. PATIENT HAVING PERIODS OF HEMATURIA, MD MADE AWARE AND HEPARIN WAS STOPPED ALTOGETHER. CONTINUES ON COUMADIN. INR 1.6 THIS AM. HCT 31.\n\nRESP: REMAINED ON CPAP 15/+5 WITH RR 17-25 AND SATS 92-96%. LS BRONCHIAL AND DIMINISHED ON THE RIGHT AND CLEAR TO COARSE ON THE LEFT. ASKS FREQUENTLY TO BE SXTED, AND SXTED FOR THICK WHITE/BLOODTINGED AT TIMES.\n\nGI/GU: ABD SOFT AND DISTENDED WITH +BS. NO STOOL. OGT IN PLACE. U/O 15-60CC/HR. INITIALLY URINE WAS YELLOW BUT TURNED RED, APPEARED TO BE CLEARING THEN BECAME RED AGAIN. HEPARIN STOPPED AT THIS TIME AND URINE IS NOW CLEARING.\n\nFEN: TUBE FEEDS @50CC/HR TOLERATED WITH MINIMAL RESIDUALS. LYTES PER CAREVUE. FS 103 @MN.\n\nID: TMAX 96.9 WITH WBC 12.4, NOT ON ABX AT THIS TIME.\n\nSKIN: INTACT.\n\nACCESS: PIV X2.\n\nSOCIAL/DISPO: FULL CODE. HUSBAND IN AT START OF SHIFT. POSSIBLE FAMILY MTG TO DISCUSS OPTIONS.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-09 00:00:00.000", "description": "Report", "row_id": 1514836, "text": "nsg progress note 7a-7p\nNeuro: Alert and following commands. MAE's. C/o pain in throat s/p XRT tx. treated with tylenol.\n\nCV: vss, afib 50-60's. Rare PVC this am, none noted this PM. 90-120's/50-60's. Heparin gtt for afib. Currently @ 900u/hr last PTT @ 1200 33.0. Repeat due @ 1900. Received coumadin last night. To receive another dose tonight. 3+ pedal pulses, 2+ edema.\n\nRESP: AC 400 X18 Fio2 40% Peep 5. Lungs coarse t/o, dim @ right base. Occassionally left side clear. Sx'd Q2hr for thick white secretions. Pt calls when needs to be sx'd. XRT tx this am 0900-1145 off the floor to . with ALS and RN. No events. Refused lung bx.\n\nGI: abd softly distended, + BS. Dulcolax given with Lg result formed stool. Guiac neg. Probalance @ 50cc/hr goal\n\nGU: lasix given 10mg IV this afternoon for goal 1liter neg. Currently -200cc.\n\nSkin: intact.\nAccess: Two outdated PIV's in left upper extrem. d/c'd and Two new #20's placed in right FA. Patent.\n\nFull code.\nPlan: to XRT to decrease size of tumor with hopes of extubating so pt can go home with hospice.\nHusband in this am. Likely to return tonight.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-10 00:00:00.000", "description": "Report", "row_id": 1514837, "text": "Respiratory Care:\nPatient remains on ventilatory support (A/C) with no parameter changes throughout the night (see CareVue). No ABG results at this time.\n\nFailed RSBI (190.1).\n" }, { "category": "Nursing/other", "chartdate": "2185-03-10 00:00:00.000", "description": "Report", "row_id": 1514838, "text": "NPN-MICU\nMrs. has rested comfortable overnight.\nResp: no vent changes made, still coarse but sputum is clean and white. Her O2 sat are >97%. She again recieved more lasix rsp well but it is less each time despite larger dose given. She cont to c/o intermittent throat pain but it is relieved with tylenol.\nCV:her BP has been on the lower side 96-105/50's since the increased dose of lasix. Her HR cont to be 58-60's, min VEA noted.\nHeme: she cont on Heparin for anticoag s/p her valve and AF.Her level is still not quite therapeutic so it tis at 1200U/HR, no signs of bleeding noted.\nGI: she con to TF and tol well, no asp, no further stool.\nA/P:Will cont with plan to await results of and cont to wean if able to get pt home.\n Asses for pain and watch for dry skins on chest s/p \n Note PTT and cont to get heparin within range, Next level at 8am.\n Plan to cont to get pt neg per I&O, Watch BP\n Cont with bowel regime\n\n" }, { "category": "Nursing/other", "chartdate": "2185-03-10 00:00:00.000", "description": "Report", "row_id": 1514839, "text": "See Carevue for objective data.\n\nAssessment remains relatively unchanged. However, some progress was made with respiratory status. Placed on 15PS/5PEEP and has tolerated this all afternoon. Attempted to drop PS to 12 with increase in RR and returned PS to 15 with pt comfort. Maintaining sats and RR on 15/5.\nSuctioned for scant amt of tan secretions even though pt sounds secretional(? from rx tx yesterday)\nAlso given 60 mg lasix IV with excellent diuresis (1500 cc's) as well.\nK/MG repleted.\nMedicated with tylenol for C/O throat pain with fair effect and requested ativan X 2 with good effect. Husband in and updated on POC.\nLg BM on bed pan -guiac. No belly pain and tolertaing TF well.\nPTT due at 2100.\n\nContinue current therapy and attempt to wean PS further in attempts to extubate. Mass still impeding airway and pt can receive no further radiation rx. Team will speak to husband in AM about direction of care if pt cannot be extubated in AM-hospice vs withdrawal?\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-03-11 00:00:00.000", "description": "Report", "row_id": 1514841, "text": "nsg progress note 7a-7p\nNeuro: Alert and following commands.MAE's. C/o throat pain x1, medicated w/tylenol m ng with effect.\n\nCV: vss, ?afib vs junctional rhythm since it is somewhat regular 60-70's, no ectopy. Bp 95-120's/ 30-50. 2+ pedal edema. 3+ pedal pulses. Hct stable this am. on heparin for afib- was shut off overnoc for hematuria , resumed @ 1100 on previous setting of 1200u/hr. Repeat PTT @ 1700 pending along with lytes. To get 7.5mg coumadin tonight. Replaced K+3.9 with KCl 40meq today. Ion ca with ABG 1.23.\n\nResp: CXR this afternoon improved per team. Lung sounds on right bronchial/tubular in upper, dim @ base. left side coarse, occassionally clear. Sx'd Q1-2hrs for thin white secretions. On CPAP. Decreased PS to 12 from 15, peep 5 Fio2 40% Abg this afternoon on this setting 7.45/53/162/11/38. Resp rate 21-23. TV's .250's. Lasix 60mg IV @ 1700 Goal -1L today. receive another dose this pm.\n\nGI: Abd softly distended, + BS. On bowel regime. need dulcolax supp tomorrow. Probalance @ 50cc/hr goal via OG tube. Placement confirmed. + flatus.\n\nGU: no hematuria this shift. Lasix given as mentioned, currently diuresing, clear yellow.\n\nSkin: intact.\nDispo: full code.\nSocial: married with children. Unsure of family's idea of pt's prognosis. Husband in earlier, unable to talk with team. Code status needs to be addressed as well as plan for extubation vs CMO. Unlikely pt will be able to go home as planned. Cont to diurese to promote optimal resp function. Attempt to wean further as tolerated. Pt has recieved two high dose tx's in last week. Follow up lytes and PTT.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-15 00:00:00.000", "description": "Report", "row_id": 1514854, "text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT ALERT, FOLLOWS COMMANDS, ABLE TO WRITE OR MOUTH NEEDS. PT GIVEN TOTAL 3MG IV ATIVAN OVERNIGHT FOR ANXIETY AND SLEEP. PT DID NOT SLEEP MUCH OVERNIGH.\n\nRESP: NO VENT CHANGES MADE. LS DIMINISHED ON RIGHT, LEFT SIDE COARSE. PT Q1HR FOR THICK TO THIN YELLOW SECREATIONS. MODERATE AMT ORAL SECREATIONS. PT C/O GAGING FROM ETT. PT GIVEN HURRICANE SPRAY PRN. PT STATES IT HELPS.\n\nCV: HR 70'S AFIB, SBP 90-110'S. PT CONT ON HEPARIN GTT AT 900U/HR. P0T GIVEN 10MG COUMADIN LAST NIGHT. AM PTT PENDING. PT AFEBRILE.\n\nGI/GU: ABD SOFT, +BS, +BMX2. STOOL FORMED, BROWN, GUAIC NEG. PT CONT ON PROBALANCE 50CC/HR VIA OGT. URINE RED W/ SEDIMENT. LASIX 20MG IV GIVEN AT 2400. U/O POST LASIX ~800CC.\n\nDISPO: PT FAMILY IN DURING EVENING HOURS. CONT WITH SUPPORTIVE CARE. TEAM TO TALK WITH FAMILY AGAIN TODAY IN TO PT'S PROGNOSIS. ETHICS DUE TO EVALUATE PT TODAY. PT IS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-15 00:00:00.000", "description": "Report", "row_id": 1514855, "text": "Resp: pt on 18/400/+5/40%. Alarms on and functioning. Ambu/sryringe @ hob. BS auscultated reveal bilateral coarse sounds with scattered ronchi. for moderate amounts of thick yellow secretions, minimal oral secretions. MDI's administered Q4 hrs Alb/Atr. RSBI=145, no SBT initiated. No further changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-13 00:00:00.000", "description": "Report", "row_id": 1514846, "text": "Resp: pt on a/c 18/400/+5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral crackles with a few scattered wheezes. Suctioned x3 for moderate amounts of thick yellow secretions. MDI's given Q4 hrs Atr/Alb with no adverse reactions. RSBI=144 this AM. Pt is alert and awake. 02 sats @ 100%. Ett retaped and secure @ 20 cmh20/lip. No further changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-13 00:00:00.000", "description": "Report", "row_id": 1514847, "text": "NPN 7p-7a:\n Nuero: awake, mae. med x 1 with 1mg iv mso4 for throat pain with good effect. med x 1 with 1mg ativan for sleep with fair effect. napping off and on.\n CV: hemodynamically stable. ptt 94 at 8pm. heparin held x 1 hr, then restarted at 900u/hr. am ptt 63. cont on coumadin. await inr level this am.\n RESP: vented on A/C 400 x 18/peep5/.40. sx frequently for thick yellow secretions. cx pending. LS with rhonchi/wheezing Left, bronchial R. sats high 90's.\n GI: tf's at goal. + flatus. no stool. ab soft, distended.\n GU: foley intact. urine red at times, and amber at others. uo 20-30cc's/hr.\n Integ: intact.\n Access: piv's changed x 2 as old iv's were due for change today.\n Social: husband at bedside in evening. pt communicating via clipboard.\n FE: fluid balance 1L + yesterday. await am lytes.\n A/P: await plan from icu team/onc team r/e code status/ onc issues. cont heparin at this time. cont pulmonary toilet. await am labs.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-14 00:00:00.000", "description": "Report", "row_id": 1514850, "text": "NPN 7p-7a:\n Nuero: Pt awake and following commands. mae. requesting ativan x 3 o/n. received tylenol x 3 for throat pain with good effect. assists to turn.\n CV: HR 60's-70's AF. therapeutic on heparin gtt at 900u/hr for af. inr 2.0 this am. received coumadin 7.5 mg at hs. treated with 250cc's ns fluid bolus x 2 o/n for decrease uo x 1 and for sbp down to 80's x 1. otherwise bp 90's-110 systolic.\n FE: fluid balance 1.5 L + yesterday, already +500cc's today. team aware. lytes pending. on goal tf's. fsbs wnl.\n RESP: vented AC 400 x 18/peep5/.40. overbreathing to 19-20/min. sats high 90's. sx frequently for thick yellow secretions. LS rhonchorous. may need steroid inhaler. pred taper finished yesterday.\n GU: cont wiht hematuria. uo tapering to 15-20cc's/hr. received 250cc ns bolus as noted above.\n GI: ab large/distended/soft. bs + x 4. + flatus, no stool.\n ID: low grade temp. sputum/urine cx pending.\n social: husband in at onset of shift. plan is at some point to have meeting for pt/husband to meet with oncologist/team to discuss plan.\n Access: piv x 2.\n A/P: stable o/n. has not tolerated ps trial past 2 days. cont pulmonary toilet as doing. Await further input from onc.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-14 00:00:00.000", "description": "Report", "row_id": 1514851, "text": "Resp: pt on a/c 18/400/+5/40%. Alarms on and functioning. Ambu/syringe @ hob. Cuff pressure @ 23 cmh2o. BS auscultated bilateral wheezing. Suctioned for moderate amounts of thick yellow secretions. MDI's administered Q 4 hrs Alb/atr. RSBI=142. Suggested flovent inhaler. No further changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-15 00:00:00.000", "description": "Report", "row_id": 1514856, "text": "nsg progress note 7a-7p\nNeuro: A+O, folowing commands. Appropriate. Interacting with staff and husband. C/o throat pain X 2 medicated x1with tylenol and X1 with lidocaine spray. Pt c/o anxiety X1 when switched to PS on vent. Once returned back to AC pt felt no anxiety.\n\nCV: hemodynamically stable. See for objective data. HR afib 70's, no ectopy. Lytes repleted this am. Heparin d/c'd late morning since INR almost therapeutic ( goal 2.5-3.0). To get coumadin 10mg tonight. Cont with LE edema right> left. 3+ pedal pulses.\n\nRESP: ls cont to be coarse t/o, decreased on right. frequently at least Q1hr and sometimes 3X/hr. Secretions thick yellow. Able to cough some up to ETT. Tried PS with increased anxiety, high resp rate. Back on AC 400 now on 16 resp, peep 5 40% Fio2 100% sats overbreaths by 2-3 bpm.\n\nGI: no BM today. ABd softly distended. + flatus. Probalalnce TF's @ 50cc/hr, goal.\n\nGU: urine bloody this am. Starting to clear since heparin d/c'd. Output 30-45cc/hr. Goal to keep even fluid balance today. No lasix ordered yet.\n\nSkin: intact.\nDispo: still full code. Pt and husband met with ethic MD, Dr. and had discussion. Husband wants to explore trach possibilites and then to extended care facility. Both are still not able to come to terms with prognosis and want to still consider last alternatives before making end of life decision. Case manager to meet with husband either today or tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-15 00:00:00.000", "description": "Report", "row_id": 1514857, "text": "resp care\npt remains intubated and mech ventilated. see carevue for settings/changes. pt failed cpap+ps x2. first try d/t apnea, second attempt c/o sob, rr 30's. b/s coarse w/exp wh. sxn thk yel. mdi's given x3 w/good effect. plan: cont w/mech suppport.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-13 00:00:00.000", "description": "Report", "row_id": 1514848, "text": "NPN MICU-B 7AM-7PM\nS/O: RESPIR: Rec'd on A/C 40/400/18 with Peep-5, L/S course, diminished on L, with O2 sats 95-99%, suctioning q1-2hr for lrge amts thick yellow sputum. Attempted to place on PSV-20 again today failed yesterday, and failed again today, RR-30's, HR up to 130's, c/o'd of being SOB and became extremely anxious. Placed back on A/C.\n\nC/V: BP 97-120/60, HR when calm and not on PSV- 60-70's, as above HR up to 130's while attempting PSV. No c/o's CP. K+-3.6, phos-2.4, rec'd K+phos 15mm over 6hrs. Repeat lytes to be drawn @ 6pm.\n\nGI: TF's Probalance @50cc/hr, had one lrge soft formed brown OB neg stool. remains distended with +BS's.\n\nGU: U/O down to 10cchr with BP 97/50, rec'd 250cc NS IVB with very mild response, u/o 40cc/hr. U/O dropped again in afternoon rec'd another NS bolus with good response. Urine remains red with no clots noted.\n\nHeme: Remains on Heparin Gtt @ 1100 units hr for A-fib, HCT down to 28.6 this AM, repeat level to be drawn @ 6pm. Coumadin 7.5mg due this evening.\n\nNeuro: A&Ox3, but anxious in the AM, rec'd Ativan 1mg times one with good effect.\n\nSocial: Husband and son in to visit, will call in the AM to set up family meeting for some time tomorrow.\n\nA/P: Continue with aggressive Pulmon tiolet, monitor O2sats. Monitor BP and u/o administer NS IV boluses as needed. Replete lytes as needed. Check PTT and adjust Heparin Gtt as per s/s. Set up fmaily for tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-13 00:00:00.000", "description": "Report", "row_id": 1514849, "text": "Resp. Care:\n Pt. remains intubated and on vent. support. Brief trial of PS 20/C-PAP 5 today, but pt. again failed. Please see flow sheet for more information. Albuterol and atrovent (4-6puffs) given q4hrs.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-14 00:00:00.000", "description": "Report", "row_id": 1514852, "text": "nsg progress note 7a-7p\nNeuro: Alert and following commands. Writes and mouths words appropriately. C/o throat pain x1 r/t ett. Tx'd with tylenol. Anxiety and tx'd with ativan 1mg X1 with effect. MAE's.\n\nCV: vss, afib 70's. no ectopy. Bp 90-110/50's. 2+ pedal edema on left 3+ on right. On heparin for afib, PTT this am 65, therapeutic. Goal 60-80. Repeat with am labs. Pt also on coumadin INR 2.0 to get coumadin 10mg tonight.\n\nResp: AC 400 X 18 Peep 5 40% sats 100%. Secretions have inceased over weekend. Now thick yellow, sx'd Q1hr, strong cough and gag. Lg oral secretions. Sputum cx pending from weekend. Ls on right bronchial and dim @ base. left side coarse t/o. Did not tolerate PS over weekend.\n\nGI: Probalance @ 50cc/hr, goal. via OG. Placement verified. No stool today. Abd softly distended and also is somewhat larger. Pt has had a bm last few days, on bowel regime. + flatus. Denies discomfort.\n\nGU: U/o 30-45cc/hr, blood tinged, clear. Occassional sediment. No clots noted. Team aware. Will d/c heparin if lg clots found.\n\nSkin: intact. Bears watching since pt only tolerates supine and right side lying.\n\nDispo: full code. Family meeting with pt present this afternoon. Discussed grim outlook and no available tx since didn't work. Dr. from ethics to come in am to meet with family to help come to terms and decisions of pt's end of life decisions.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-14 00:00:00.000", "description": "Report", "row_id": 1514853, "text": "resp care\npt remains intubated and mech ventilated. no vent changes this shift. b/s coarse w/coarse exp wh, occ insp wh. sxn thk yel. mdi given x3 w/good effect. plan: cont w/mech support.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-12 00:00:00.000", "description": "Report", "row_id": 1514844, "text": "Respiratory Care Note:\n Patient remains on full support, inutbated, awake and alert. PSV trial this am failed after increased HR and RR. Suctioned for tenacious yellow secretions. She continues to receive albuterol and atrovent MDIs with some effect. See Carevue flowsheet for specifics.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-12 00:00:00.000", "description": "Report", "row_id": 1514845, "text": "NPN MICU-B 7AM-7PM\nS/O: RESPIR: Remains intubated on A/C 40/400/18/Peep-5, increased suctioning needs noted q1-2hr for mod-lrge amts thick yellow/tan secretions. Spec sent for C&S and cytology. Attempted to place on PS-14 but did not tolerate for long increased RR- to 30's, had lrge sputum plug, became extrememly anxious, HR 140-150's A-fib with frequ PVC's desated with low VT's, placed back on A/C @ above settings. Has no A-line in place so no ABG drawn. O2 sats 95-99%.\n\nNeuro: Alert and interactive was very anxious in the AM request Ativan times two, rec'd 1mg IV twice with good results, none needed since late morning. No c/o's throat pain no MSO4 needed.\n\nGU: U/O very low to 10cc/hr in the AM, red urine but no clots noted team made aware on rounds. BUN/CRE-35/0.5, increased u/o with Sodium Phos gtt over 6hrs was ordered. u/o up to 40-60cc/hr. Phos-2.2. K+-3.2 rec'd a total of 60mEq PO, MgS+ 1.8 repleted with 1gm IV. Repeat lytes due @ 8pm.\n\nGI: Rec'ing Probalance @ 50cc/hr, distended with +BS's, had one mod size stool brown OB+. HCT-30.6\n\nC/V: BP 98-118/60, HR 60-70's A-fib, had one episode of HR to 130-150's with frequent PVC's, lasting 10min this AM when placed on PSV, no further episodes noted. Remains on Heparin Gtt, was on 1200 units/hr was decreased to 1100 units/hr due to Hematuria. PTT due @ 8pm. Coumdin due @ 10pm, last PTT 81.9, INR-1.9.\n\nID: Temp 100.0 PO max with WBC 12.4, on no antibx's.\n\nSocial: Husband in to visit this AM is thinking about Status and will talk to other family members about it. Plan for family meeting on Monday. Also asked that only himself his children and the pt's sister be aloud to visit.\n\nA/P: Continue to monitor VS's and observe I&O's closely. Administer Ativan as needed. Aggressive Pulmonary tiolet, assess L/S and O2 sats.\nCheck PTT's levels and adjust Heparin Gtt as needed. Support pt and family during this difficult time.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-03-08 00:00:00.000", "description": "Report", "row_id": 1514833, "text": "MICU NPN 7P-7A\nNEURO: PATIENT NOT SEDATED. ALERT AND COMMUNICATING VIA MOUTHING, NODDING AND WRITING. FOLLOWING COMMANDS. MOVING ALL EXTREMITIEES. DENIES PAIN/DISCOMFORT. REQUESTED SLEEPING MED, GIVEN 0.5MG ATIVAN IV WITH FAIR EFFECT.\n\nCARDIAC: HR 61-70 AFIB WITH OCCASIONAL ECTOPY. MONITOR ON OCCASION WILL SAY SR BUT UNABLE TO IDENTIFY P WAVES. BP 113-130/51-70. RECIEVED PATIENT ON HEPARIN @800U/HR. PTT SENT BUT CAME BACK 27.3, DOWN FROM 67.9 EARLIER IN THE EVENING. MD CALLED AND AGREED TO REPEAT TEST WHICH CAME BACK AT 28.3, MODERATELY HEMOLYZED. PER SS HEP ORDER GIVEN 1800U BOLUS AND INCREASED GTT BY 200U TO 1000U/HR. CHANGED @0230, NEXT PTT DUE AT 0830. NO BLEEDING NOTED. HCT STABLE @31. PEDAL PULSES PRESENT.\n\nRESP: REMAINS ON A/C 400X16 40% +5PEEP. OVERBREATHING VENT BY 1-4 BREATHS. SATTING 94-97%. LS COARSE TO CLEAR WITH DIMINISHED RIGHT BASE. SXTED FOR THICK WHITE SPUTUM. MDI'S AS ORDERED.\n\nGI/GU: ABD SOFT AND DISTENDED WITH +BS. NO STOOL. OGT IN PLACE. U/O 15-60CC/HR YELLOW/AMBER AND CLEAR. CRE STABLE @0.5.\n\nFEN: NS @50CC/HR CONTINUES. +9.2L LOS. 1+ PEDAL EDEMA. LYTES PER CAREVUE. FS 150/120. TUBE FEEDS @50CC/HR WITH MINIMAL RESIDUALS.\n\nID: TMAX 96.3 WITH WBC 14.9 DOWN FROM 15.2 YESTERDAY. CURRENTLY ON LEVOFLOXACIN.\n\nSKIN: INTACT.\n\nACCESS: PIV X2.\n\nSOCIAL/DISPO: REMAINS A FULL CODE. HUSBAND VISITING LAST EVENING. STILL TO BE DECIDED BY PT AND FAMILY IS; LUNG BX AND FURTHER XRT.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-08 00:00:00.000", "description": "Report", "row_id": 1514834, "text": "Please see data, MD notes/orders. Neuro: Pt alert, appears oriented and appropriate. Communicates by writing, mouthing words and nodding head to questions.Has intermitent anxiety releived with prn ativan.CV: Chronic afib with occ pvc's noted. SBP stable 90'-1teens. Pulm: No vent changes, lungs coarse very rhoncorous at times. Sx for thick tan/rusty sputum with sample sent for cytology. FIO2 Incr to 50% for low 02s sats with increase from 92 to 97% noted. Please see Rt notes/abg's/am cxr. GU: Uo clear amber draining 15-40cc/hr. Occasional blood noted in tubing. GI: Abd soft/distended, bs+, pt passing flatus, denies need for bedpan. Currently on colace/senna. TF at goal rate 50cc/hr with minimal residual. Soc: Has husband, two children and several grandchildren. Treatment/diagnostic options discussed with pt/husband and attending physician . . Pt/husband decided to decline lung bx and to have one more radiation treatment with ultimate goal to get pt extubated and sent home with hospice support. P: Continue full support, full code status. Radiation tx as ordered. ?rsbi/spont weaning trial once radiation comepleted. Fluid bolus for low uo/note response to same. Keep family/pt up to date, offer emotional support. R: As above,500cc ns bolus given with little effect on uo/team aware. Radiation scheduled in basement of building at 0915 . Ambulance service arranged. Pt informed of and agreeable to plan. Ativan .5-1mg being given q3-4hrs.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-07 00:00:00.000", "description": "Report", "row_id": 1514831, "text": "Respiratory Care\nPt remain intubated and on vent support, no vent changes, Sx mod amount thick white secreation, BS coarse,RSBI was done on PS 5/0 it was 162, no SBT at this time, Mantain a good sat through out the night.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-07 00:00:00.000", "description": "Report", "row_id": 1514832, "text": "NPN 07:00-19:00 MICU\n*Please see carevue for additional patient information\n*Full Code\n\n*Brief summary: patient is a 62 y/o woman who was admitted , w/ pmh Rheumatic Fever, Mitral valve replacement, a-fib, COPD (home o2). CXR done showing RUL mass, and CT , MD's note\"identified heterogenous mass w/ some degree of RUL collapse; *Mass=10x15cm size.)\nPt had Bronchoscopy and Thoracentesis done , requiring intubation. ( MD's note, Lung mass most likely squamous cell carcinoma.)\n\n*ROS:\n\nNeuro: Intubated (no sedation), A/O, communicating through mouthing words and writing tablet. No c/o pain, MAE's on bed. SR up for patient safety.\n\nCV: VSS, HR 54-63, A-fib, started on Heparin gtt 800u/hr (no bolus given; goal 60-100), will check PTT at 16:00. Afebrile.\n\nResp: No vent changes made A/C 400x16/peep 5/FiO2 40%, not breathing over vent. O2 sat's mid-high 90's. Sxn q4hr for small amounts of thick bld tinged sputum. **Pt can only tolerate being on R side or Supine. *Dr. spoke to family about lung biopsy for definative dx of squamous cell carcinoma, although, per team treatment would probably not change. Family thinking about procedure.\n\nGI/GU: OGT in place. Tolerating TF's, +BS, no bm (?need suppository.)U/O: wnl, amber-pinkish urine at times, overall amount wnl. *Goal to keep pt. Even.\n\nEndo: RISS, bs=178.\nAccess: PIV x2, L arm and hand, both wnl.\n*Electrolytes: hypercalcemia92/2 malignancy) on Pamidronate gtt which will be completed at ~16:00.\n\nSocial: Husband in to visit today, Dr. in to speak w/ family, updated on pt's status, and overall plan of care. Attending spoke to family at length regarding overall plan of care, and code status, which continues to be FULL.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-03-06 00:00:00.000", "description": "Report", "row_id": 1514826, "text": "NPN-MICU\nMrs. has rested well overnight\nResp: she cont on A/C to rest. She cont with a fair amt of thick sticky sputum with no blood noted. Her sats are >96%.\nNeuro: she cont to be awake,comfortable and interactive, she recieved 1mg IVP ativan to sleep.\nGI: she cont to tol her TF now at goal rate.She had a med size stool and feels much better after that. She cont to pass flatus.\nGU:I&O stil sl + so she got another dose of Bumex at 9:30pm. She rsp well and is about equal now.\nCV: HR cont to be about the same,has only dropped HR to 40 when she is fast asleep x1. BP has been 100-110/50's\nID:afebrile, on IVAB\nA/P:Will cont with the slow wean and breathing trials, pulm toilet as needed\n Asses tol of TF and note stool amts\n Follow I&O and keep equal\n Cont to follow HR and BP\n\n" }, { "category": "Nursing/other", "chartdate": "2185-03-06 00:00:00.000", "description": "Report", "row_id": 1514827, "text": "RESPIRATORY CARE\nPT REMAIN INTUBATED AND ON VENT SUPPORT, VENT SETTING UNCHANGED, BS COARSE, SOME END EXP WHEEZES, SX THICK SECREATION.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-06 00:00:00.000", "description": "Report", "row_id": 1514828, "text": "Respiratory Care\nPt remains on CMV mode, RSBI 0f greater than 170 earlier prevented weaning from ventilator. Suction small amounts thick secreations. MDI's given as ordered. Breath sounds coarse throughout. RRT\n" }, { "category": "Nursing/other", "chartdate": "2185-03-06 00:00:00.000", "description": "Report", "row_id": 1514829, "text": "FOCUS; NURSING PROGRESS NOTE\nREVIEW OF SYSTEMS-\nNEURO- ALERT AND ABLE TO COMMUNICATE BY WRITING. MAE. AFFECT FLAT.\nRESP- CONT TO BE INTUBATED AND VENTED ON 40% FIO2/ 400CC TV/ RESP RATE OF 16 OVERBREATHING BY UP TO 4 BREATHS. AND 5 PEEP. SUCTIONED FOR THICK YELLOW SPUTUM. BS COARSE.\nCARDIAC- HR AFIB RATE OF 50-60. THIS AM WITH OCCASIONAL DIPS TO 38. DIG DC'D THIS AM DUE TO THIS. SBP 120-130. K 3.5 REPLETED WITH 60MEQ KCL. MG 1.8 TX WITH 2GMS OF MAG. CA DOWN TO 11.8 TODAY FROM 12 YESTERDAY. CONT ON CALCITONIN AND WAS STARTED ON PAMIDRONATE.\nGI- CONT ON TF OF PROBALANCE OF 50CC/HR THAT IS GOAL RATE. MINIMAL RESIDUALS. ABD SOFT DISTENDED WITH POS BS. NO STOOL TODAY. LAST STOOL YESTERDAY.\nGU- UO 40CC OR GREATER THIS SHIFT. CONT ON PO BUMEX QD. GOAL IS FOR PATIENT TO BE EQUAL TO 500CC NEG TODAY. SHE IS EVEN AT PRESENT.\nENDO- BS 195 AT NOON TX WITH SS INSULIN.\nID- CONT ON LEVOFLOX. WBC UP TO 14.7 TODAY. AFEBRILE.\n HUSBAND AND DAUGHTER IN AND SPOKE WITH DR FROM ONCOLOGY. SHE RELAYED GRIM PROGNOSIS TO THE FAMILY WITH PATIENT'S EXPECTED SURVIVAL OF 2 MONTHS. THEY SPOKE IN PATIENT'S ROOM. PATIENT APPEARED TO SLEEP THROUGH THE PROCEDURE. FAMILY STAYED ONLY A FEW MINUTES AFTER THE DISCUSSION AND THEN LEFT.\nDISPO- REMAINS IN THE MICU A FULL CODE.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-03-07 00:00:00.000", "description": "Report", "row_id": 1514830, "text": "NPN-MICU\nMrs. has been comf on vent overnight.\nResp: pt cont on A/C with no c/o SOB. Sputum is white and a few blood flecks noted but no change in amts. sats cont to be >96%.\nCV: no extreme bradycardia noted, HR in the 50's mostly. BP higher at 110-120/50's.\nGU: I&O sl + at 12 pt got IV lasix is rsp well so far. She cont on the\npamidronate till 2pm. Labs are pnd.\nGI: cont to tol TF well, soft abs, no stool as yet.\nID: remains afebrile\nA/P:Will cont to eval for weaning from vent\n Will cont to keep I&O equal, follow lytes and replace as needed, eval rsp of calcium.\n ? need for suppository this am.\n" }, { "category": "ECG", "chartdate": "2185-03-03 00:00:00.000", "description": "Report", "row_id": 313128, "text": "Atrial fibrillation\nRight atrial deviation\nLow limb leads voltage\nNonspecific ST-T wave changes - consider in part metabolic/drug effect\nClinical correlation is suggested also suggested for possible chronic pulmonary\ndisease/RV overload or possible prior lateral myocardial infarct\nSince previous tracing of , may be no significant change but baseline\nartifact on previous tracing makes comparison difficult\n\n" }, { "category": "ECG", "chartdate": "2185-03-02 00:00:00.000", "description": "Report", "row_id": 313129, "text": "Baseline artifact\nProbable atrial fibrillation\nRight atrial deviation\nLow limb leads voltage\nDiffuse nonspecific ST-T wave changes\nClinical correlation is suggested for possible chronic pulmonary disease/RV\noverload or possible lateral myocardial infarct\nSince previous tracing of , probably no significant change but baseline\nartifact makes comparison difficult\n\n" }, { "category": "ECG", "chartdate": "2185-02-26 00:00:00.000", "description": "Report", "row_id": 313348, "text": "Atrial fibrillation, average ventricular rate 71. Compared to the previous\ntracing of multiple abnormalities as previously noted persist without\nmajor change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2200-02-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002983, "text": " 3:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with black stools brought in from nursing home with anemia.\n Trached, on vent at night.\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: GI bleeding, brought in from nursing home with anemia. On\n tracheostomy tube.\n\n FINDINGS: In comparison with the study of , there is again severe\n cardiomegaly with enlargement of the pulmonary arteries that are longstanding\n and unchanged. Moderate right pleural effusion is again seen. Opacification\n at the left base could represent atelectatic change, though the retrocardiac\n area is impossible to evaluate in the absence of a lateral view. The upper\n lung zones are grossly clear.\n\n Tracheostomy tube is in place. Midline sternal sutures are again visualized.\n There has been placement of a right subclavian catheter that extends to the\n lower portion of the SVC.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2200-02-05 00:00:00.000", "description": "Report", "row_id": 1661999, "text": "Resp Care Note, Pt rested overnight on vent. See vent flow sheet for details. Suctioned for mod amts thick tan secretions. MDI'S given while on vent.HR-PVC'S.RSBI done on 0 peep/5 ips 33.5. pt awake and . Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2200-02-05 00:00:00.000", "description": "Report", "row_id": 1662000, "text": "cv: hr 85-90 nsr accasional pvc. 104/51-90/37.\n\ngi: tube feeding started at . nutren pullmonary at 10 cc/hr started and increased by 10 cc q 4 hours currently at 40 cc/hr since 0600. also free h2o bolulses 250 cc q 4 hours begun at 0600 due to elevated na of 152. tube dressing dry and intact.no stool overnight\n\ngu: foley draining yelow urine 100 cc-25 cc/hr\n\nmental status: pt mouthing approprpiate anses to questions. obeys commands. c/o anxiety at bedtime and requested his anxiety med\" (clonazpam). he was given .5 mg via at 2200 and pt calm and slept.\n\nresp: trach collar until 2200. resting on vent overnight. suctioned a few times for thick tan.\n\nendo: blod sugars checked q 6 hours no addtiional reg required .pt recieved 10 lantus at 2200.\n\nheme: hct stable 24.4 no stool\n" }, { "category": "Nursing/other", "chartdate": "2200-02-05 00:00:00.000", "description": "Report", "row_id": 1662001, "text": "MICU Nursing Progress Note 0700-1100\n\nCode: Full\nAllergies: Aldactone\n\nReceived pt in no apparent distress, and oriented x 3, hemodynamically stable, swtiched over to trach mask and tolerating well. One medium guiac positive stool. Foley patent and draining adequate UO. No contact from family. DC'd to rehab.\n" }, { "category": "ECG", "chartdate": "2200-02-03 00:00:00.000", "description": "Report", "row_id": 218505, "text": "Sinus tachycardia with atrial and ventricular ectopy. Right ventricular\nconduction delay. Rightward axis. Compared to the previous tracing of \nthere is frequent ventricular ectopy and atrial ectopy. Otherwise, no\ndiagnostic interim change.\n\n" } ]

[ { "category": "ECG", "chartdate": "2121-10-31 00:00:00.000", "description": "Report", "row_id": 186207, "text": "Baseline artifact\nSinus rhythm\nAtrial premature complexes\nRight bundle branch block\nNo previous tracing available for comparison\n\n" }, { "category": "Radiology", "chartdate": "2121-10-31 00:00:00.000", "description": "ERCP BILIARY ONLY BY GI UNIT", "row_id": 932130, "text": " 4:09 PM\n ERCP BILIARY ONLY BY GI UNIT Clip # \n Reason: R/O CBD stone\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with cholangitis. H/O previous ERCP with sphincterotomy in\n . Recommend CCY but never had surgery.\n ERCP performed , req sent \n REASON FOR THIS EXAMINATION:\n R/O CBD stone\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old man with cholangitis.\n\n ERCP: Twelve ERCP images were obtained by Dr. . Cholangiogram\n demonstrates prominent dilatation of the common duct. Multiple rounded\n filling defects are observed consistent with stones. Final image demonstrates\n placement of a plastic biliary stent. Note is made of multiple lumbar pedicle\n screws. The patient is also status post lumbar laminectomies.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-10-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 931491, "text": " 5:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for ETT placement\n Admitting Diagnosis: COMMON BILE DUCT STONE\\ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with s/p intubation during procedure\n REASON FOR THIS EXAMINATION:\n assess for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old man status post intubation during ERCP with suction\n of bilious fluid. Evaluate endotracheal tube placement.\n\n COMPARISON: None.\n\n AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: An endotracheal tube is positioned 4 cm\n above the carina. A curvilinear opacity at the right lung base may be\n associated with an obtructed righ bronchus. The cardiac silhouette is upper\n limits of normal. The aorta contains intramural calcifications. There is no\n pneumothorax. Linear atelectasis is seen at the left lung base. The\n surrounding soft tissues demonstrate interpedicular screws and a mid lumbar\n vertebral body.\n\n IMPRESSION: Right lower lung consolidation, possibly associated with\n obstruction of the right-sided bronchus. Further evaluation with CT is\n recommended.\n\n These findings were discussed with Dr. at 6:15 p.m. on\n .\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-01 00:00:00.000", "description": "Report", "row_id": 1456709, "text": "MICU nursing progress note 7P-7A\nPt is 81 yo male transferred from OSH-> for emergent ERCP for ascending cholangitis. Pt presented to OSH with fever/chills /nausea.BC x 1 bottle + e-coli. ^^ LFTs. US showed dilated intra- and extra- hepatic bile ducts. ? sepsis d/t biliary Dx. During ERCP @ , pt sedated with versed, fentanyl, phenergan. Became lethargic, dropped sats/RR. Narcan with no change. Intubated for airway protection. Biliary duct stented. Tx MICU on propofol gtt. In MICU, propofol gtt titrated off, pt woke up, + commands. Weaned from vent, extubated without incident. PMHx - asthma, GERD, arthritis, hiatal hernia, anemia ?iron deficiency, ^ cholesterol, laminectomy, ERCP .\n\nNeuro - A&O x 3. MAE, stands at bedside to void in urinal. Denies pain. Using call light appropriately.\n\nResp - Lungs clear, diminished at bases. No resp distress. On MDIs. Sats 98% 2L NC.\n\nCV - NBP 119-144/55-69. NSR 70s with frequent PACs. K 3.0. 40meq IV -repeat K 3.3, will need further repletion.\n\nGI - NPO. Abd soft, +BS. No flatus/stool. LFTs trending down.\n\nGU - Voiding QS in urinal dark yellow urine.\n\nID - Afebrile. Levoflox IV.\n\nSocial - Married, wife is retired RN. Pt is retired microbiologist.\n\nPlan - IV antibx for e-coli. NPO until discussed with GI whether to advance diet. ? c/o to floor.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-01 00:00:00.000", "description": "Report", "row_id": 1456710, "text": "pmicu progress and transfer note\ngi: abdomin soft with + bowel sounds. pt denies any abdominal pain or tenderness. tolerating clear liquids without difficulty, although is having loose brown stools--?? from antibiotic. lfts improving.\n\ncardiac: bp 123-165/46-72 with a pulse of 77-86 sr, occasional pacs and pvcs. given 40 meq of kcl po. denied any chest pain.\n\nresp: room air sats of 97-99%. pt did get sob with physical activity and with speaking. placed on 2l nasal prongs when washing pt up as he appeared slightly sob. lung sounds clear in the upper lobes and deminished in the bases.\n\nid: temps of 98.1po and 98po. on levo. prior to discharge pt was given prescription for antibiotic and paperwork, with correct and pertinent info, from doctor and nurse if pt were to have problems. 2 cx bottles [positive for e.coli out of 6.\n\ngu: pt used urineal without difficulty. urine was clear and yellow.\n" }, { "category": "Nursing/other", "chartdate": "2121-10-31 00:00:00.000", "description": "Report", "row_id": 1456707, "text": "Nursing Note:\npt arrived in MICU/SICU from endoscopy at 1645, pt intubated, sats 100, vitals stable, sedated on propofol drip, accompainied by endoscopy RN and anesthesia, report received, foley cath inserted, titrating down propofol drip, plan to extubate pt when awake, assessment ongoing.\n" }, { "category": "Nursing/other", "chartdate": "2121-10-31 00:00:00.000", "description": "Report", "row_id": 1456708, "text": " Care\nPt vent settings weaned to minimal settings. MDI Albuterol given for wheezing and diminished BS. Increased aeration and corrected wheezing after MDI puffs given. Pt then extubated to 60% cool aerosol face-mask. Cuff leak heard prior to removing tube. Pt tolerated extubation well. BS coarse/diminished at lung bases. SpO2=98%. Pt now weaned to 40% face mask. MDI Albuterol and Atrovent will continue as well as Advair to be given by RN.\n" } ]

[ { "category": "Echo", "chartdate": "2148-03-13 00:00:00.000", "description": "Report", "row_id": 98657, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function.\nHeight: (in) 64\nWeight (lb): 300\nBSA (m2): 2.33 m2\nBP (mm Hg): 120/70\nHR (bpm): 89\nStatus: Outpatient\nDate/Time: at 09:46\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 systolic function\n(LVEF>55%). Normal regional LV systolic function.\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 with trivial MR. Normal LV inflow\npattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n\n\n" }, { "category": "ECG", "chartdate": "2148-03-11 00:00:00.000", "description": "Report", "row_id": 273978, "text": "Baseline artifact. Sinus tachycardia. Diffuse non-specific T wave changes.\nSince the previous tracing of there may be no significant change but\nbaseline artifact makes comparison difficult.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2148-03-11 00:00:00.000", "description": "Report", "row_id": 273979, "text": "Sinus tachycardia. Modest diffuse non-specific T wave changes. Since the\nprevious tracing of sinus tachycardia and diffuse T wave changes are\npresent.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2148-03-12 00:00:00.000", "description": "Report", "row_id": 1440281, "text": "Resp Care Note:\n\nPt seen for med neb with standard dose ALB/ATR via HHN. Lung sounds sl I/E wheeze changing to diffuse I/E wheeze with exertion. Pt also on CPAP @ 9cmH2O overnoc. Cont present regime.\n" }, { "category": "Nursing/other", "chartdate": "2148-03-12 00:00:00.000", "description": "Report", "row_id": 1440282, "text": "NPN 7A-7P\n\n\nNEURO: PT /OX3. DENIES PAIN. ABLE TO MAE.\n\nRESP: NOW ON RA.02 SAT 100%. COUGHING UP CLEAR SPUTUM AT TIMES. WITH ACTIVITY SOB NOTED.HR Q4 PRN ALSO MDI.AT TIMES SHE DOES HAVE A SHARP PAIN UNDER HER RIGHT SIDE OF CHEST WITH DEEP BREATH.\n\nCV: NSR NO ECTOPY NOTED. B/P 120/70 HR 80-90.\n\nGI/GU: DIABETIC DIET TOL WELL. GOOD PO FLUID INTAKE. ABD OBESE WITH +BS. NO BM. OOB TO VOID.\n\nSKIN: INTACT.\n\nPOC: CALLED OUT.\n" }, { "category": "Nursing/other", "chartdate": "2148-03-12 00:00:00.000", "description": "Report", "row_id": 1440280, "text": "Smicu nsg admission note\nVery pleasant 43 yo woman with hx asthma on long-term prednisone with freq previous admissions admitted again for asthma exacerbation. See fhpa for detail pmh/hpi.\nR.O.S\nResp- Admitted on 2l np with sats 96-97%. Lung with inspir/expir wheezing thoughout although with good air movement. Pt does become sob with audible wheezing with activity but settles when resting. Recieving neb tx q2hrs. Productive cough clear white secretions. Place on cpap of 9 (which pt uses at home). Tolerated without problem. Pt also on droplet percautions. Will need nasal aspir in am.\n\nCardiac- Bp and hr stable. Pt denies cp. Ekg without change. Voiding in commode.\n\nNeuro- Denies pain. Alert oriented and cooperative.\n\nGi- Taking po's without problem. Pt on ss insulin. Given 10u reg sq per ss. Will recheck and give insulin as needed.\n\nPlan- Follow resp status. Nebs as needed. R/o influenza. Increase activity as tolerated. Follow bs/fs.\n" } ]

[ { "category": "Radiology", "chartdate": "2100-12-26 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 774260, "text": " 11:28 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: preop cabg\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with cad\n REASON FOR THIS EXAMINATION:\n preop cabg\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Preop CABG.\n\n PA AND LATERAL CHEST: The heart size is normal. No evidence for CHF. The\n lungs are clear. There is flattening of the diaphragms. No change since prior\n study of .\n\n IMPRESSION: Probable COPD. No evidence for CHF or pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-17 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 773679, "text": " 3:59 PM\n CHEST (PA & LAT) Clip # \n Reason: pt c/o chest pain\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with\n REASON FOR THIS EXAMINATION:\n pt c/o chest pain\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain.\n\n CHEST, PA AND LATERAL: The cardiac, mediastinal and hilar contours are\n unremarkable. The lungs are clear. The pulmonary vasculature is normal. The\n soft tissue and osseous structures are unremarkable.\n\n IMPRESSION: Normal radiographic appearance of the chest.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-31 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 774677, "text": " 11:13 AM\n CHEST (PA & LAT) Clip # \n Reason: R arm picc line for IV abx. Please page with wet read\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with cad\n REASON FOR THIS EXAMINATION:\n R arm picc line for IV abx. Please page with wet read as soon as\n available. Thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: PICC line.\n\n Comparison is made to previous films from .\n\n PA AND LATERAL CHEST: There is mild cardiomegaly. Compared to the previous\n exam, the mediastinum is slightly widened which is likely related to recent\n CABG. The right PICC tip is in the distal SVC. There is no evidence of\n vascular congestion. There is minimal blunting of the CP angles bilaterally\n consistent with small bilateral pleural effusions. Linear opacities in the\n left mid lung zones are likely related to a small amount of fluid in the\n fissure and/or atelectasis.\n\n IMPRESSION: Right PICC tip in the distal SVC.\n\n" }, { "category": "Nursing/other", "chartdate": "2100-12-28 00:00:00.000", "description": "Report", "row_id": 1522812, "text": "PT UPDATE\n PT IS S/P CABG X2 .\n\n NEURO: PT IS A&O X3. VERY PLEASANT AND COOPERATIVE.\n\n RESP: BS CLEAR, SOMEWHAT DECREASED IN BASES. USING IS WITH ENCOURAGEMENT. PT HAS GOOD STRONG COUGH. NP WEANED TO 2L WITH SATS 97-98.\n\n CARDIAC: HR 90'S. SR. MILRINONE WEANED OFF AT 11:15. CI REMAINS 2.5. PT SOMEWHAT HYPERTENSIVE THIS AM-MAP 100. PT STARTED ON CAPTOPRIL THIS AM. SBP 120-130 RANGE SINCE THEN. ?PA LINE TO BE D/C'D LATER THIS AFTERNOON IF CI REMAINS GOOD.\n\n GU: PT SPONTANEOUSLY DIURESING THIS AFTERNOON-300CC/HR RANGE-HAS NOT RECEIVED LASIX. WEIGHT THIS AM INACCURATE-WILL RECALIBRATE BED BEFORE PT GETS BACK IN.\n\n GI: NO FURTHER C/O N/V. APPETITE ONLY FAIR-TAKING FLUIDS W/O DIFFICULTY; BUT NOT EATING MUCH. HYPOACTIVE BS THIS AFTERNOON.\n\n LAB: K, HCT STABLE. BS UP TO 200 THIS AFTERNOON-SS COVERAGE.\n\n OTHER: PT ASSISTED WELL GETTING UP; BUT SOMEWHAT UNCOMF. IN CHAIR-ENCOURAGED TO STAY UP FOR AT LEAST AN HOUR. PT STARTED ON TORADOL FOR PAIN-STATES GOOD RESPONSE. PT TAKES PERCOCET FOR CHRONIC BACK PAIN AT HOME; BUT DOES NOT WANT THIS YET AS HE IS NOT EATING MUCH. STATES HE IS FAIRLY COMF AT THIS TIME. TO CONT ON VANCO FOR MRSA IN RT ANTECUB. WOUND; AREA IS SUTURED AND CLOSED WITH NO DRG. DSD CHANGED. CT'S D/C'D. PT DOING WELL; BUT IS TO STAY IN CSRU FOR TONIGHT SINCE MILRINONE NOT OFF UNTIL 11A.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-28 00:00:00.000", "description": "Report", "row_id": 1522813, "text": "PT UPDATE\n SINCE 1745-PT HAVING PAC'S-? TO GO INTO AFIB. RX WITH 2 GM MG. PT ALSO GIVEN 2.5MG IV LOPRESSOR AS ORDERED. THEN PT STARTED TO HAVE FREQUENT PVC'S WITH COUPLETS. TEAM HAD MADE ROUNDS WHEN ECTOPY STARTED (MG AND LOPRESS ORDERED). DR. CALLED AND IN TO SEE PT. ECTOPY MUCH DECREASED AFTER LOPRESSOR GIVEN. K ALSO HUNG. LABS SENT AND PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-29 00:00:00.000", "description": "Report", "row_id": 1522814, "text": "neuro: Alert and oriented without complaints. mae to command. denies pain and still recieves toradol.\ncv/resp no issues, No ectopy nsr. o2 sats good. lungs clear.\ngi/gu foley remains in place. clear yellow urine. q.s.no stools.\ninteg skin intact plan transfer to floor today. D/c lines for transfer..\n" }, { "category": "Nursing/other", "chartdate": "2100-12-27 00:00:00.000", "description": "Report", "row_id": 1522810, "text": "S/P CABG X2\n\"IT'S NOT THAT BAD\", \"I WILL TAKE CARE OF MYSELF\"\nO: CARDIAC: SR-ST WITH RARE PVC NOTED @ 2200. RECIEVED LR FOR ST 110'S WITH GOOD EFFECT, DOBUT DECREASED WITH CI>2. DOBUT OFF WITH DECREASE IN CI<2 THEREFORE RESTARTED 500 HESPAN AND CHANGED TO MILRINONE. WITH MILRINONE BOLUS ST 130' AND SBP 80'S RESOLVED SR80'S-90'S. MILRINONE @ .25 MCQ WITH 2200 CI 2.18. SBP 100'S, TRANSIENT NTG WITH AGITATION. PAD'S 20'S WITH FLUID, CVP 15-21. MINIMAL CT DRAINAGE- INR UPON ARRIVAL 2.3 NP NILLSON AWARE AND NO TREATMENT UNLESS BLEEDING, NO REPEAT COAGS ORDERED. DSGS D+I. HCT 29-34-30. K 3.8 RECIEVED 40 MEQ WITH K 5.7-5. CA AND MAG REPLACED. DOPP PP.\n RESP: EXTUBATED @ 1745 WITHOUT INCIDENT, 50% FACE TENT WITH O2 SATS >98%. DB +IS WELL FAIR COUGH. RR TEENS. GOOD ABG POST EXTUBATION.\n NEURO: PLEASANT, CALM, ORIENTED TO PERSON AND PLACE. PRIOR TO EXTUBATION PT TRYING TO GET OOB, PRECEDEX WITH GOOD EFFECT. PERL, GRASPS EQUAL AND STRONG. MAE. FOLLOWS COMMANDS.\n GI: HAS NOT TAKING PO YET, DENIES NAUSEA. ABD FIRM BUT PT STATES THIS IS THE WAY HIS ABD IS. ABSENT BOWEL SOUNDS.\n GU: GOOD UO. CREAT 1.1\n ID: VANCO 1 GM @ , TO CONTINUE PAST 4 DOSES TO TREAT PHLEBITIS.LEFT ANTECUBITAL AREA RED AND HARD SLIGHTLY WARM. NS WASH AND DSD APPLIED.\n PAIN: MSO4 WITH FAIR EFFECT CHANGED TO DILAUDID - RECIEVED .5 MG IV @ 2200.\n SOCIAL: I HAVE NOT SPOKEN TO ANY FAMILY PT STATES HE DOES NOT HAVE ANYONE TO HELP HIM AT HOME\"I WILL TAKE CARE OF MYSELF\"\n ENDO: REQUIRED INSULIN GTT , PRESENTLY @ 6 UNITS/HR.\n SKIN : AS ABOVE OTHERWISE INTACT.\nA: REQUIRING MILRINONE, INSULIN, PLEASANT AT PRESENT.PAD'S 20'S\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, CI, PP, DSGS, PA#,CT DRAINAGE, RESP STATUS-PULM TOILET, NEURO STATUS, I+O, LABS - GLUCOSE Q 1HR,AS PER ORDERS.\n\n" }, { "category": "Nursing/other", "chartdate": "2100-12-28 00:00:00.000", "description": "Report", "row_id": 1522811, "text": "NEURO: A&OX3. MAE. FOLLOWS COMMANDS.\nCV: CONT ON MILRINONE .25MCG. CI>2. BP 110-130/70 HR 80-90'S NO ECTOPY NOTED. FEM ALINE D/C'D 0530. CT->SX NO LEAK MIN SERO DRNG. 2A 2V WIRES ON AD 60.\nRESP: 4L NC. SATS >95% USING IS W/ ENCOURAGEMENT. NEEDS ENCOURAGEMENT C/DB. WEAK COUGH.\nGI/GU: U/O>30CC/HR. C/O NAUSEA OVERNIGHT. RECEIEVED REGLAN W/ NO EFFECT. VOMITED SM AMT BILIOUS EMESIS. ZOFRAN W/ EFFECT. NO TAKING PO'S YET.\nSKIN: STERNAL DSG INTACT. LT LEG RE-ACED. LEFT FOREARM CELLULITIS SITE C/D/I.\nPAIN: RECIEVED DIDLAUDID 1.5 MG IV W/ GOOD RELEIF OF STERNAL INC PAIN.\nENDO: INSULIN GTT OFF AT 0200 FOR BS 57. BS 126 AT 0500 RECIEVED 3UREG SC.\nPLAN: CONT TO ASSESS CARDIO/RESP STATUS. ? D/C MILRINONE THIS AM. FOLLOW BS. ADV DIET AS TOL. ? OOB WHEN ABLE.\n" }, { "category": "Radiology", "chartdate": "2100-12-23 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1260380, "text": " 6:47 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with Myocardial infarction\n REASON FOR THIS EXAMINATION:\n Any CHF or infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MI.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST: The heart size is within normal limits. The aorta is\n mildly tortuous. There is no evidence of vascular congestion, pleural\n effusions, or focal consolidations. No pneumothorax.\n\n IMPRESSION: No evidence of CHF or pneumonia.\n\n" }, { "category": "ECG", "chartdate": "2100-12-18 00:00:00.000", "description": "Report", "row_id": 171829, "text": "Sinus rhythm\n - frequent multifocal PVCs\n - supraventricular extrasystoles\nLead(s) unsuitable for analysis: V6\nInferior infarct - age undetermined\nProbable anterolateral infarct - age undetermined\nSince last ECG, Q waves in leads V3-V6 Consistent with anterolateral wall\nmyocardial infarct - new from previous\n\n" }, { "category": "ECG", "chartdate": "2100-12-27 00:00:00.000", "description": "Report", "row_id": 171826, "text": "Poor quality tracing. Probable sinus tachycardia. Since the previous tracing\nof wide complex beats are no longer seen. R wave progression is\nimproved and may be related to lead position.\n\n" }, { "category": "ECG", "chartdate": "2100-12-17 00:00:00.000", "description": "Report", "row_id": 171827, "text": "Sinus rhythm\n - bigeminal PVCs\nInferior infarct - age undetermined\nPossible old anterior infarct\n\n" }, { "category": "ECG", "chartdate": "2100-12-17 00:00:00.000", "description": "Report", "row_id": 171828, "text": "Sinus rhythm\nInferior infarct - age undetermined\nPossible anterior infarct - age undetermined\n Lateral T wave changes offer additional evidence of ischemia\nSince last ECG, Lateral T wave changes more pronounced\n\n" } ]

[ { "category": "Radiology", "chartdate": "2175-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 739434, "text": " 6:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p open heart surgery-to look for mediastinal widening\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with CABG\n REASON FOR THIS EXAMINATION:\n s/p open heart surgery-to look for mediastinal widening\n ______________________________________________________________________________\n FINAL REPORT\n\n AP CHEST RADIOGRAPH .\n\n INDICATION: Status post open heart surgery with question of mediastinal\n widening.\n\n COMPARISON: PA and lateral chest radiographs from earlier the same day.\n\n FINDINGS: There are new midline sternal wires and surgical clips. An NG tube\n extends into the stomach. There is a new right-sided central venous line, the\n tip of which appears to be in the right main pulmonary artery but is not\n clearly visualized. No pneumothorax is present. There is an endotracheal\n tube situated 6 cm from the carina. There is partial collapse of the left\n lower lobe with air bronchograms superior to this region, consistent with\n developing consolidation. No large pleural effusions are identified.\n\n IMPRESSION:\n 1. Endotracheal tube in expected position. There is a PA catheter whose tip\n is not clearly visualized but which appears to be in the main pulmonary\n artery. There is no pneumothorax.\n 2. Partial collapse of the left lower lobe with overlying consolidation\n consistent with developing pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2175-07-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 739455, "text": " 7:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval pt s/p cabg w/ desatting occassionally\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with CABG\n REASON FOR THIS EXAMINATION:\n please eval pt s/p cabg w/ desatting occassionally\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG, desaturation.\n\n PORTABLE AP UPRIGHT CHEST: Compared with 5/26, there has been marked interval\n improvement with apparent decrease in size of the bilateral right greater than\n left pleural effusions and clearing of left-sided CHF. There is patchy\n streaky right infrahilar opacity consistent with atelectasis, although a\n pulmonary infiltrate cannot be excluded.\n\n The distal portion of the right IJ line (?Swan-Ganz?) cannot be followed\n beyond the level of the mid right atrium.\n\n" }, { "category": "Radiology", "chartdate": "2175-07-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 739448, "text": " 1:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABGx3, respiratory distress with temperatures, acidemia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with CABG\n REASON FOR THIS EXAMINATION:\n s/p CABGx3, respiratory distress with temperatures, acidemia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CABG x 3. Respiratory distress with ---- acidemia.\n\n PORTABLE AP CHEST: Comparison to portable chest dated .\n\n Evaluation is limited by body habitus and technique. Mediastinal surgical\n clips and wires are again noted. The ET tube has been removed. There is a\n right sided swan ganz catheter. Its tip is not well visualized beyond the main\n pulmonary artery. There is cardiac enlargement. There is opacification of the\n right hemithorax. Appearance is consistent with layering pleural effusion and\n alveolar process. Underlying infectious process cannot be excluded. There is a\n small left pleural effusion.\n\n IMPRESSION:\n 1. Swan ganz catheter with tip in right pulmonary artery, tip not well\n visualized beyond the main pulmonary artery.\n 2. Stable cardiac enlargement.\n 3. Rapid interval increase in layering right pleural effusion. Though the\n imaging characteristics are nonspecific, the rapid development raises the\n possibility of a hemothorax. There is a small left pleural effusion.\n 4. Diffuse alveolar process in right lung. Underlying infectious process\n cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2175-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 739436, "text": " 9:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: to look for mediastinal widening\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with CABG\n REASON FOR THIS EXAMINATION:\n to look for mediastinal widening\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, SINGLE AP FILM.\n\n HISTORY: CABG.\n\n S/P CABG. ET tube is 7 cm above carina. Distal end of cv line is in region\n of cavo-atrial junction or could be in upper right atrium. NG tube is present\n but distal end cannot be delineated on this film. There is cardiomegaly. The\n mediastinum is widened, but allowing for technical differences, probably\n unchanged since previous film of . The diaphragms are obscured, likely\n secondary to atelectasis/consolidation in the left lower lobe. No\n pneumothorax and no evidence for CHF/pulmonary edema.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2116-10-19 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1216664, "text": " 8:01 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: post subclavian\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with cardiac arrest post line placement\n REASON FOR THIS EXAMINATION:\n post subclavian\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, single supine AP portable view.\n\n CLINICAL INFORMATION: 70-year-old female with history of cardiac arrest\n post-line placement.\n\n COMPARISON: 11/21/2011at 19:06.\n\n FINDINGS: Single supine AP portable view of the chest was obtained. Interval\n placement of a left subclavian central venous catheter terminating in the\n mid-to-distal SVC. Ovoid lucency projecting over the left lower hemithorax is\n again seen, unchanged in size, represent loculated pneumothorax versus less\n likely a bulla on subsequent chest CT. There has been interval increase in\n right pulmonary opacity. Mild left pulmonary opacity is grossly stable.\n There is blunting of bilateral costophrenic angles, suggesting pleural\n effusions. Cardiac and mediastinal silhouettes are stable and unremarkable.\n Endotracheal tube remains approximately 1 cm above the carina and should be\n withdrawn approximately 3-4 cm. The endotracheal tube balloon appears\n hyperinflated. A nasogastric tube is again seen coursing below the diaphragm,\n in standard expected position of the stomach.\n\n IMPRESSION:\n 1. Low-lying endotracheal tube, suggest withdrawal by at least 3-4 cm. This\n finding was discussed with at approximately 8:20 p.m. on\n via telephone.\n 2. Interval placement of a left subclavian central venous catheter\n terminating in the mid-to-distal SVC without evidence of new pneumothorax.\n Lucency overlying the left lower hemithorax is stable in size since the prior\n study and found to represent loculated pneumothorax versus less likely a\n bulla.\n 3. Slight interval increase in right pulmonary opacity. Stable mild left\n pulmonary opacity. Blunting of the bilateral costophrenic angles suggest\n pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2116-10-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1216665, "text": " 8:08 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evidence of ICH?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with post arrest,\n REASON FOR THIS EXAMINATION:\n evidence of ICH?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: OXZa MON 9:31 PM\n no acute intracranial process\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post-cardiac arrest.\n\n TECHNIQUE: Multidetector CT scan of the head was obtained without the\n administration of contrast. Coronal and sagittal reformations were prepared.\n\n COMPARISON: None available.\n\n FINDINGS: There is no evidence of acute hemorrhage, edema, mass effect, or\n recent infarction. The ventricles and sulci are age appropriate in\n appearance. Areas of periventricular and subcortical white matter hypodensity\n likely reflect sequela of chronic small vessel ischemic disease. No\n concerning osseous lesion or fracture is identified. There are air-fluid\n levels within the nasopharynx and mild mucosal thickening of the ethmoid air\n cells, compatible with intubation. The mastoid air cells are grossly clear.\n There is minimal mucosal thickening of the right maxillary sinus.\n\n IMPRESSION: No evidence of acute intracranial process.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-10-19 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1216666, "text": " 8:08 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evidence of PE?\n Field of view: 34 Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with post arrest,\n REASON FOR THIS EXAMINATION:\n evidence of PE?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: OXZa MON 9:33 PM\n 1. massive dependent consolidation consistent with aspiration. pulmonary\n edema.\n 2. small loculated left basilar pneumothorax\n 3. low-lying ETT with tip at carina\n 4. left thyroid enlarged\n 5. non-displaced sternal fracture\n 6. large ETT balloon\n 7. no PE\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post-cardiac arrest.\n\n TECHNIQUE: Multidetector helical CT scan of the chest was obtained before and\n after the administration of 100 mL IV Optiray contrast. Coronal, sagittal,\n and oblique reformations were prepared.\n\n COMPARISON: None available.\n\n FINDINGS: There are massive bilateral dependent consolidations.\n Additionally, within the aerated portions of the lungs, there are bilateral\n ground-glass opacities extending from the hila. Additional nodular opacities\n are likely related to acute process, though no prior exams are available for\n comparison.\n\n A small amount of free air is noted along the left base. While this is not\n clearly localized, there is suggestion on coronal images (601B:24-26) that the\n collection is above the diaphragm and within the pleural space.\n\n The pulmonary arterial tree is well opacified and no filling defect to suggest\n pulmonary embolism is seen. No evidence of acute aortic syndrome is\n identified. There are coronary artery calcifications. No pericardial\n effusion is seen.\n\n The patient is intubated with the endotracheal tube tip low lying at the level\n of the carina. Additionally, the balloon of the endotracheal tube appears\n hyperinflated.\n There is a left-sided subclavian central venous catheter with tip reaching the\n SVC.\n\n An esophageal catheter is in place, incompletely imaged; however, coursing to\n (Over)\n\n 8:08 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evidence of PE?\n Field of view: 34 Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the stomach at least.\n\n No lymphadenopathy is identified.\n\n The left thyroid lobe is enlarged. Limited views of the upper abdomen\n demonstrate at least two calcified splenic artery aneurysms.\n\n Bone windows demonstrate a nondisplaced sternal fracture (602B:34), which may\n be related to chest compressions.\n\n IMPRESSION:\n 1. Massive bilateral dependent consolidations, compatible with aspiration.\n Ground-glass opacities consistent with pulmonary edema.\n 2. Air collection at the left base felt more likely above the diaphragm\n representing small pneumothorax vs bulla as opposed to contained within the\n peritoneum. In comparison with prior radiographs of the chest, it appears this\n was present prior to placement of central line.\n 3. Low-lying endotracheal tube with tip at the level of the carina and\n hyperinflation of the endotracheal tube balloon.\n 4. Enlargement of the left thyroid lobe.\n 5. Non-displaced sternal fracture may be related to chest compressions.\n\n" }, { "category": "Radiology", "chartdate": "2116-10-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1216829, "text": " 12:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for worsening pneumothorax\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p CPR, pneumothorax seen on previous CXR, now with\n increasing O2 requirement\n REASON FOR THIS EXAMINATION:\n Please eval for worsening pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:03 A.M. \n\n HISTORY: Possible pneumothorax. Increasing hypoxia.\n\n IMPRESSION: AP chest compared to through 22:\n\n There is no longer any indication of pneumothorax. Severe pulmonary\n opacification has worsened progressively since consistent with\n pulmonary edema. In the setting of normal heart size this is probably\n noncardiogenic despite small-to-moderate left pleural effusion. As before,\n the cuff of the endotracheal tube is severely over-distended. Tip of the tube\n is no more than 18 mm from the carina and should be withdrawn 2 cm for\n standard positioning. Left subclavian line ends in the mid SVC. Nasogastric\n tube passes below the diaphragm and out of view.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-10-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1216660, "text": " 7:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute cp process?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with card arrest\n REASON FOR THIS EXAMINATION:\n acute cp process?\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, single AP portable view.\n\n CLINICAL INFORMATION: 70-year-old female with history of cardiac arrest.\n\n COMPARISON: None.\n\n FINDINGS: AP supine portable view of the chest was obtained. The\n endotracheal tube is low in position, terminating approximately 1 cm above the\n level of the carina and should be withdrawn by at least 2 cm. The\n endotracheal tube balloon appears overinflated. Nasogastric tube is seen\n coursing below the level of the diaphragm, extending to the expected position\n of the stomach. There are right greater than left pulmonary opacities. There\n may be a small left pleural effusion. The cardiac silhouette is not enlarged.\n The aorta is calcified and tortuous. Prominence of the central vasculature\n suggests a component of pulmonary edema. Lucency projecting over the left\n lower hemithorax is seen to represent a likely loculated pneumothorax vs less\n likely bulla on subsequent chest CT.\n\n IMPRESSION:\n 1. Low-lying endotracheal tube terminates just above the carina. Recommend\n withdrawal by approximately 3 cm. Above findings were discussed with Dr.\n at approximately 8:20 p.m. on via telephone.\n 2. Lucency projecting over the left lower hemithorax represents likely\n loculated pneumothorax, less likely bulla on subsequent chest CT.\n 3. Bilateral pulmonary opacities may be due to aspiration and edema, although\n underlying contusion cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2116-10-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1216677, "text": " 1:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p cardiac arrest\n REASON FOR THIS EXAMINATION:\n Please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:10 A.M., \n\n HISTORY: 72-year-old woman after cardiac arrest.\n\n IMPRESSION: AP chest compared to :\n\n Cuff of the ET tube is no longer hyperinflated. Tip of the tube is\n approximately 2 cm above the carina, and could be withdrawn 15 mm to ovoid\n inadvertent unilateral intubation. Widespread pulmonary edema is improving,\n but the lung bases, particularly the right, remain densely consolidated.\n There is only a small volume of pleural fluid, unchanged, and the elliptical\n lucency projecting over the left diaphragmatic region has been a constant\n feature since . This is a loculated collection of air whether it\n is in the pleural or extra-pleural space and does not warrant evacuation.\n Heart size and mediastinal contours are normal. Left subclavian line ends in\n the mid SVC, nasogastric tube coils in a non-distended stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-10-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1216734, "text": " 10:56 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval for interval change\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p PEA arrest on cooling protocol, with high peak\n inspiratory pressures.\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH:\n\n INDICATION: evaluation for interval change.\n\n COMPARISON: , 2:10 a.m.\n\n FINDINGS: As compared to the previous radiograph, there is a reduction in\n lung volumes and an increase in pleural effusions. In addition, the lung\n parenchyma appears essentially denser on the right. This could reflect\n increasing pulmonary fluid overload. The areas of atelectatic regions the\n lung bases have increased in extent. The monitoring and support devices are\n unchanged.\n\n At the time of dictation, the referring physician, , was paged\n for notification at 11:33 a.m., .\n\n" }, { "category": "Echo", "chartdate": "2116-10-20 00:00:00.000", "description": "Report", "row_id": 93748, "text": "PATIENT/TEST INFORMATION:\nIndication: Cardiac Arrest assess LV/RV Function\nHeight: (in) 64\nWeight (lb): 145\nBSA (m2): 1.71 m2\nBP (mm Hg): 101/89\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 14:17\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -\nhypo; septal apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Focal apical hypokinesis of RV\nfree wall.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or\nelectrodes. Suboptimal image quality as the patient was difficult to position.\nSuboptimal image quality - body habitus. Suboptimal image quality -\nventilator.\n\nConclusions:\nLeft ventricular wall thicknesses and cavity size are normal. There is mild\nregional left ventricular systolic dysfunction with distal septal hypokinesis.\nThe remaining segments contract normally (LVEF = 45%). The right ventricular\ncavity is moderately dilated with focal hypokinesis of the apical free wall.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis or aortic regurgitation. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+)\nmitral regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Dilated right ventricle with mild systolic dysfunction. Mild\nregional left ventricular systolic dysfunction. Mild mitral regurgitation.\nModerate pulmonary hypertension.\n\n\n" }, { "category": "ECG", "chartdate": "2116-10-19 00:00:00.000", "description": "Report", "row_id": 248662, "text": "Sinus rhythm with atrial premature beats. Incomplete right bundle-branch\nblock. Consider right ventricular hypertrophy. Generalized low QRS voltage.\nNo previous tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2200-07-10 00:00:00.000", "description": "B HAND, AP & LAT. VIEWS BILAT", "row_id": 1142525, "text": " 9:39 PM\n HAND, AP & LAT. VIEWS BILAT Clip # \n Reason: eval for fx\n Admitting Diagnosis: FACIAL TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man s/p trauma\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old man status post trauma.\n\n COMPARISON: None.\n\n TWO VIEWS RIGHT HAND: Evaluation is limited by overlying gauze. There is no\n fracture or dislocation. -like radiopacities overlie the distal ulna\n seen only on the frontal view. This may represent artifact or foreign bodies.\n Clinically correlate.\n\n THREE VIEWS, LEFT WRIST: There is no acute fracture or dislocation. Two\n -like radiopacities overlie the first web interspace. They are only seen\n on the frontal view and likely represent artifact. This should be clinically\n correlated. There is soft tissue swelling adjacent to the distal radius.\n\n Findings discussed with , the RN on .\n\n" }, { "category": "Radiology", "chartdate": "2200-07-10 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 1142469, "text": " 3:11 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: Eval for trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with facial trauma\n REASON FOR THIS EXAMINATION:\n Eval for trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:42 PM\n No acute facial bone fracture.\n Right fronto-parietal scalp hematoma, left periorbital scalp hematoma.\n Globes intact.\n Soft tissue laceration anterior to the left maxilla, with some punctate foci\n of hyperdensity may represent foreign body.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old man with facial trauma.\n\n COMPARISON: No prior studies available.\n\n TECHNIQUE: Contiguous axial images were acquired through the facial bones\n without intravenous contrast. Sagittal and coronal reformats were generated\n and reviewed.\n\n FINDINGS: No acute facial bone fracture is detected. Right frontoparietal\n and left periorbital scalp hematoma is present. Soft tissue laceration is\n seen in the left maxillary and mandibular region. Punctate foci of\n hyperdensity in the region of laceration(3:130, 3:77 and 3:72, 3:53) may\n represent foreign bodies. Recommended clinical correlation. The globes are\n intact. Mild mucosal thickening in the right maxillary sinus and secretions\n in the nasopharynx likely relate to the endotracheal intubation\n\n IMPRESSION:\n 1. No acute facial bone fracture detected.\n 2. Globes are intact.\n 3. Soft tissue laceration in the left periorbital, maxillary and mandibular\n regions with hyperdense foci, could represent foreign bodies. Recommended\n clinical correlation.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-07-10 00:00:00.000", "description": "R SHOULDER 1 VIEW RIGHT", "row_id": 1142527, "text": " 10:00 PM\n SHOULDER 1 VIEW RIGHT Clip # \n Reason: s/p fall\n Admitting Diagnosis: FACIAL TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with bruised and swollen right shoulder\n REASON FOR THIS EXAMINATION:\n s/p fall\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old man with fall.\n\n COMPARISON: Chest radiograph .\n\n SINGLE FRONTAL VIEW, RIGHT SHOULDER: There is a comminuted fracture through\n the distal clavicle with minimal superior displacement of the distal fracture\n fragment. The acromioclavicular joint appears intact.\n\n On this limited view of the humeral head there is no fracture.\n\n An endotracheal tube and nasogastric tube are noted.\n\n IMPRESSION: Comminuted minimally displaced right distal clavicle fracture.\n\n" }, { "category": "Radiology", "chartdate": "2200-07-10 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1142458, "text": " 2:33 PM\n TRAUMA #3 (PORT CHEST ONLY); CHEST (PORTABLE AP) Clip # \n Reason: ?tube placement, PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with trauma, now s/p ETT placement\n REASON FOR THIS EXAMINATION:\n ?tube placement, PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma, status post endotracheal tube placement.\n\n TECHNIQUE: Single portable chest radiograph.\n\n COMPARISON: None.\n\n FINDINGS: There are low lung volumes and minimal left basilar atelectasis,\n otherwise, the lungs are clear. No pleural effusion, pneumothorax, or\n pulmonary edema is seen. An endotracheal tube is in place with tip\n approximately 6.2 cm above the carina. There is a displaced oblique fracture\n of the right distal clavicle incompletely assessed on this single view.\n\n IMPRESSION:\n 1. Status post endotracheal tube placement in appropriate position. No\n pneumothorax.\n 2. Fracture of the right distal clavicle.\n\n" }, { "category": "Radiology", "chartdate": "2200-07-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1142465, "text": " 2:59 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with trauma\n REASON FOR THIS EXAMINATION:\n ?bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:40 PM\n No acute intracranial hemorrhage or fractures\n R frontoparietal sub-galeal hematoma\n Left maxillar soft tissue defect,few tiny hyperdense foci within,could\n represent foreign bodies.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old man with trauma.\n\n COMPARISON: No prior studies available for comparison.\n\n TECHNIQUE: Contiguous axial images were acquired through the brain without\n intravenous contrast. Sagittal and coronal reformats were generated and\n reviewed.\n\n FINDINGS: No acute intracranial hemorrhage, edema is detected. No masses,\n mass effect, or major vascular territorial infarction is detected. The\n ventricles and sulci are normal in caliber and configuration. The basal\n cisterns are widely patent.\n\n No acute fractures are detected. A right frontoparietal and left periorbital\n scalp hematoma is noted. Additionally, there is a soft tissue laceration\n involving the left maxillary region with punctate hyperdense foci, suggesting\n possible foreign bodies. Minimal mucosal thickening is seen in the right\n maxillary sinus. Secretions in the nasopharynx relate to the endotracheal\n intubation. The external auditory canals are clear.\n\n IMPRESSION:\n 1. No acute intracranial hemorrhage or fracture is detected.\n 2. Subgaleal hematoma in the right frontoparietal and left periorbital\n region. Left maxillary soft tissue laceration with hyperdense foci, which may\n represent foreign bodies. Recommended clinical correlation.\n\n" }, { "category": "Radiology", "chartdate": "2200-07-10 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1142466, "text": " 3:00 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ?fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with trauma\n REASON FOR THIS EXAMINATION:\n ?fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:40 PM\n No acute fracture or mal-alignment seen.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old man with trauma.\n\n COMPARISON: No prior studies available.\n\n FINDINGS: No acute cervical spine fractures or malalignment is detected. The\n vertebral body heights are well maintained. There is no prevertebral soft\n tissue swelling. Secretions in the nasopharynx relate to the endotracheal\n intubation. Mild degenerative changes are seen in multiple levels of the\n cervical spine, worse at C5-C6 level with diffuse disc bulge and posterior\n osteophytes causing indentation of the thecal sac and spinal canal narrowing\n at this level.\n\n Visualized portion of the thyroid gland and lung apices are unremarkable.\n Incidental note is made of a comminuted right clavicle fracture visualized on\n the scout radiograph.\n\n IMPRESSION:\n 1. No acute cervical spine fracture or malalignment detected.\n 2. Multilevel degenerative changes of the cervical spine with disc bulge with\n posterior osteophyte causing spinal canal narrowing at C5-C6.\n 3. Comminuted right distal clavicle fracture.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2171-03-16 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1065320, "text": " 1:19 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ?perforation, pulmonary pathology\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n Field of view: 34 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with GIB, ETOH abuse, hypotensive, tachycardia, epigastric\n pain and elevated WBC with GIB\n REASON FOR THIS EXAMINATION:\n ?perforation, pulmonary pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKPe SAT 2:14 AM\n no parenchymal abnormalities, no pna. Equivical mild ascending colon colitis.\n 6mm contrast collection related to either pseudoaneurysm or active extrav in\n rt groin off branch of rt SFA within surrounding hematoma. Recommend\n compression to region.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Alcohol abuse, GI bleed, hypotensive, tachycardic with epigastric\n pain and leukocytosis. Evaluate for underlying pulmonary pathology or GI\n perforation.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the chest,\n abdomen, and pelvis with intravenous contrast only. Coronal and sagittal\n reformations were evaluated.\n\n CT CHEST WITH IV CONTRAST: The heart and great vessels are normal. No\n pathologically enlarged central or axillary lymph nodes are identified. There\n is no pleural or pericardial effusion. A few scattered ground-glass nodules\n may be present within the right middle lobe, although the exam is somewhat\n limited due to motion artifact, which may make this lesion artifactual. No\n focal consolidation is identified. There is bibasilar atelectasis.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST ONLY: The exam is somewhat\n limited again by respiratory motion. The liver, gallbladder, spleen, fluid-\n filled stomach, pancreas, kidneys, and adrenal glands are unremarkable. There\n are probable regions of focal fat deposition noted along the falciform\n ligament and adjacent to the gallbladder fossa. No free air, free fluid, or\n pathologically enlarged lymph nodes are identified.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST ONLY: A left femoral central\n venous catheter is in place. Air is noted within a Foley containing urinary\n bladder. Uterus and adnexa appear unremarkable. No free fluid or\n pathologically enlarged lymph nodes are present. Intrapelvic large bowel\n evaluation is limited without any oral contrast; however, no definite\n abnormality is present. Mild colonic diverticulosis is noted without evidence\n of acute diverticulitis. Slight prominence of the wall involving the\n ascending colon is likely related to underdistention.\n\n There is induration and hyperdense fluid surrounding the region of the left\n (Over)\n\n 1:19 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ?perforation, pulmonary pathology\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n Field of view: 34 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n groin with a collection measuring approximately 10 x 55 mm noted.\n Additionally, extending off the branch of the right superficial femoral artery\n is a lobulated 6 mm high-attenuation lesion centered within the hematoma.\n\n BONE WINDOWS: No malignant- appearing osseous lesions are identified.\n\n IMPRESSION:\n 1. No definite etiology for leukocytosis and pain identified. No\n pneumoperitoneum.\n\n 2. Colon is decompressed, no definite colitis. If needed, CT with oral\n contrast can be obatined.\n\n 3. Active extravasation or pseudoaneurysm formation involving a branch of the\n right superficial femoral artery with surrounding hematoma.\n\n These findings were discussed with Dr. on date of exam at 2:10 a.m.\n\n" }, { "category": "Radiology", "chartdate": "2171-03-21 00:00:00.000", "description": "R FEMORAL VASCULAR US RIGHT", "row_id": 1066140, "text": " 10:06 AM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: pls evaluate for pseudoaneurysm over right femoral artery\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with large right femoral hematoma and concern for\n pseudoaneurysm given new bruit\n REASON FOR THIS EXAMINATION:\n pls evaluate for pseudoaneurysm over right femoral artery\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:10 PM\n PFI: Findings consistent with arteriovenous fistula and probable thrombosed\n prior pseudoaneurysm in the right groin, underlying the site of prior\n puncture.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 44-year-old female with large right femoral hematoma and concern for\n pseudoaneurysm given new bruit.\n\n COMPARISON: None available.\n\n RIGHT FEMORAL VASCULAR ULTRASOUND: There is a large area of multicolored\n speckled appearance on color Doppler examination in the region of the right\n superficial femoral artery and vein, consistent with perivascular tissue\n thrill/vibration artifact. Pulsed wave Doppler interrogation of the\n superficial femoral artery in this region demonstrates low resistance flow\n with increased flow during diastole. Waveforms obtained in the adjacent\n superficial femoral vein demonstrates increased and turbulent flow. These\n findings are consistent with an arteriovenous fistula. There is also\n relatively well- circumscribed anechoic structure medial to this region, which\n demonstrates no flow on Doppler examination and which does not compress,\n likely representing a thrombosed pseudoaneurysm.\n\n IMPRESSION: Findings are consistent with arteriovenous fistula likely arising\n from the proximal superficial femoral vein, as well as a probable thrombosed\n previous pseudoaneurysm, both in the right groin underlying prior puncture\n site.\n\n Findings were discussed with Dr. over the phone upon completion\n of the study.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2171-03-21 00:00:00.000", "description": "R FEMORAL VASCULAR US RIGHT", "row_id": 1066141, "text": "-, D. MED FA2 10:06 AM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: pls evaluate for pseudoaneurysm over right femoral artery\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with large right femoral hematoma and concern for\n pseudoaneurysm given new bruit\n REASON FOR THIS EXAMINATION:\n pls evaluate for pseudoaneurysm over right femoral artery\n ______________________________________________________________________________\n PFI REPORT\n PFI: Findings consistent with arteriovenous fistula and probable thrombosed\n prior pseudoaneurysm in the right groin, underlying the site of prior\n puncture.\n\n" }, { "category": "Radiology", "chartdate": "2171-03-20 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1065994, "text": " 1:09 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Looking for CBD dilation or evidence of gallstones as cause\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with history of alcohol abuse presented with abdominal pain\n and nausea as well as elevated lipase.\n REASON FOR THIS EXAMINATION:\n Looking for CBD dilation or evidence of gallstones as cause of possible\n gallstone pancreatitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 44-year-old female with history of alcohol abuse. Now presenting\n with abdominal pain, nausea, and elevated lipase. Here to evaluate for\n evidence of biliary dilatation or gallstones as the cause of possible\n gallstone pancreatitis.\n\n COMPARISON: CT torso of .\n\n ABDOMINAL ULTRASOUND: There is mild diffuse increased echogenicity of the\n liver suggesting underlying fatty infiltration. Incidentally noted is a 2.1 x\n 2.1 x 1.5 cm cyst in the left hepatic lobe. No focal solid liver lesion is\n seen. The main portal vein is patent with normal hepatopetal directional flow.\n No intra- or extra- hepatic biliary ductal dilatation is noted; the common\n duct measures 3 mm. The gallbladder appears normal without evidence of stones.\n The pancreas appears normal. The spleen is not enlarged, measuring 9.1 cm. No\n ascites is seen.\n\n IMPRESSION:\n 1. Mildly echogenic liver is consistent with mild diffuse fatty infiltration.\n However, more advanced liver disease such as cirrhosis or fibrosis cannot be\n excluded. No focal solid liver lesion seen.\n\n 2. No evidence of cholelithiasis or biliary obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2171-03-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1065315, "text": " 12:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pulmonary pathology\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with GIB., dyspnea/tachypnea\n REASON FOR THIS EXAMINATION:\n ?pulmonary pathology\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Gastrointestinal bleeding, questionable thoracic pathology.\n\n COMPARISON: No comparison available at the time of dictation.\n\n FINDINGS: Minimal atelectasis at the left lung base, otherwise the radiograph\n is normal. No focal parenchymal opacities, no overhydration, no masses,\n normal size of the cardiac silhouette.\n\n\n" }, { "category": "ECG", "chartdate": "2171-03-16 00:00:00.000", "description": "Report", "row_id": 225506, "text": "Sinus tachycardia. Non-specific ST-T wave changes. Compared to the previous\ntracing ST-T wave changes are new.\n\n" }, { "category": "Physician ", "chartdate": "2171-03-16 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 661989, "text": "Chief Complaint: GIB\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 women with h/o ETOH abuse, presents with hematemesis, melena.\n Came to ED where initial BP stable, but tachy to 147, had brief period\n of HOTN and IVF and blood. Also found to be in acute renal\n failure with anion gap acidosis. Also with evidence of pancreatitis\n 24 Hour Events:\n MULTI LUMEN - START 02:51 AM\n EKG - At 04:28 AM\n Allergies:\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 02:30 AM\n Ciprofloxacin - 03:26 AM\n Metronidazole - 08:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:15 AM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n cipro\n vanco\n flagyl\n folate\n protonix\n thiamine\n pyridoxine\n CIWA with ativan\n zofran\n Changes to medical and family history:\n no h/o withdrawl from ETOH\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 09:48 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: 112 (109 - 133) bpm\n BP: 128/92(100) {122/90(98) - 151/111(119)} mmHg\n RR: 23 (18 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 65 kg (admission): 65 kg\n Total In:\n 5,637 mL\n PO:\n TF:\n IVF:\n 3,937 mL\n Blood products:\n Total out:\n 0 mL\n 1,440 mL\n Urine:\n 840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,197 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.22/11/183/15/-20\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)\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: Tender: difusely, no rebound.\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: 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, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 12.0 g/dL\n 109 K/uL\n 375 mg/dL\n 0.8 mg/dL\n 15 mEq/L\n 4.2 mEq/L\n 6 mg/dL\n 102 mEq/L\n 136 mEq/L\n 34.4 %\n 10.7 K/uL\n [image002.jpg]\n 02:55 AM\n 03:53 AM\n 07:15 AM\n WBC\n 14.5\n 10.7\n Hct\n 43.5\n 34.4\n Plt\n 136\n 109\n Cr\n 1.1\n 0.8\n TropT\n <0.01\n TCO2\n 5\n Glucose\n 288\n 375\n Other labs: PT / PTT / INR:15.0/25.3/1.3, CK / CKMB /\n Troponin-T:99//<0.01, ALT / AST:25/64, Alk Phos / T Bili:132/0.6,\n Amylase / Lipase:/723, Differential-Neuts:81.0 %, Band:11.0 %,\n Lymph:2.0 %, Mono:6.0 %, Eos:0.0 %, Lactic Acid:1.8 mmol/L, Albumin:3.7\n g/dL, LDH:420 IU/L, Ca++:7.5 mg/dL, Mg++:1.2 mg/dL, PO4:0.6 mg/dL\n Imaging: CT torso: Mild colitis. No evidence of pancreatic edema\n Assessment and Plan\n UGIB: Not further bleeding. Could be tear versus PUD.\n Less likely variceal bleed as now clear evidence of cirrhosis.\n Continue PPI\n Metabolic acidosis: likely partially due to lactic acidosis from\n wretching as well as alchoholic ketosis.\n ETOH abuse: continue multivitamins,thiamine, folate. CIWA scale.\n Pancreatitis/abdominal pain: likely due to ETOH, no stones on CT.\n Keep close watch on urine output, if decreasing increase fluids.\n antibiotics: no clear evidence of infection.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:51 AM\n Comments: if stable can remove groin line\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: 40 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2171-03-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 662197, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Pt cont to have low electrolyte values. Urine output acceptable.\n Taking clear liquids w/o incident. VSS, no ectopy noted.\n Action:\n Lytes replaced as needed md\ns orders.\n Response:\n K 3.4 from 2.9, magnesium level to be rechecked. Hct stable.\n Plan:\n Cont serial labs replace as needed and ordered by md.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt c/o mild to mod abd pain w/ movement.\n Action:\n Pt repositioned, pain assessed\n medication offered.\n Response:\n Pt admits to good pain management w/ out pain med.\n Plan:\n Cont to monitor for worsening pain, pain meds if needed.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting. Stool x2,\n Action:\n Response:\n Plan:\n Pt is a 44 y.o. female with PMH of bipolar disorder, ETOH abuse,\n smoking, depression. C/o epigastric pain x 2+ days, vomiting\n BRB/coffeegrounds x 12hrs before EMTs were called to pt\ns place of\n living in group home. When EMT arrived, pt\ns SBP 60s, HR 150s, RR 40s,\n O2 sats 90. No IV access could be achieved in the field except for an\n 18g in pts R ankle. On arrival to , pt\ns vitals were unchanged. R fem\n stick attempt at central access yielding in knicked artery\n compression\n held x1hr, pressure dsg applied, hematoma at R fem site. L fem site\n central access achieved. Pt given emergent 2 U PRBCs. At this time, pt\n became HYPERtensive to 170s. Labs significant for elevated K (most\n recent 6.3), Bicarb 5, INR 1.4 (Given 10mg Vit K.) and abnormal ABG\n severe resp acidosis.\n" }, { "category": "Physician ", "chartdate": "2171-03-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 662159, "text": "Chief Complaint: GIB, ETOH ketosis\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 women with ETOH abuse, UGIB, ETOH ketoacidosis. EGD yesterday\n with tear. Required potassium and phosphate. On insulin\n drip. More comfortable and alert today.\n 24 Hour Events:\n ENDOSCOPY - At 12:30 PM\n BLOOD CULTURED - At 05:32 PM\n taken from central line\n URINE CULTURE - At 05:32 PM\n BLOOD CULTURED - At 08:18 PM\n taken from central line\n Allergies:\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:26 AM\n Metronidazole - 08:00 AM\n Vancomycin - 09:30 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:19 PM\n Lorazepam (Ativan) - 02:04 AM\n Dextrose 50% - 04:54 AM\n Other medications:\n folate\n protonix\n thiamine\n vitamin B12\n insulin drip\n ativan prn\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: mild abdominal pain. No SOB, no cough, no nausea,\n no melena\n Flowsheet Data as of 10:33 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: 37.2\nC (98.9\n HR: 87 (86 - 121) bpm\n BP: 117/75(85) {88/52(60) - 127/105(109)} mmHg\n RR: 22 (15 - 32) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65 kg (admission): 65 kg\n Total In:\n 10,101 mL\n 2,592 mL\n PO:\n TF:\n IVF:\n 8,401 mL\n 2,567 mL\n Blood products:\n Total out:\n 2,950 mL\n 930 mL\n Urine:\n 2,350 mL\n 930 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,151 mL\n 1,662 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: 7.51/32/113/26/3\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: 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, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 10.0 g/dL\n 81 K/uL\n 144 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 3.1 mEq/L\n 3 mg/dL\n 112 mEq/L\n 146 mEq/L\n 27.8 %\n 6.3 K/uL\n [image002.jpg]\n 02:55 AM\n 03:53 AM\n 07:15 AM\n 03:01 PM\n 08:00 PM\n 11:44 PM\n 12:16 AM\n 01:44 AM\n 09:14 AM\n WBC\n 14.5\n 10.7\n 6.6\n 6.3\n Hct\n 43.5\n 34.4\n 29.3\n 28.5\n 27.7\n 27.8\n Plt\n 136\n 109\n 83\n 81\n Cr\n 1.1\n 0.8\n 0.5\n 0.5\n 0.5\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 5\n 26\n Glucose\n 288\n 375\n 85\n 121\n 118\n 99\n 144\n Other labs: PT / PTT / INR:14.3/26.4/1.2, CK / CKMB /\n Troponin-T:66/4/<0.01, ALT / AST:20/62, Alk Phos / T Bili:83/0.6,\n Amylase / Lipase:230/565, Differential-Neuts:81.0 %, Band:11.0 %,\n Lymph:2.0 %, Mono:6.0 %, Eos:0.0 %, Lactic Acid:2.5 mmol/L, Albumin:3.1\n g/dL, LDH:243 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:1.5 mg/dL\n Assessment and Plan\n UGIB: due to tear.\n Acidosis: Largely ETOH ketosis. No need for insulin drip, can stop.\n HgA1c was 5.2 on .\n No need for antibiotics.\n Can advance to clear fluid diet.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:51 AM\n Comments: will try to get peripheral IVs and d/c fem line.\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Transfer to floor once off insulin drip and\n femoral line removed.\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2171-03-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 662135, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - EGD showed tear and gastritis\n - Hct slowly trending downward but stable\n - treated with bicarb in AM, anion gap closed but had hyopkalemia and\n hypophosphatemia so just continued with IVFs without bicarb\n - pt continued to have mixed gap and nongap acidosis, likely in setting\n of mild pancreatitis, tx with IVFs during day\n - continued D5W and insulin gtt for initial DKA\n - needed to aggressively replace electrolytes\n - pt mental status better in evening, more conversant\n ENDOSCOPY - At 12:30 PM\n BLOOD CULTURED - At 05:32 PM\n taken from central line\n URINE CULTURE - At 05:32 PM\n BLOOD CULTURED - At 08:18 PM\n taken from central line\n Allergies:\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:26 AM\n Metronidazole - 08:00 AM\n Vancomycin - 09:30 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:19 PM\n Lorazepam (Ativan) - 02:04 AM\n Dextrose 50% - 04:54 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 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 (98.9\n HR: 87 (87 - 121) bpm\n BP: 119/79(88) {88/52(60) - 128/105(109)} mmHg\n RR: 21 (15 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65 kg (admission): 65 kg\n Total In:\n 10,101 mL\n 2,064 mL\n PO:\n TF:\n IVF:\n 8,401 mL\n 2,039 mL\n Blood products:\n Total out:\n 2,950 mL\n 710 mL\n Urine:\n 2,350 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,151 mL\n 1,354 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: 7.51/32/113/26/3\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 81 K/uL\n 10.0 g/dL\n 144 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 3.1 mEq/L\n 3 mg/dL\n 112 mEq/L\n 146 mEq/L\n 27.7 %\n 6.3 K/uL\n [image002.jpg]\n 02:55 AM\n 03:53 AM\n 07:15 AM\n 03:01 PM\n 08:00 PM\n 11:44 PM\n 12:16 AM\n 01:44 AM\n WBC\n 14.5\n 10.7\n 6.6\n 6.3\n Hct\n 43.5\n 34.4\n 29.3\n 28.5\n 27.7\n Plt\n 136\n 109\n 83\n 81\n Cr\n 1.1\n 0.8\n 0.5\n 0.5\n 0.5\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 5\n 26\n Glucose\n 288\n 375\n 85\n 121\n 118\n 99\n 144\n Other labs: PT / PTT / INR:14.3/26.4/1.2, CK / CKMB /\n Troponin-T:66/4/<0.01, ALT / AST:20/62, Alk Phos / T Bili:83/0.6,\n Amylase / Lipase:230/565, Differential-Neuts:81.0 %, Band:11.0 %,\n Lymph:2.0 %, Mono:6.0 %, Eos:0.0 %, Lactic Acid:2.5 mmol/L, Albumin:3.1\n g/dL, LDH:243 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:1.5 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n ACIDOSIS, RESPIRATORY\n ACUTE PAIN\n ALCOHOL ABUSE\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ALTERATION IN NUTRITION\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n HEMOPTYSIS\n HYPERGLYCEMIA\n HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)\n IMPAIRED HEALTH MAINTENANCE\n TACHYCARDIA, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:51 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2171-03-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 662136, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - EGD showed tear and gastritis\n - Hct slowly trending downward but stable\n - treated with bicarb in AM, anion gap closed but had hyopkalemia and\n hypophosphatemia so just continued with IVFs without bicarb\n - pt continued to have mixed gap and nongap acidosis, likely in setting\n of mild pancreatitis, tx with IVFs during day\n - continued D5W and insulin gtt for initial DKA\n - needed to aggressively replace electrolytes\n - pt mental status better in evening, more conversant\n ENDOSCOPY - At 12:30 PM\n BLOOD CULTURED - At 05:32 PM\n taken from central line\n URINE CULTURE - At 05:32 PM\n BLOOD CULTURED - At 08:18 PM\n taken from central line\n Allergies:\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:26 AM\n Metronidazole - 08:00 AM\n Vancomycin - 09:30 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:19 PM\n Lorazepam (Ativan) - 02:04 AM\n Dextrose 50% - 04:54 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 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 (98.9\n HR: 87 (87 - 121) bpm\n BP: 119/79(88) {88/52(60) - 128/105(109)} mmHg\n RR: 21 (15 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65 kg (admission): 65 kg\n Total In:\n 10,101 mL\n 2,064 mL\n PO:\n TF:\n IVF:\n 8,401 mL\n 2,039 mL\n Blood products:\n Total out:\n 2,950 mL\n 710 mL\n Urine:\n 2,350 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,151 mL\n 1,354 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: 7.51/32/113/26/3\n Physical Examination\n General: Alert, uncomfortable, oriented\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, Tender in epigastrum, non-distended, bowel sounds\n present.\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema.\n right pressure dressing over femoral artery. Left Fem CVL.\n Labs / Radiology\n 81 K/uL\n 10.0 g/dL\n 144 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 3.1 mEq/L\n 3 mg/dL\n 112 mEq/L\n 146 mEq/L\n 27.7 %\n 6.3 K/uL\n [image002.jpg]\n 02:55 AM\n 03:53 AM\n 07:15 AM\n 03:01 PM\n 08:00 PM\n 11:44 PM\n 12:16 AM\n 01:44 AM\n WBC\n 14.5\n 10.7\n 6.6\n 6.3\n Hct\n 43.5\n 34.4\n 29.3\n 28.5\n 27.7\n Plt\n 136\n 109\n 83\n 81\n Cr\n 1.1\n 0.8\n 0.5\n 0.5\n 0.5\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 5\n 26\n Glucose\n 288\n 375\n 85\n 121\n 118\n 99\n 144\n Other labs: PT / PTT / INR:14.3/26.4/1.2, CK / CKMB /\n Troponin-T:66/4/<0.01, ALT / AST:20/62, Alk Phos / T Bili:83/0.6,\n Amylase / Lipase:230/565, Differential-Neuts:81.0 %, Band:11.0 %,\n Lymph:2.0 %, Mono:6.0 %, Eos:0.0 %, Lactic Acid:2.5 mmol/L, Albumin:3.1\n g/dL, LDH:243 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:1.5 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n ACIDOSIS, RESPIRATORY\n ACUTE PAIN\n ALCOHOL ABUSE\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ALTERATION IN NUTRITION\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n HEMOPTYSIS\n HYPERGLYCEMIA\n HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)\n IMPAIRED HEALTH MAINTENANCE\n TACHYCARDIA, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:51 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2171-03-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 662137, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - EGD showed tear and gastritis\n - Hct slowly trending downward but stable\n - treated with bicarb in AM, anion gap closed but had hyopkalemia and\n hypophosphatemia so just continued with IVFs without bicarb\n - pt continued to have mixed gap and nongap acidosis, likely in setting\n of mild pancreatitis, tx with IVFs during day\n - continued D5W and insulin gtt for initial DKA\n - needed to aggressively replace electrolytes\n - pt mental status better in evening, more conversant\n ENDOSCOPY - At 12:30 PM\n BLOOD CULTURED - At 05:32 PM\n taken from central line\n URINE CULTURE - At 05:32 PM\n BLOOD CULTURED - At 08:18 PM\n taken from central line\n Allergies:\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:26 AM\n Metronidazole - 08:00 AM\n Vancomycin - 09:30 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:19 PM\n Lorazepam (Ativan) - 02:04 AM\n Dextrose 50% - 04:54 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 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 (98.9\n HR: 87 (87 - 121) bpm\n BP: 119/79(88) {88/52(60) - 128/105(109)} mmHg\n RR: 21 (15 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65 kg (admission): 65 kg\n Total In:\n 10,101 mL\n 2,064 mL\n PO:\n TF:\n IVF:\n 8,401 mL\n 2,039 mL\n Blood products:\n Total out:\n 2,950 mL\n 710 mL\n Urine:\n 2,350 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,151 mL\n 1,354 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: 7.51/32/113/26/3\n Physical Examination\n General: Alert, uncomfortable, oriented\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, Tender in epigastrum, non-distended, bowel sounds\n present.\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema.\n right pressure dressing over femoral artery. Left Fem CVL.\n Labs / Radiology\n 81 K/uL\n 10.0 g/dL\n 144 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 3.1 mEq/L\n 3 mg/dL\n 112 mEq/L\n 146 mEq/L\n 27.7 %\n 6.3 K/uL\n [image002.jpg]\n 02:55 AM\n 03:53 AM\n 07:15 AM\n 03:01 PM\n 08:00 PM\n 11:44 PM\n 12:16 AM\n 01:44 AM\n WBC\n 14.5\n 10.7\n 6.6\n 6.3\n Hct\n 43.5\n 34.4\n 29.3\n 28.5\n 27.7\n Plt\n 136\n 109\n 83\n 81\n Cr\n 1.1\n 0.8\n 0.5\n 0.5\n 0.5\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 5\n 26\n Glucose\n 288\n 375\n 85\n 121\n 118\n 99\n 144\n Other labs: PT / PTT / INR:14.3/26.4/1.2, CK / CKMB /\n Troponin-T:66/4/<0.01, ALT / AST:20/62, Alk Phos / T Bili:83/0.6,\n Amylase / Lipase:230/565, Differential-Neuts:81.0 %, Band:11.0 %,\n Lymph:2.0 %, Mono:6.0 %, Eos:0.0 %, Lactic Acid:2.5 mmol/L, Albumin:3.1\n g/dL, LDH:243 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:1.5 mg/dL\n Assessment and Plan\n This is a 44F with EtOH, abdominal pain, hemetemesis and significant\n metabolic acidosis.\n .\n # Acidosis: Patient has Metabolic Anion Gap acidosis, with likely some\n metabolic alkalosis given emesis and respiratory compensation. Her Osm\n Gap is elevated at 23 (nl<10). Most likely this is alcoholic\n ketoacidosis with a few urine ketones (mostly not captured by ketone\n assay in alcoholic ketoacidosis). Would also consider other\n ingestions. She has mild lactate. She has a good respiratory\n compensation for this.\n - Rehydration with bicarb with dextrose\n - Phosphate repletion as needed\n - thiamine, folate, b6\n .\n # ?Bloody emesis: Pt could have tears, variceal\n bleeding, gastritis or PUD.\n - NPO for EGD in am or sooner\n - Monitor hcts\n - GI following, if hct drop or evidence of continued bleeding, will\n call them in again.\n - PPI IV\n .\n # Abdominal Pain: Pt with epigastric pain, nausea, vomitting, elevated\n lipase, likely Pancreatitis. Patient had elevated WBC and appeared\n hemoconcentrated. CT with ?colitis, but pt without diarrhea.\n - NPO & IVF\n - vanc/cipro/flagyl to cover for potential abdominal infection\n .\n # Tachycardia: Likely multifactorial from pain, etoh withdrawl, with\n other potential components including hypovolemia and sepsis.\n - IVF\n - CIWA and treatment\n .\n # Hypotension: Resolved with 2L NS and 1upRBC. Will monitor closely\n .\n # Hyperkalemia: likely to resolve as acidosis resolves.\n - Monitor with Q4hr labs, and EKG as needed\n - Telemetry\n .\n # Hyperglycemia: ISS\n .\n # Elevated Cr: Likely ARF given baseline of 0.5-0.6. Trial of\n rehydration. Watch carefully as also a result of other ingestions.\n - IVF\n .\n # Right SFA exavezation:\n - pressure dressing\n - monitor hcts/size of hematoma\n .\n # Alcohol Abuse:\n - CIWA with ativan.\n - Thiamine, folate\n .\n # FEN: No IVF, replete electrolytes, NPO\n # Prophylaxis: Pneumoboots, consider hep sq in am\n # Access: peripherals, left fem\n # Code: presumed full\n # Communication: Patient\n # Disposition: icu\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:51 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2171-03-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 662165, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - EGD showed tear and gastritis\n - Hct slowly trending downward but stable\n - treated with bicarb in AM, anion gap closed but had hyopkalemia and\n hypophosphatemia so just continued with IVFs without bicarb\n - pt continued to have mixed gap and nongap acidosis, likely in setting\n of mild pancreatitis, tx with IVFs during day\n - continued D5W and insulin gtt for initial DKA\n - needed to aggressively replace electrolytes\n - pt mental status better in evening, more conversant\n ENDOSCOPY - At 12:30 PM\n BLOOD CULTURED - At 05:32 PM\n taken from central line\n URINE CULTURE - At 05:32 PM\n BLOOD CULTURED - At 08:18 PM\n taken from central line\n Allergies:\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:26 AM\n Metronidazole - 08:00 AM\n Vancomycin - 09:30 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:19 PM\n Lorazepam (Ativan) - 02:04 AM\n Dextrose 50% - 04:54 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 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 (98.9\n HR: 87 (87 - 121) bpm\n BP: 119/79(88) {88/52(60) - 128/105(109)} mmHg\n RR: 21 (15 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65 kg (admission): 65 kg\n Total In:\n 10,101 mL\n 2,064 mL\n PO:\n TF:\n IVF:\n 8,401 mL\n 2,039 mL\n Blood products:\n Total out:\n 2,950 mL\n 710 mL\n Urine:\n 2,350 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,151 mL\n 1,354 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: 7.51/32/113/26/3\n Physical Examination\n General: Alert, uncomfortable, oriented\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, Tender in epigastrum, non-distended, bowel sounds\n present.\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema.\n right pressure dressing over femoral artery. Left Fem CVL.\n Labs / Radiology\n 81 K/uL\n 10.0 g/dL\n 144 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 3.1 mEq/L\n 3 mg/dL\n 112 mEq/L\n 146 mEq/L\n 27.7 %\n 6.3 K/uL\n [image002.jpg]\n 02:55 AM\n 03:53 AM\n 07:15 AM\n 03:01 PM\n 08:00 PM\n 11:44 PM\n 12:16 AM\n 01:44 AM\n WBC\n 14.5\n 10.7\n 6.6\n 6.3\n Hct\n 43.5\n 34.4\n 29.3\n 28.5\n 27.7\n Plt\n 136\n 109\n 83\n 81\n Cr\n 1.1\n 0.8\n 0.5\n 0.5\n 0.5\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 5\n 26\n Glucose\n 288\n 375\n 85\n 121\n 118\n 99\n 144\n Other labs: PT / PTT / INR:14.3/26.4/1.2, CK / CKMB /\n Troponin-T:66/4/<0.01, ALT / AST:20/62, Alk Phos / T Bili:83/0.6,\n Amylase / Lipase:230/565, Differential-Neuts:81.0 %, Band:11.0 %,\n Lymph:2.0 %, Mono:6.0 %, Eos:0.0 %, Lactic Acid:2.5 mmol/L, Albumin:3.1\n g/dL, LDH:243 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:1.5 mg/dL\n Assessment and Plan\n This is a 44F with EtOH, abdominal pain, hemetemesis and significant\n metabolic acidosis.\n .\n # Acidosis: Patient has Metabolic Anion Gap acidosis, with likely some\n non gap metabolic alkalosis given emesis and respiratory compensation.\n Her Osm Gap is elevated at 23 (nl<10). Most likely this is alcoholic\n ketoacidosis with a few urine ketones (mostly not captured by ketone\n assay in alcoholic ketoacidosis). She has mild lactate. She has a\n good respiratory compensation for this.\n - Rehydration with bicarb with dextrose, now normalized and switched\n the D5NS yesterday\n - was on insulin gtt and dextrose, stopping today\n - severely hyperkalemic with insulin\n repleted aggressively\n - Phosphate repletion as needed\n - thiamine, folate, b6\n .\n # ?Bloody emesis: Pt could have tears, variceal\n bleeding, gastritis or PUD.\n - EGD showed gastritis and tear, no longer bleeding,\n stable Hcts, guiac neg stools\n - Monitor hcts\n - GI following, if hct drop or evidence of continued bleeding, will\n call them in again.\n - PPI IV\n .\n # Abdominal Pain: Pt with epigastric pain, nausea, vomitting, elevated\n lipase, likely Pancreatitis. Patient had elevated WBC and appeared\n hemoconcentrated. CT with ?colitis, but pt without diarrhea.\n - off abx for now, no signs of infection\n - amylase lipase trending down, will advance diet to clears today\n .\n # Right SFA exavezation\n pseudoaneursym seen on CT scan:\n - stable, consider repeat US for follow up but not necessarily needed\n as exam shows smaller palpable mass, has intact pulses and no bruit;\n hct stable, no pain. If changes would image then\n - pressure dressing\n - monitor hcts/size of hematoma\n .\n # Tachycardia: Likely multifactorial from pain, etoh withdrawl, with\n other potential components including hypovolemia and sepsis, improving,\n still with HRs in 100s.\n - IVF\n - CIWA and treatment\n .\n # Hypotension: Resolved with 2L NS and 1upRBC. Will monitor closely\n .\n # Hyperkalemia: likely to resolve as acidosis resolves.\n - Monitor with Q4hr labs, and EKG as needed\n .\n # Hyperglycemia: ISS\n .\n # Elevated Cr: Likely ARF given baseline of 0.5-0.6. Trial of\n rehydration. Watch carefully as also a result of other ingestions.\n - IVF\n .\n # Alcohol Abuse:\n - CIWA with ativan being changed to PO valium.\n - Thiamine, folate\n .\n # FEN: No IVF, replete electrolytes, NPO\n # Prophylaxis: Pneumoboots, no SQ hep b/c of groin, PPI\n # Access: peripherals, left fem\n # Code: presumed full\n # Communication: Patient\n # Disposition: icu, call out to floor today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:51 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2171-03-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 662218, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Pt cont to have low electrolyte values. Urine output acceptable.\n Taking clear liquids w/o incident. VSS, no ectopy noted.\n Action:\n Lytes replaced as needed md\ns orders.\n Response:\n K 3.4 from 2.9, magnesium level to be rechecked. Hct stable.\n Plan:\n Cont serial labs replace as needed and ordered by md.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt c/o mild to mod abd pain w/ movement.\n Action:\n Pt repositioned, pain assessed\n medication offered.\n Response:\n Pt admits to good pain management w/ out pain med.\n Plan:\n Cont to monitor for worsening pain, pain meds if needed.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting. Stool x2\n Action:\n stool guiac\nd, pt started on clear liquids.\n Response:\n stool guiac negative, tolerating po\n Plan:\n Cont serial hct\ns, monitor for s/s of bleeding.\n Pt is a 44 y.o. female with PMH of bipolar disorder, ETOH abuse,\n smoking, depression. C/o epigastric pain x 2+ days, vomiting\n BRB/coffeegrounds x 12hrs before EMTs were called to pt\ns place of\n living in group home. When EMT arrived, pt\ns SBP 60s, HR 150s, RR 40s,\n O2 sats 90. No IV access could be achieved in the field except for an\n 18g in pts R ankle. On arrival to , pt\ns vitals were unchanged. R fem\n stick attempt at central access yielding in knicked artery\n compression\n held x1hr, pressure dsg applied, hematoma at R fem site. L fem site\n central access achieved. Pt given emergent 2 U PRBCs. At this time, pt\n became HYPERtensive to 170s. Labs significant for elevated K (most\n recent 6.3), Bicarb 5, INR 1.4 (Given 10mg Vit K.) and abnormal ABG\n severe resp acidosis.\n ICU course: EGD done showing small tear. Acidosis\n improved w/ bicarb drip, pt became consistently hypokalemic, mult k\n boluses given, sugars elevated, on insulin gtts which was d/c\nd today.\n Mental status improved, pt a/ox3. Pupils equal and reactive. Lungs\n cta bilat. No c/o sob. Abd soft, positive bowel sounds. R groin\n hematomas significantly smaller, pressure dressing changed.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n SYNCOPE;TELEMETRY\n Code status:\n Height:\n Admission weight:\n 65 kg\n Daily weight:\n 65 kg\n Allergies/Reactions:\n Aspirin\n Unknown;\n Precautions:\n PMH: ETOH, GI Bleed, Smoker\n CV-PMH:\n Additional history: Bipolar disorder. Diagnosed in . Hospitalized\n 3 times in the past, last in . She does have a history of suicidal\n ideation but none currently. Sees Dr. at once every 3 months. Does not see a therapist.\n 2. Alcohol abuse.\n 3. Tobacco abuse.\n 4. Status post right anterior tibial tendon repair in \n The patient lives in the Group Home in . Her family\n lives on . She has been ondisability since due to\n bipolar disorder. Prior to that,\n she worked as a cook.\n Surgery / Procedure and date: -- post right anterior tibial\n tendon repair\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:93\n Temperature:\n 98.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 3,885 mL\n 24h total out:\n 1,740 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 12:50 PM\n Potassium:\n 3.5 mEq/L\n 12:50 PM\n Chloride:\n 111 mEq/L\n 12:50 PM\n CO2:\n 24 mEq/L\n 12:50 PM\n BUN:\n 3 mg/dL\n 12:50 PM\n Creatinine:\n 0.4 mg/dL\n 12:50 PM\n Glucose:\n 141 mg/dL\n 12:50 PM\n Hematocrit:\n 27.6 %\n 12:50 PM\n Finger Stick Glucose:\n 170\n 04:00 PM\n Valuables / Signature\n Patient valuables: coat\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: 221\n Date & time of Transfer: 18:30\n" }, { "category": "Physician ", "chartdate": "2171-03-16 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 662002, "text": "Chief Complaint: abdominal pain, vomitting\n HPI:\n 44M with Bipolar and alcohol abuse who presents with 1 day of\n epigastric pain and vomitting of bloody emesis (red and black). She\n also reports black stools recently. She reports that she drinks vodka\n daily (or every other day). She has not been sober for over a year.\n She has not had withdrawl before. She denies any sob/cp/urinary sxs.\n .\n In the ED, initial vs were: 99.4 148 116/50 37 90% on NRB but BP\n dropped to 60/42 transiently and improved when patient was given 2LNS\n and 1 upRBCs. Pt also given protonix, octreotide, and vanco. Labs\n with severe anion gap acidosis, ARF, leukocytosis. NG lavage with\n light yellow liquid. No stool in the vault. GI saw and deferred scope\n unless actively bleeding.\n .\n In the MICU she was normotensive, tachycardic, nauseous with some\n coffee ground emesis. She denies any ingestion of asa/nsaids/other\n pills/other fluids. Denies suicidal ideation.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 02:30 AM\n Ciprofloxacin - 03:26 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:15 AM\n Other medications:\n seroquel\n celexa\n lamictal\n percocet\n Past medical history:\n Family history:\n Social History:\n Bipolar, h/o suicidal ideation\n Alcohol abuse\n Percocet abuse\n Tobacco abuse\n Strong family h/o alcohol abuse.\n Occupation: diability\n Drugs: percocet\n Tobacco: yes\n Alcohol: Yes - last drink 2 days ago\n Other: lives in group home.\n Review of systems:\n Constitutional: Weight loss\n Ear, Nose, Throat: Dry mouth\n Nutritional Support: NPO\n Gastrointestinal: Abdominal pain, Nausea, Emesis\n Endocrine: Hyperglycemia\n Heme / Lymph: Coagulopathy\n Psychiatric / Sleep: Agitated\n Pain: Severe\n Pain location: epigastrium - band\n Flowsheet Data as of 05:47 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: 131 (131 - 133) bpm\n BP: 125/93(101) {125/93(101) - 151/111(119)} mmHg\n RR: 32 (18 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 65 kg (admission): 65 kg\n Total In:\n 3,715 mL\n PO:\n TF:\n IVF:\n 2,015 mL\n Blood products:\n Total out:\n 0 mL\n 1,060 mL\n Urine:\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,660 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.22/11/183/6/-20\n Physical Examination\n General: Alert, uncomfortable, oriented\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, Tender in epigastrum, non-distended, bowel sounds\n present.\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema.\n right pressure dressing over femoral artery. Left Fem CVL.\n Labs / Radiology\n 136 K/uL\n 14.6 g/dL\n 288 mg/dL\n 1.1 mg/dL\n 7 mg/dL\n 6 mEq/L\n 100 mEq/L\n 6.3 mEq/L\n 134 mEq/L\n 43.5 %\n 14.5 K/uL\n [image002.jpg]\n \n 2:33 A2/28/ 02:55 AM\n \n 10:20 P2/28/ 03:53 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 14.5\n Hct\n 43.5\n Plt\n 136\n Cr\n 1.1\n TropT\n <0.01\n TC02\n 5\n Glucose\n 288\n Other labs: PT / PTT / INR:15.0/25.3/1.3, CK / CKMB /\n Troponin-T:99//<0.01, ALT / AST:31/92, Alk Phos / T Bili:132/0.6,\n Amylase / Lipase:/723, Differential-Neuts:81.0 %, Band:11.0 %,\n Lymph:2.0 %, Mono:6.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L, Albumin:4.5\n g/dL, LDH:420 IU/L, Ca++:8.4 mg/dL, Mg++:1.4 mg/dL, PO4:2.1 mg/dL\n Imaging: CT Torso: no parenchymal abnormalities, no pna. Equivical mild\n ascending colon colitis.\n 6mm contrast collection related to either pseudoaneurysm or active\n extrav in rt groin off branch of rt SFA within surrounding hematoma.\n Recommend compression to region.\n Microbiology: pending\n ECG: Sinus Tach with nl axis, nl intervals - narrow complex QRS, T\n waves possibly slightly peaked in V2-V6.\n Assessment and Plan\n Assessment and Plan: This is a 44F with EtOH, abdominal pain,\n hemetemesis and significant metabolic acidosis.\n .\n # Acidosis: Patient has Metabolic Anion Gap acidosis, with likely some\n metabolic alkalosis given emesis and respiratory compensation. Her Osm\n Gap is elevated at 23 (nl<10). Most likely this is alcoholic\n ketoacidosis with a few urine ketones (mostly not captured by ketone\n assay in alcoholic ketoacidosis). Would also consider other\n ingestions. She has mild lactate. She has a good respiratory\n compensation for this.\n - Rehydration with bicarb with dextrose\n - Phosphate repletion as needed\n - thiamine, folate, b6\n .\n # ?Bloody emesis: Pt could have tears, variceal\n bleeding, gastritis or PUD.\n - NPO for EGD in am or sooner\n - Monitor hcts\n - GI following, if hct drop or evidence of continued bleeding, will\n call them in again.\n - PPI IV\n .\n # Abdominal Pain: Pt with epigastric pain, nausea, vomitting, elevated\n lipase, likely Pancreatitis. Patient had elevated WBC and appeared\n hemoconcentrated. CT with ?colitis, but pt without diarrhea.\n - NPO & IVF\n - vanc/cipro/flagyl to cover for potential abdominal infection\n .\n # Tachycardia: Likely multifactorial from pain, etoh withdrawl, with\n other potential components including hypovolemia and sepsis.\n - IVF\n - CIWA and treatment\n .\n # Hypotension: Resolved with 2L NS and 1upRBC. Will monitor closely\n .\n # Hyperkalemia: likely to resolve as acidosis resolves.\n - Monitor with Q4hr labs, and EKG as needed\n - Telemetry\n .\n # Hyperglycemia: ISS\n .\n # Elevated Cr: Likely ARF given baseline of 0.5-0.6. Trial of\n rehydration. Watch carefully as also a result of other ingestions.\n - IVF\n .\n # Right SFA exavezation:\n - pressure dressing\n - monitor hcts/size of hematoma\n .\n # Alcohol Abuse:\n - CIWA with ativan.\n - Thiamine, folate\n .\n # FEN: No IVF, replete electrolytes, NPO\n # Prophylaxis: Pneumoboots, consider hep sq in am\n # Access: peripherals, left fem\n # Code: presumed full\n # Communication: Patient\n # Disposition: icu\n .\n ICU Care\n Nutrition:\n Glycemic Control: ISS\n Lines: fem line\n 18 Gauge - 02:46 AM\n Multi Lumen - 02:51 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: ICU\n ------ Protected Section ------\n Patient has anion gap metabolic acidosis and urine ketones consistent\n with alcoholic ketoacidosis. Giving banana bag and 150 meq HCO3 at\n 250cc/hr to correct acidosis. Will fluid resuscitation, lactate was\n been resolving.\n Lipase is significantly elevated in the 700s. Acute pancreatitis is the\n cause of new back pain. For EtOH gastritis gave PPI ggt transitioning\n to PPI IV BID.\n Does not appear that there is an intraabdominal infection stopping\n vanc/cipro/flagyl. WBC from pancreatitis.\n Spoke to GI and will not place NG tube since may induce retracing and\n worsen - tear. Will maintain NPO.\n Will call out late afternoon if stable. Patient does not appear to be\n significantly withdrawing.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:53 ------\n" }, { "category": "Physician ", "chartdate": "2171-03-16 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 662009, "text": "Chief Complaint: GIB\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 women with h/o ETOH abuse, presents with hematemesis, melena.\n Came to ED where initial BP stable, but tachy to 147, had brief period\n of HOTN and got IVF and blood. Also found to be in acute renal failure\n with anion gap acidosis. Also with evidence of pancreatitis\n 24 Hour Events:\n MULTI LUMEN - START 02:51 AM\n EKG - At 04:28 AM\n Allergies:\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 02:30 AM\n Ciprofloxacin - 03:26 AM\n Metronidazole - 08:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:15 AM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n cipro\n vanco\n flagyl\n folate\n protonix\n thiamine\n pyridoxine\n CIWA with ativan\n zofran\n Changes to medical and family history:\n no h/o withdrawl from ETOH\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 09:48 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: 112 (109 - 133) bpm\n BP: 128/92(100) {122/90(98) - 151/111(119)} mmHg\n RR: 23 (18 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 65 kg (admission): 65 kg\n Total In:\n 5,637 mL\n PO:\n TF:\n IVF:\n 3,937 mL\n Blood products:\n Total out:\n 0 mL\n 1,440 mL\n Urine:\n 840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,197 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.22/11/183/15/-20\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)\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: Tender: difusely, no rebound.\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: 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, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 12.0 g/dL\n 109 K/uL\n 375 mg/dL\n 0.8 mg/dL\n 15 mEq/L\n 4.2 mEq/L\n 6 mg/dL\n 102 mEq/L\n 136 mEq/L\n 34.4 %\n 10.7 K/uL\n [image002.jpg]\n 02:55 AM\n 03:53 AM\n 07:15 AM\n WBC\n 14.5\n 10.7\n Hct\n 43.5\n 34.4\n Plt\n 136\n 109\n Cr\n 1.1\n 0.8\n TropT\n <0.01\n TCO2\n 5\n Glucose\n 288\n 375\n Other labs: PT / PTT / INR:15.0/25.3/1.3, CK / CKMB /\n Troponin-T:99//<0.01, ALT / AST:25/64, Alk Phos / T Bili:132/0.6,\n Amylase / Lipase:/723, Differential-Neuts:81.0 %, Band:11.0 %,\n Lymph:2.0 %, Mono:6.0 %, Eos:0.0 %, Lactic Acid:1.8 mmol/L, Albumin:3.7\n g/dL, LDH:420 IU/L, Ca++:7.5 mg/dL, Mg++:1.2 mg/dL, PO4:0.6 mg/dL\n Imaging: CT torso: Mild colitis. No evidence of pancreatic edema\n Assessment and Plan\n UGIB: Not further bleeding. Could be tear versus PUD.\n Less likely variceal bleed as now clear evidence of cirrhosis.\n Continue PPI\n Metabolic acidosis: likely partially due to lactic acidosis from\n wretching as well as alchoholic ketosis.\n ETOH abuse: continue multivitamins,thiamine, folate. CIWA scale.\n Pancreatitis/abdominal pain: likely due to ETOH, no stones on CT.\n Keep close watch on urine output, if decreasing increase fluids.\n antibiotics: no clear evidence of infection.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:51 AM\n Comments: if stable can remove groin line\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: 40 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2171-03-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 662200, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Pt cont to have low electrolyte values. Urine output acceptable.\n Taking clear liquids w/o incident. VSS, no ectopy noted.\n Action:\n Lytes replaced as needed md\ns orders.\n Response:\n K 3.4 from 2.9, magnesium level to be rechecked. Hct stable.\n Plan:\n Cont serial labs replace as needed and ordered by md.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt c/o mild to mod abd pain w/ movement.\n Action:\n Pt repositioned, pain assessed\n medication offered.\n Response:\n Pt admits to good pain management w/ out pain med.\n Plan:\n Cont to monitor for worsening pain, pain meds if needed.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting. Stool x2\n Action:\n stool guiac\nd, pt started on clear liquids.\n Response:\n stool guiac negative, tolerating po\n Plan:\n Cont serial hct\ns, monitor for s/s of bleeding.\n Pt is a 44 y.o. female with PMH of bipolar disorder, ETOH abuse,\n smoking, depression. C/o epigastric pain x 2+ days, vomiting\n BRB/coffeegrounds x 12hrs before EMTs were called to pt\ns place of\n living in group home. When EMT arrived, pt\ns SBP 60s, HR 150s, RR 40s,\n O2 sats 90. No IV access could be achieved in the field except for an\n 18g in pts R ankle. On arrival to , pt\ns vitals were unchanged. R fem\n stick attempt at central access yielding in knicked artery\n compression\n held x1hr, pressure dsg applied, hematoma at R fem site. L fem site\n central access achieved. Pt given emergent 2 U PRBCs. At this time, pt\n became HYPERtensive to 170s. Labs significant for elevated K (most\n recent 6.3), Bicarb 5, INR 1.4 (Given 10mg Vit K.) and abnormal ABG\n severe resp acidosis.\n ICU course: EGD done showing small tear. Acidosis\n improved w/ bicarb drip, pt became consistently hypokalemic, mult k\n boluses given, sugars elevated, on insulin gtts which was d/c\nd today.\n Mental status improved, pt a/ox3. Pupils equal and reactive. Lungs\n cta bilat. No c/o sob. Abd soft, positive bowel sounds. R groin\n hematomas significantly smaller, pressure dressing changed.\n" }, { "category": "Nursing", "chartdate": "2171-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 662077, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt a/ox3, lethargic but easy to awaken. No emesis, no stool. Pt c/o\n abd pain w/ movement\n otherwise appears comfortable at rest, at times\n restless/anxious. Pt started ice chips, no c/o nausea. Pt states she is\n feeling hungry again.\n Action:\n Given 2mg ativan for restlessness ~0200.\n Response:\n Hct cont with slightly downward trend. No melena or emesis. No\n apparent s/s bleeding.\n Plan:\n Cont to monitor for s/s of bleeding. Serial labs. Pt teaching and\n support.\n Hyperglycemia\n Assessment:\n Blood sugars cont to be elevated (see flowsheets for details).\n Action:\n Pt on titrated insulin gtt.\n Response:\n Blood sugars labile between 70-200s.\n Plan:\n Cont to monitor glucose per protocol. Discontinue and use RISS when\n more controlled.\n" }, { "category": "Nursing", "chartdate": "2171-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 662078, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Electrolytes cont to be abnormal. K 3.1 with this AM\ns labs, phos 1.5.\n No viewed ectopy, HR NSR-ST.\n Action:\n Lytes repleted\n 2gm mag, Kphos 15mmol/500cc, 30mmol/500cc x2, KCl\n 20mEq/50cc x2.\n Response:\n Plan:\n Cont to monitor continuous EKG. Replete lytes PRN, Labs PRN.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt a/ox3, lethargic but easy to awaken. No emesis, no stool. Pt c/o\n abd pain w/ movement\n otherwise appears comfortable at rest, at times\n restless/anxious. Pt started ice chips, no c/o nausea. Pt states she is\n feeling hungry again.\n Action:\n Given 2mg ativan for restlessness ~0200.\n Response:\n Hct cont with slightly downward trend. No melena or emesis. No\n apparent s/s bleeding.\n Plan:\n Cont to monitor for s/s of bleeding. Serial labs. Pt teaching and\n support.\n Hyperglycemia\n Assessment:\n Blood sugars cont to be elevated (see flowsheets for details).\n Action:\n Pt on titrated insulin gtt.\n Response:\n Blood sugars labile between 70-200s.\n Plan:\n Cont to monitor glucose per protocol. Discontinue and use RISS when\n more controlled.\n" }, { "category": "Nursing", "chartdate": "2171-03-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 662198, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Pt cont to have low electrolyte values. Urine output acceptable.\n Taking clear liquids w/o incident. VSS, no ectopy noted.\n Action:\n Lytes replaced as needed md\ns orders.\n Response:\n K 3.4 from 2.9, magnesium level to be rechecked. Hct stable.\n Plan:\n Cont serial labs replace as needed and ordered by md.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt c/o mild to mod abd pain w/ movement.\n Action:\n Pt repositioned, pain assessed\n medication offered.\n Response:\n Pt admits to good pain management w/ out pain med.\n Plan:\n Cont to monitor for worsening pain, pain meds if needed.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting. Stool x2\n Action:\n stool guiac\nd, pt started on clear liquids.\n Response:\n stool guiac negative, tolerating po\n Plan:\n Cont serial hct\ns, monitor for s/s of bleeding.\n Pt is a 44 y.o. female with PMH of bipolar disorder, ETOH abuse,\n smoking, depression. C/o epigastric pain x 2+ days, vomiting\n BRB/coffeegrounds x 12hrs before EMTs were called to pt\ns place of\n living in group home. When EMT arrived, pt\ns SBP 60s, HR 150s, RR 40s,\n O2 sats 90. No IV access could be achieved in the field except for an\n 18g in pts R ankle. On arrival to , pt\ns vitals were unchanged. R fem\n stick attempt at central access yielding in knicked artery\n compression\n held x1hr, pressure dsg applied, hematoma at R fem site. L fem site\n central access achieved. Pt given emergent 2 U PRBCs. At this time, pt\n became HYPERtensive to 170s. Labs significant for elevated K (most\n recent 6.3), Bicarb 5, INR 1.4 (Given 10mg Vit K.) and abnormal ABG\n severe resp acidosis.\n ICU course: acidosis improved w/ bicarb drip, pt became consistently\n hypokalemic, mult k boluses given, sugars elevated, on insulin gtts\n which was d/c\nd today. Mental status improved, pt a/ox3. Pupils equal\n and reactive. Lungs cta bilat. No c/o sob. Abd soft, positive bowel\n sounds. R groin hematomas significantly smaller, pressure dressing\n changed.\n" }, { "category": "Physician ", "chartdate": "2171-03-16 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 661931, "text": "Chief Complaint: abdominal pain, vomitting\n HPI:\n 44M with Bipolar and alcohol abuse who presents with 1 day of\n epigastric pain and vomitting of bloody emesis (red and black). She\n also reports black stools recently. She reports that she drinks vodka\n daily (or every other day). She has not been sober for over a year.\n She has not had withdrawl before. She denies any sob/cp/urinary sxs.\n .\n In the ED, initial vs were: 99.4 148 116/50 37 90% on NRB but BP\n dropped to 60/42 transiently and improved when patient was given 2LNS\n and 1 upRBCs. Pt also given protonix, octreotide, and vanco. Labs\n with severe anion gap acidosis, ARF, leukocytosis. NG lavage with\n light yellow liquid. No stool in the vault. GI saw and deferred scope\n unless actively bleeding.\n .\n In the MICU she was normotensive, tachycardic, nauseous with some\n coffee ground emesis. She denies any ingestion of asa/nsaids/other\n pills/other fluids. Denies suicidal ideation.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 02:30 AM\n Ciprofloxacin - 03:26 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:15 AM\n Other medications:\n seroquel\n celexa\n lamictal\n percocet\n Past medical history:\n Family history:\n Social History:\n Bipolar, h/o suicidal ideation\n Alcohol abuse\n Percocet abuse\n Tobacco abuse\n Strong family h/o alcohol abuse.\n Occupation: diability\n Drugs: percocet\n Tobacco: yes\n Alcohol: Yes - last drink 2 days ago\n Other: lives in group home.\n Review of systems:\n Constitutional: Weight loss\n Ear, Nose, Throat: Dry mouth\n Nutritional Support: NPO\n Gastrointestinal: Abdominal pain, Nausea, Emesis\n Endocrine: Hyperglycemia\n Heme / Lymph: Coagulopathy\n Psychiatric / Sleep: Agitated\n Pain: Severe\n Pain location: epigastrium - band\n Flowsheet Data as of 05:47 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: 131 (131 - 133) bpm\n BP: 125/93(101) {125/93(101) - 151/111(119)} mmHg\n RR: 32 (18 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 65 kg (admission): 65 kg\n Total In:\n 3,715 mL\n PO:\n TF:\n IVF:\n 2,015 mL\n Blood products:\n Total out:\n 0 mL\n 1,060 mL\n Urine:\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,660 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.22/11/183/6/-20\n Physical Examination\n General: Alert, uncomfortable, oriented\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, Tender in epigastrum, non-distended, bowel sounds\n present.\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema.\n right pressure dressing over femoral artery. Left Fem CVL.\n Labs / Radiology\n 136 K/uL\n 14.6 g/dL\n 288 mg/dL\n 1.1 mg/dL\n 7 mg/dL\n 6 mEq/L\n 100 mEq/L\n 6.3 mEq/L\n 134 mEq/L\n 43.5 %\n 14.5 K/uL\n [image002.jpg]\n \n 2:33 A2/28/ 02:55 AM\n \n 10:20 P2/28/ 03:53 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 14.5\n Hct\n 43.5\n Plt\n 136\n Cr\n 1.1\n TropT\n <0.01\n TC02\n 5\n Glucose\n 288\n Other labs: PT / PTT / INR:15.0/25.3/1.3, CK / CKMB /\n Troponin-T:99//<0.01, ALT / AST:31/92, Alk Phos / T Bili:132/0.6,\n Amylase / Lipase:/723, Differential-Neuts:81.0 %, Band:11.0 %,\n Lymph:2.0 %, Mono:6.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L, Albumin:4.5\n g/dL, LDH:420 IU/L, Ca++:8.4 mg/dL, Mg++:1.4 mg/dL, PO4:2.1 mg/dL\n Imaging: CT Torso: no parenchymal abnormalities, no pna. Equivical mild\n ascending colon colitis.\n 6mm contrast collection related to either pseudoaneurysm or active\n extrav in rt groin off branch of rt SFA within surrounding hematoma.\n Recommend compression to region.\n Microbiology: pending\n ECG: Sinus Tach with nl axis, nl intervals - narrow complex QRS, T\n waves possibly slightly peaked in V2-V6.\n Assessment and Plan\n Assessment and Plan: This is a 44F with EtOH, abdominal pain,\n hemetemesis and significant metabolic acidosis.\n .\n # Acidosis: Patient has Metabolic Anion Gap acidosis, with likely some\n metabolic alkalosis given emesis and respiratory compensation. Her Osm\n Gap is elevated at 23 (nl<10). Most likely this is alcoholic\n ketoacidosis with a few urine ketones (mostly not captured by ketone\n assay in alcoholic ketoacidosis). Would also consider other\n ingestions. She has mild lactate. She has a good respiratory\n compensation for this.\n - Rehydration with bicarb with dextrose\n - Phosphate repletion as needed\n - thiamine, folate, b6\n .\n # ?Bloody emesis: Pt could have tears, variceal\n bleeding, gastritis or PUD.\n - NPO for EGD in am or sooner\n - Monitor hcts\n - GI following, if hct drop or evidence of continued bleeding, will\n call them in again.\n - PPI IV\n .\n # Abdominal Pain: Pt with epigastric pain, nausea, vomitting, elevated\n lipase, likely Pancreatitis. Patient had elevated WBC and appeared\n hemoconcentrated. CT with ?colitis, but pt without diarrhea.\n - NPO & IVF\n - vanc/cipro/flagyl to cover for potential abdominal infection\n .\n # Tachycardia: Likely multifactorial from pain, etoh withdrawl, with\n other potential components including hypovolemia and sepsis.\n - IVF\n - CIWA and treatment\n .\n # Hypotension: Resolved with 2L NS and 1upRBC. Will monitor closely\n .\n # Hyperkalemia: likely to resolve as acidosis resolves.\n - Monitor with Q4hr labs, and EKG as needed\n - Telemetry\n .\n # Hyperglycemia: ISS\n .\n # Elevated Cr: Likely ARF given baseline of 0.5-0.6. Trial of\n rehydration. Watch carefully as also a result of other ingestions.\n - IVF\n .\n # Right SFA exavezation:\n - pressure dressing\n - monitor hcts/size of hematoma\n .\n # Alcohol Abuse:\n - CIWA with ativan.\n - Thiamine, folate\n .\n # FEN: No IVF, replete electrolytes, NPO\n # Prophylaxis: Pneumoboots, consider hep sq in am\n # Access: peripherals, left fem\n # Code: presumed full\n # Communication: Patient\n # Disposition: icu\n .\n ICU Care\n Nutrition:\n Glycemic Control: ISS\n Lines: fem line\n 18 Gauge - 02:46 AM\n Multi Lumen - 02:51 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2171-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 661940, "text": "Pt is a 44 y.o. female with PMH of bipolar disorder, ETOH abuse,\n smoking, depression. C/o epigastric pain x 2+ days, vomiting\n BRB/coffeegrounds x 12hrs before EMTs were called to pt\ns place of\n living in group home. When EMT arrived, pt\ns SBP 60s, HR 150s, RR 40s,\n O2 sats 90. No IV access could be achieved in the field except for an\n 18g in pts R ankle. On arrival to , pt\ns vitals were unchanged. R fem\n stick attempt at central access yielding in knicked artery\n compression\n held x1hr, pressure dsg applied, hematoma at R fem site. L fem site\n central access achieved. Pt given emergent 2 U PRBCs. At this time, pt\n became HYPERtensive to 170s. Labs significant for elevated K (most\n recent 6.3), Bicarb 5, INR 1.4 (Given 10mg Vit K.) and abnormal ABG\n severe resp acidosis.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt reports drinking ~pint vodka/day. States her last drink was 2 days\n ago. Extremely restless, agitated. Several attempts to get oob and\n remove invasive lines made. Pt is ox2-3 upon questioning, but at same\n time confused.\n Action:\n Pt safety measures taken. Ativan per CIWA scale, given as 1x order MR1\n for total of 2mg.\n Response:\n Following ativan boluses, pt slightly more relaxed and able to sleep\n for ~15 min intervals. HR still tachycardic~120s.\n Plan:\n Cont pt safety measures. Pt needs sitter. Ativan PRN per CIWA. Monitor\n for s/s of worsening withdrawal.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K with AM labs 6.3\n Action:\n Thiamine 100mg given IVP in anticipation for insulin/glucose IVP per\n order MICU. Decision made for no treatment of elevated K\n monitoring,\n EKG done.\n Response:\n No ectopy, abnormal EKG seen.\n Plan:\n Cont to monitor. Re-check labs again in AM per order MICU.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt vomiting in ED\nclear, green emesis\n. Upon arrival to SICU, vomiting\n brown/black colored emesis into bed sheets.\n Action:\n Zofran ordered, but never given as pt calmed down after turning. Bucket\n kept at bedside.\n Response:\n No more episodes of emesis this shift.\n Plan:\n Cont to monitor. ?Scope necessary. ?NGT placement by MICU for lavage.\n Guaic next available specimen for gastric occult blood.\n" }, { "category": "Nursing", "chartdate": "2171-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 662046, "text": "Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt a/ox3, lethargic but easy to awaken. No emesis, no stool. Pt c/o\n abd pain w/ movement\n otherwise appears comfortable at rest, no pain\n medications required this shift. Pt started ice chips, no c/o nausea.\n Action:\n Pt underwent an endoscopy by GI Fellow and attending. Per fellow pt\n has sm\n tear\n Response:\n Hct trending down. No melena or emesis.\n Plan:\n Cont to monitor for s/s of bleeding. Serial labs. Pt teaching and\n support.\n Hyperglycemia\n Assessment:\n Blood sugars cont to be elevated (see flowsheets for details).\n Action:\n Pt started on insulin gtts.\n Response:\n Blood sugars decreased to low of 60\n amp D50 given, bsugar improved.\n Plan:\n Cont to monitor glucose per protocol, ssri vs insulin gtt.\n Pt\ns electrolytes cont to be abnormal. Electrolytes repleted as\n indicated md\ns orders. Repeat labs this pm. VSS, lowgrade temp.\n 1l NS bolus given for increasing lactate md\ns orders.\n" }, { "category": "Physician ", "chartdate": "2171-03-16 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 661918, "text": "Chief Complaint: 44 year woman with BiPolar Disease, EtOH abuse, now\n with vomiting bloody and bilious material with black stools as well\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 In ED tachycardic, tachypneic with BP's in 110's. Pressure dropped and\n received 2 liters NS, 1 Unit PRBC. Seen by GI and not thought to be\n actively bleeding. Noted to have acidosis. Abdom CT was unremarkable\n except for r groin hematoma from attempt at groin line placment\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Aspirin\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 02:30 AM\n Ciprofloxacin - 03:26 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:15 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n EtOH Abuse\n Percocet Abuse\n Polar\n EtOH abuse\n Occupation: Unemployed\n Drugs: Above\n Tobacco: Yes\n Alcohol: Above\n Other:\n Review of systems:\n Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth\n Nutritional Support: NPO\n Respiratory: Tachypnea\n Gastrointestinal: Abdominal pain, Nausea, Emesis\n Genitourinary: Foley\n Endocrine: Hyperglycemia\n Neurologic: Numbness / tingling\n Psychiatric / Sleep: Agitated\n Pain: Moderate\n Pain location: Abdomen\n Flowsheet Data as of 04:58 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: 131 (131 - 133) bpm\n BP: 125/93(101) {125/93(101) - 151/111(119)} mmHg\n RR: 32 (18 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 65 kg (admission): 65 kg\n Total In:\n 3,380 mL\n PO:\n TF:\n IVF:\n 1,680 mL\n Blood products:\n Total out:\n 0 mL\n 1,060 mL\n Urine:\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,320 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.22/11/183/6/-20\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy\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: Bowel sounds present, Tender:\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x 3, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 136 K/uL\n 43.5 %\n 14.6 g/dL\n 288 mg/dL\n 1.1 mg/dL\n 7 mg/dL\n 6 mEq/L\n 100 mEq/L\n 6.3 mEq/L\n 134 mEq/L\n 14.5 K/uL\n [image002.jpg]\n 02:55 AM\n 03:53 AM\n WBC\n 14.5\n Hct\n 43.5\n Plt\n 136\n Cr\n 1.1\n TC02\n 5\n Glucose\n 288\n Other labs: PT / PTT / INR:15.0/25.3/1.3, CK / CKMB / Troponin-T:99//,\n ALT / AST:31/92, Alk Phos / T Bili:132/0.6, Amylase / Lipase:/723,\n Differential-Neuts:81.0 %, Band:11.0 %, Lymph:2.0 %, Mono:6.0 %,\n Eos:0.0 %, Lactic Acid:2.0 mmol/L, Albumin:4.5 g/dL, LDH:420 IU/L,\n Ca++:8.4 mg/dL, Mg++:1.4 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n Assessment and Plan: This is a 44F with EtOH, abdominal pain,\n significant metabolic acidosis.\n .\n # Acidosis: Patient has Metabolic Anion Gap acidosis, with likely some\n metabolic alkalosis given emesis and respiratory compensation. Her Osm\n Gap is elevated at 23 (nl<10). Most likely this is alcoholic\n ketoacidosis with a few urine ketones (mostly not captured by ketone\n assay in alcoholic ketoacidosis). Would also consider other treatment\n and diagnosis ingestions.\n - Rehydration with bicarb, NS\n - dextrose\n - Phosphate repletion as needed\n # ?Bloody emesis: Pt could have tears, variceal\n bleeding, gastritis or PUD.\n - NPO for EGD in am or sooner\n - Monitor hcts\n - GI following, if hct drop or evidence of continued bleeding, will\n call them in again.\n - octreotide\n .\n # Abdominal Pain: Pt with epigastric pain, nausea, vomitting, elevated\n lipase, likely Pancreatitis. Patient had elevated WBC and appeared\n hemoconcentrated. CT with ?colitis, but pt without diarrhea.\n - NPO\n - IVF\n - vanc/cipro/flagyl to cover for abdominal infection.\n .\n # Tachycardia: Likely multifactorial from pain, etoh withdrawl, with\n other potential components including hypovolemia and sepsis.\n - IVF\n - CIWA and treatment\n .\n # Hypotension: Resolved with 2L NS and 1upRBC. Will monitor closely\n .\n # Elevated Cr: Likely ARF given baseline of 0.5-0.6. Trial of\n rehydration.\n - IVF\n .\n # Right SFA exavesation:\n - pressure dressing\n - monitor hcts/size of hematoma\n - vit K\n .\n # Alcohol Abuse:\n - CIWA with ativan.\n - Thiamine, folate, pyr\n .\n # FEN: No IVF, replete electrolytes, NPO\n # Prophylaxis: Pneumoboots, consider hep sq in am\n # Access: peripherals, left fem\n # Code: presumed full\n # Communication: Patient\n # Disposition: icu\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 02:46 AM\n Multi Lumen - 02:51 AM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2171-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 662047, "text": "Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt a/ox3, lethargic but easy to awaken. No emesis, no stool. Pt c/o\n abd pain w/ movement\n otherwise appears comfortable at rest, no pain\n medications required this shift. Pt started ice chips, no c/o nausea.\n Action:\n Pt underwent an endoscopy by GI Fellow and attending. Per fellow pt\n has sm\n tear\n Response:\n Hct trending down. No melena or emesis.\n Plan:\n Cont to monitor for s/s of bleeding. Serial labs. Pt teaching and\n support.\n Hyperglycemia\n Assessment:\n Blood sugars cont to be elevated (see flowsheets for details).\n Action:\n Pt started on insulin gtts.\n Response:\n Blood sugars decreased to low of 60, insulin gtt stopped -\n amp D50\n given, bsugar improved.\n Plan:\n Cont to monitor glucose per protocol, ssri vs insulin gtt.\n Pt\ns electrolytes cont to be abnormal. Electrolytes repleted as\n indicated md\ns orders. Repeat labs this pm. VSS, lowgrade temp.\n 1l NS bolus given for increasing lactate md\ns orders.\n" }, { "category": "Nursing", "chartdate": "2171-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 661919, "text": "Pt is a 44 y.o. female with PMH of bipolar disorder, ETOH abuse,\n smoking, depression. C/o epigastric pain x 2+ days, vomiting\n BRB/coffeegrounds x 12hrs before EMTs were called to pt\ns place of\n living in group home. When EMT arrived, pt\ns SBP 60s, HR 150s, RR 40s,\n O2 sats 90. No IV access could be achieved in the field except for an\n 18g in pts R ankle. On arrival to , pt\ns vitals were unchanged. R fem\n stick attempt at central access yielding in knicked artery\n compression\n held x1hr, pressure dsg applied, hematoma at R fem site. L fem site\n central access achieved. Pt given emergent 2 U PRBCs. At this time, pt\n became HYPERtensive to 170s. Labs significant for elevated K (most\n recent 6.3), Bicarb 5, INR 1.4 (Given 10mg Vit K.) and abnormal ABG\n severe resp acidosis.\n" }, { "category": "Nursing", "chartdate": "2171-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 662051, "text": "Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt a/ox3, lethargic but easy to awaken. No emesis, no stool. Pt c/o\n abd pain w/ movement\n otherwise appears comfortable at rest, no pain\n medications required this shift. Pt started ice chips, no c/o nausea.\n Action:\n Pt underwent an endoscopy by GI Fellow and attending. Per fellow pt\n has sm\n tear\n Response:\n Hct trending down. No melena or emesis.\n Plan:\n Cont to monitor for s/s of bleeding. Serial labs. Pt teaching and\n support.\n Hyperglycemia\n Assessment:\n Blood sugars cont to be elevated (see flowsheets for details).\n Action:\n Pt started on insulin gtts.\n Response:\n Blood sugars decreased to low of 60, insulin gtt stopped -\n amp D50\n given, bsugar improved.\n Plan:\n Cont to monitor glucose per protocol, ssri vs insulin gtt.\n Pt\ns electrolytes cont to be abnormal. Electrolytes repleted as\n indicated md\ns orders. Repeat labs this pm. VSS, lowgrade temp.\n 1l NS bolus given for increasing lactate md\ns orders. Acidosis\n improved with bicarb drip\n last ph 7.40, HCO3 28. Repeat vbg tonight.\n" }, { "category": "Nursing", "chartdate": "2171-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 662040, "text": "Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" } ]

[ { "category": "Echo", "chartdate": "2112-09-06 00:00:00.000", "description": "Report", "row_id": 83286, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for pericardial window. Aortic valve disease. Left ventricular function. Pericardial effusion. Preoperative assessment. Prosthetic valve function. Right ventricular function. Shortness of breath. Valvular heart disease.\nHeight: (in) 69\nWeight (lb): 150\nBSA (m2): 1.83 m2\nBP (mm Hg): 121/56\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 08:52\nTest: TEE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mildly depressed LVEF.\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). No AR.\n\nMITRAL VALVE: Mild (1+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPERICARDIUM: Large pericardial effusion. Effusion circumferential. Sustained\nRA diastolic collapse, c/w low filling pressures or early tamponade. \n collapse.\n\nGENERAL COMMENTS: Informed consent was obtained. The patient was under general\nanesthesia throughout the procedure. No TEE related complications. The patient\nappears to be in sinus rhythm. Results were personally reviewed with the MD\ncaring for the patient.\n\nConclusions:\nPre pericardial window\n\nOverall left ventricular systolic function is mildly depressed (LVEF= 45 %).\nwith mild global RV free wall hypokinesis. A bioprosthetic aortic valve\nprosthesis is present. No aortic regurgitation is seen. There is mild mitral\nregurgitation. There is a large pericardial effusion. The effusion appears\ncircumferential that more to the left and posterior. There is sustained right\natrial collapse, consistent with low filling pressures or early tamponade.\nThere is left atrial diastolic collapse. Fibrinous material noted behind the\nleft atrial wall. Dr. was notified in person of the results on\n at 830 am .\n\n\nPost pericardial window\n\nThere is trivial pericardial effusion. The fibrinous material behind the left\natrium still exists. Rest of examination in unchanged.\n\n\n" }, { "category": "Echo", "chartdate": "2112-09-05 00:00:00.000", "description": "Report", "row_id": 83287, "text": "PATIENT/TEST INFORMATION:\nIndication: fever, fatigue s/p dental. Bentall aortic root replacement with a size 27 mm Freestyle porcine composite graft on \nHeight: (in) 69\nWeight (lb): 165\nBSA (m2): 1.91 m2\nBP (mm Hg): 110/77\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 17:24\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Overall normal LVEF (>55%). Beat-to-beat variability on LVEF\ndue to irregular rhythm/premature beats. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS. Mild PR.\n\nPERICARDIUM: Large pericardial effusion. RV diastolic collapse, c/w impaired\nfillling/tamponade physiology.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). There is\nconsiderable beat-to-beat variability of the left ventricular ejection\nfraction due to an irregular rhythm/premature beats. Right ventricular chamber\nsize and free wall motion are normal. A bioprosthetic aortic valve prosthesis\nis present. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen. The pulmonary artery systolic pressure could not be\ndetermined. There is a large pericardial effusion.\n\nIMPRESSION: Large pericardial effusion - measuring up to 7 cm behind the left\nventricle and up to 2 cm in front of the right ventricle. This appears to\ntrack up anterior to the pulmonary trunk. There is intermittent invagination\nof the right ventricle (see image #87, third beat) consistent with early\ntamponade physiology. No endocarditis seen (cannot exclude). AVR appears to be\nworking appropriately.\n\nCompared with the prior study (images reviewed) of , the patient has\nhad Bentall surgery with a bioprosthetic aortic valve. There is now a large\npericardial effusion.\n\nCase discussed with Dr. , Dr. and Dr. at 1745 on day of\nstudy.\n\n\n" }, { "category": "ECG", "chartdate": "2112-09-06 00:00:00.000", "description": "Report", "row_id": 227031, "text": "Sinus rhythm with ventricular premature beats. Borderline prolongation of the\nQ-T interval. Poor R wave progression with slight ST segment elevations and\nT wave inversions in the precordial leads raise concern for myocardial\nischemia. Compared to the previous tracing of the rate has decreased\nslightly. Limb lead voltages are higher. ST-T wave changes in the precordial\nleads are similar.\n\n" }, { "category": "ECG", "chartdate": "2112-09-05 00:00:00.000", "description": "Report", "row_id": 227032, "text": "Sinus rhythm. Occasional ventricular premature beats. Borderline low limb\nlead voltage. Diffuse non-specific ST-T wave changes. Possible anteroseptal\nmyocardial infarction. Compared to the previous tracing no clear change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2112-09-05 00:00:00.000", "description": "Report", "row_id": 227033, "text": "Sinus rhythm. Possible old anteroseptal myocardial infarction. Non-specific\nT wave changes. Compared to the previous tracing of voltage is lower\nand ST-T wave changes are diffuse.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2112-09-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1256972, "text": " 9:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with s/p subxiphoid pericardial window\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old man status post subxiphoid pericardial window.\n Evaluation for pneumothorax.\n\n COMPARISON: Comparison is made to radiographs of the chest from and .\n\n FINDINGS: Frontal radiograph of the chest demonstrates interval removal of a\n left pleural tube. There is no pneumothorax. There is continued left lower\n lobe atelectasis with associated volume loss. The right lung is grossly\n clear. There is no significant pulmonary edema. The cardiomediastinal\n silhouette is unchanged since the prior study.\n\n CONCLUSION: Interval removal of left pleural tube with no evidence of\n pneumothorax. Otherwise, unchanged since the prior study.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-09-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1256934, "text": " 12:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man extubated post pericardial window\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 51-year-old male patient extubated post pericardial window\n operation, evaluate for interval change.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position. Comparison is made with the next preceding\n similar study dated . Marked regression of enlarged heart\n silhouette consistent with the performance of a pericardial window and related\n pericardial evacuation. The previously observed row of sternal wires appears\n unchanged. There is; however, evidence of renewed substernal surgical\n approach as a pleural drainage tube has been approached from below and is seen\n to drain the lateral posterior pleural sinus. No evidence of any major\n pleural effusion and no pneumothorax is identified. There exists now an\n unexplained local parenchymal density partially overlying the left-sided heart\n border. This density was not seen on the previous portable chest examination\n as it was concealed by the, at that time, very enlarged heart shadow. There\n is no evidence of newly developed pulmonary congestion or other new\n parenchymal infiltrates. No pneumothorax on either side.\n\n" }, { "category": "Radiology", "chartdate": "2112-09-05 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1256897, "text": " 5:26 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for cardiopulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 51M with fatigue, fever\n REASON FOR THIS EXAMINATION:\n eval for cardiopulmonary process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON .\n\n COMPARISON: .\n\n CLINICAL HISTORY: Fatigue, fever, question acute process in the chest.\n\n FINDINGS: PA and lateral views of the chest are provided. There is severe\n cardiomegaly, which has increased over multiple prior radiographs. Midline\n sternotomy wires are again noted. Slightly elevated left hemidiaphragm is\n again noted with probable small effusion on the left. Retrocardiac\n atelectasis is also likely present. Right lung is clear. No pneumothorax.\n Bony structures are intact.\n\n IMPRESSION: Cardiomegaly with elevated left hemidiaphragm, left lower lobe\n atelectasis and possible small left effusion. Please correlate clinically and\n with echocardiogram as pericardial effusion is a strong concern.\n SESHa\n\n" } ]

[ { "category": "Radiology", "chartdate": "2174-10-26 00:00:00.000", "description": "MR THORACIC SPINE W/O CONTRAST", "row_id": 1212301, "text": " 5:47 PM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: discitis, myelitis, disc disease\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with low back pain, leg weakness, and fevers (101.2)\n REASON FOR THIS EXAMINATION:\n discitis, myelitis, disc disease\n CONTRAINDICATIONS for IV CONTRAST:\n chronic renal insufficiency\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n WET READ: IPf WED 9:22 PM\n Limited due to motion and lack of iv contrast (low GFR).\n Evaluation of the cord/spinal canal in the upper thoracic spine is suboptimal\n due to motion.\n No abnormal STIR signal in the vertebral bodies or disk in the thoracic and\n lumbar spine to suggest osteomyelitis-discitis on a non-contrast MRI.\n Multilevel degenrative changes in the lumbar spine.\n\n D/ at 9:15 pm on .\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 75-year-old woman with low back pain, leg weakness and\n fever. To rule out discitis or osteomyelitis.\n\n STUDY: MRI thoracic and lumbar spine without contrast.\n\n COMPARISON STUDY: None.\n\n TECHNIQUE: Sagittal T1, T2, STIR and axial T2-weighted images were obtained\n of the thoracic and lumbar spine without administration of contrast.\n\n FINDINGS:\n\n THORACIC SPINE: There is increased thoracic kyphosis with dextroscoliosis of\n the upper thoracic spine.\n\n There is decreased height with anterior wedging of T4 vertebra, approximately\n 50% wedging. There is decreased height with anterior wedging of T8 vertebra,\n approximately 30% wedging. There is no associated STIR hyperintensity. These\n are suggestive of old compression fractures. There is no associated\n retropulsion.\n\n At T11-T12, there is left paracentral disc protrusion with mild inferior\n migration indenting the thecal sac.\n\n There is no evidence of significant spinal canal or neural foraminal stenosis.\n\n\n A hyperintense area is noted in the transverse process of T7 vertebra on the\n (Over)\n\n 5:47 PM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: discitis, myelitis, disc disease\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n right side on STIR images. This likely represents an atypical hemangioma.\n\n The thoracic spinal cord is normal in caliber and signal intensity.\n\n Right-sided mild pleural effusion is noted.\n\n LUMBAR SPINE: Normal curvature and alignment of the lumbar spine is\n maintained. The vertebral bodies are normal in height and marrow signal\n intensity.\n\n At L2-L3, there is ligamentum flavum thickening.\n\n At L3-L4, there is diffuse posterior disc bulge with associated ligamentum\n flavum thickening and facet arthropathy.\n\n At L4-L5, there is diffuse posterior disc bulge with associated severe facet\n arthropathy causing indentation of the thecal sac. The disc with facet\n osteophytes causes bilateral moderate neural foraminal stenosis.\n Postoperative changes are noted in the form of L4 laminectomy.\n\n At L5-S1, there is diffuse posterior disc bulge with associated annular tear.\n There is associated facet arthropathy.\n\n The conus medullaris ends at T12-L1 level. Nerve roots of cauda equina appear\n normal.\n\n Hyperintense signal is noted on STIR images in the posterior paraspinal\n muscles which could be suggestive of edema.\n\n IMPRESSION:\n 1. No evidence of osteomyelitis or discitis.\n 2. Old compression fractures of T4 and T8 vertebra.\n 3. Moderate degenerative changes in the lumbar spine, most notable at L4-L5\n level with bilateral moderate neural foraminal stenosis.\n 4. Postoperative changes in the form of L4 laminectomy.\n\n" }, { "category": "Radiology", "chartdate": "2174-10-27 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1212448, "text": " 7:36 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: assess line placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with new CVL insertion\n REASON FOR THIS EXAMINATION:\n assess line placement\n ______________________________________________________________________________\n WET READ: IPf 8:16 PM\n R IJ with tip projecting at the right ventricule. No pneumothorax. \n d/ by 8:15 pm on by phone.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:46 P.M., \n\n HISTORY: 75-year-old woman with a new central venous line inserted.\n\n IMPRESSION: AP chest compared to , 4 p.m.:\n\n Tip of a new right jugular line is low in the right atrium, no less than 6 cm\n beyond the estimated location of the superior cavoatrial junction. Small\n right pleural effusion is stable. Severe left lower lobe atelectasis and\n small left pleural effusion are unchanged since earlier in the day but both\n are substantially worse than on . Moderate cardiomegaly stable. No\n pneumothorax. No pulmonary edema or pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-10-26 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1212248, "text": " 1:29 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: obstruction, ileus, constipation\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with abdominal pain, constipation\n REASON FOR THIS EXAMINATION:\n obstruction, ileus, constipation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain, constipation, obstruction, rule out ileus.\n\n COMPARISON: .\n\n FINDINGS: There is mild dilation of the small bowel up to 3.8 cm in the mid\n abdomen. There is air within the colon; however, the colon is not distended.\n No air-fluid levels. There is no free air. There are degenerative changes\n of the lumbar spine.\n\n IMPRESSION: Nonspecific gas pattern. No definitive evidence of obstruction\n or ileus.\n\n" }, { "category": "Radiology", "chartdate": "2174-10-27 00:00:00.000", "description": "L SHOULDER 2-3 VIEWS NON TRAUMA LEFT", "row_id": 1212376, "text": " 10:39 AM\n SHOULDER VIEWS NON TRAUMA LEFT Clip # \n Reason: please include axillary or scapular Y views\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with new L shoulder pain, not R sided pain and limited range\n of motion\n REASON FOR THIS EXAMINATION:\n please include axillary or scapular Y views\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Left shoulder, three views, .\n\n CLINICAL HISTORY: 75-year-old woman with new left-sided shoulder pain.\n\n FINDINGS: There is no sign for acute fractures or dislocations. The\n glenohumeral joint is well seated on the Y view. AP view is somewhat limited\n due to the technique and projection. The visualized left lung apex is clear.\n The AC and glenohumeral joints are grossly intact.\n\n IMPRESSION:\n\n No signs for acute fractures or dislocations.\n\n" }, { "category": "Radiology", "chartdate": "2174-10-27 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1212377, "text": " 10:40 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: LEG PAIN AND FEVERS R/O DVT\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with fever, leg pain\n REASON FOR THIS EXAMINATION:\n rule out DVT\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND EXAMINATION\n\n HISTORY: Leg pain and fever. Question deep vein thrombosis.\n\n TECHNIQUE: Bilateral lower extremity venous ultrasound examination including\n Doppler studies.\n\n FINDINGS: Grayscale and Doppler son of the bilateral common femoral,\n superficial femoral and popliteal vein show normal compressibility,\n augmentation, and Doppler flow and waveforms. Paired patent posterior tibial\n and peroneal veins are noted. There is no evidence for intraluminal\n thrombosis.\n\n IMPRESSION: No evidence of deep vein thrombosis.\n\n" }, { "category": "Radiology", "chartdate": "2174-10-27 00:00:00.000", "description": "R SHOULDER 2-3 VIEWS NON TRAUMA RIGHT", "row_id": 1212354, "text": " 8:51 AM\n SHOULDER VIEWS NON TRAUMA RIGHT Clip # \n Reason: arthritis, effusion, fracture\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with intense, R side shoulder pain\n REASON FOR THIS EXAMINATION:\n arthritis, effusion, fracture\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right shoulder, .\n\n CLINICAL HISTORY: 75-year-old woman with intense right-sided shoulder pain.\n\n FINDINGS: There is hardware within the right clavicle fixating a healed mid\n shaft fracture. Degenerative changes of the AC joint with widening of the AC\n interval is seen and this is likely related to previous trauma. There is also\n irregularity of the superolateral aspect of the humeral head presumably\n related to previous trauma. Subtle fracture in this area would be difficult\n to exclude. If there is high clinical concern, MRI could be performed.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-10-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1212489, "text": " 5:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with fever and hypoxia\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Patient with fever and hypoxia, for interval changes.\n\n TECHNIQUE: AP semi-upright portable radiograph of chest.\n\n Comparisons were made with prior chest radiographs through \n with the most recent from .\n\n FINDINGS: Right internal jugular line is in low position and is almost\n terminating into the base of the right atrium. Consider retracting the\n catheter by approximately 2-3 cm.\n\n IMPRESSION: Since , the right pulmonary artery appears\n bigger, and there is a new ill-defined hazy opacity in the right lung base.\n Pleural effusion, if any, is minimal on the right side. The heart size is\n mild to moderately enlarged. Mediastinal contours are unchanged.\n\n The appearance of prominent right pulmonary artery and new right lower lung\n opacity can be explained by cardiac decompensation leading to pulmonary\n congestion, which is further supported by mild- to moderate-sized\n cardiomegaly. Alternatively, this finding can also be seen in a large\n pulmonary embolus leading to lung infarct. Clinical correlation is required to\n see if CTA is warranted.\n\n Findings were discussed with Dr. on at 10.24 a.m.\n\n" }, { "category": "Radiology", "chartdate": "2174-10-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1211784, "text": " 1:30 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for pneumonia at LLL or other evidence of infiltrat\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with new fever and possible LLL infiltrate on portable xray\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia at LLL or other evidence of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST RADIOGRAPH DATED \n\n COMPARISON: Chest radiograph of earlier the same date.\n\n FINDINGS: Cardiac silhouette is upper limits of normal in size with left\n ventricular configuration. Aorta is tortuous, and pulmonary vascularity is\n within normal limits. Linear atelectasis within the lingula is unchanged. A\n confluent area of opacity is identified in the retrocardiac region on the\n lateral view and could reflect either atelectasis or early pneumonia.\n Bilateral small pleural effusions are present, left greater than right.\n Compression deformities in the thoracic spine are unchanged since \n chest x-ray. Healed right clavicular fracture is also unchanged.\n\n IMPRESSION: Left retrocardiac opacity which may be due to either atelectasis\n or pneumonia. Bilateral small pleural effusions, left greater than right.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-10-24 00:00:00.000", "description": "LUMBO-SACRAL SPINE (AP & LAT)", "row_id": 1211979, "text": " 6:32 PM\n LUMBO-SACRAL SPINE (AP & LAT) Clip # \n Reason: compression fracture, degenerative joint disease\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with low back and abdominal pain\n REASON FOR THIS EXAMINATION:\n compression fracture, degenerative joint disease\n ______________________________________________________________________________\n FINAL REPORT\n LUMBAR SPINE RADIOGRAPHS\n\n CLINICAL INDICATION: 75-year-old woman with low back pain and abdominal pain,\n assess for compression fracture or degenerative joint disease.\n\n COMPARISON: Abdomen and Pelvis CT.\n\n FINDINGS: Bowel gas obscures detail of the osseous sacrum and bilateral ilium.\n Multiple surgical clips are seen in the right lower quadrant and in the mid\n abdomen. Osteopenia of the osseous structures. There are mild degenerative\n changes in the lumbar spine with trace inferior endplate osteophyte formation\n at L2 and L4. No definite compression deformities are seen. L5-S1 bony fusion\n mass\n\n IMPRESSION: No definite acute fractures are seen with preserved vertebral\n alignment. If there is continued clinical concern for acute fracture,\n consider correlation with recent CT or an MRI for further assessment.\n\n" }, { "category": "Radiology", "chartdate": "2174-10-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1212419, "text": " 3:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate, edema\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with respiratory distress hypoxia\n REASON FOR THIS EXAMINATION:\n infiltrate, edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old female with respiratory distress and hypoxia.\n\n COMPARISON: Chest radiograph from .\n\n PORTABLE AP CHEST RADIOGRAPH: The patient is rotated to the right limiting\n complete evaluation of mediastinal structures. The lung volumes are also low.\n Despite technical issues, there is increased consolidation in the retrocardiac\n region, which is concerning for new aspiration or pneumonia. Additionally,\n there is increased blunting of bilateral costophrenic angles suggesting\n developing small pleural effusions. Within the limitations of the study, the\n cardiomediastinal and hilar structures appear within normal limits. No overt\n pulmonary edema is identified. Right clavicular hardware appears grossly\n intact, though incompletely evaluated.\n\n IMPRESSION:\n 1. Increasing retrocardiac density, concerning for new aspiration or\n developing pneumonia\n 2. Small bilateral pleural effusions, increased from prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-10-24 00:00:00.000", "description": "CT ABD & PELVIS WITH CONTRAST", "row_id": 1211923, "text": " 12:35 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: evaluate for intra-abd infection, ischemic mesentery, or col\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with diffuse, R sided abdominal pain primarily with fever.\n S/p colectomy previously for ischemic colitis\n REASON FOR THIS EXAMINATION:\n evaluate for intra-abd infection, ischemic mesentery, or colitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old woman with diffuse right-sided abdominal pain and\n fever. Request is to evaluate for ischemic colitis or intra-abdominal focus\n of infection.\n\n COMPARISON: Reference is made to the most recent non-contrast CT of abdomen\n and pelvis dated .\n\n TECHNIQUE: Multidetector CT-acquired axial images were obtained from the lung\n bases to the level of the lesser trochanters following administration of oral\n and intravenous contrast. Coronal and sagittal reformats were evaluated.\n\n FINDINGS:\n\n CT OF ABDOMEN:\n\n Mild dependent atelectasis is seen bilaterally and is somewhat more pronounced\n than on the prior CT scan. There are no pleural effusions. There are no\n isolated, discrete pulmonary nodules in the imaged lower lobes.\n\n No focal liver lesions are identified. There is pneumobilia and surgical\n clips in the gallbladder fossa in keeping with prior cholecystectomy and\n choledochoduodenostomy. Appearances are unchanged from the prior study.\n Normal appearance of the pancreas and spleen. Of note the pancreatic duct is\n of normal calibre measuring 2mm . Both adrenal glands are normal in size with\n no focal lesions. There is bilateral renal cortical scarring, more pronounced\n on the right side. Multiple low attenuation cortical hypodensities are in\n keeping with simple cysts. There is no hydronephrosis. Previously described\n stranding of the fat adjacent to the right lower renal pole has improved since\n the prior study. Previous colonic resection with coloileal anastomosis noted.\n The large and small bowel are within normal limits with no evidence of focal\n dilatation or mural mass lesions. There is no significant mesenteric\n stranding and no enlarged abdominal lymph nodes. The abdominal aorta is\n heavily calcified but is normal in caliber throughout its course. The celiac ,\n SMA and origins are normal in calibre.\n\n CT OF PELVIS: The bladder is distended. Satisfactory appearance of the\n rectum and sigmoid colon. Of note, oral contrast has passed to the level of\n the rectum. There are numerous nonenlarged inguinal lymph nodes. No\n pathologically enlarged inguinal or pelvic sidewall lymph nodes are\n identified. Stranding in the subcutaneous tissues posteriorly is again noted\n (Over)\n\n 12:35 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: evaluate for intra-abd infection, ischemic mesentery, or col\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n with foci of calcification (3:49, 48), findings are unchanged.\n\n OSSEOUS STRUCTURES: Note is made of a previous laminectomy at the level of L5\n with associated post-surgical changes. No lytic or sclerotic bone lesions are\n identified.\n\n IMPRESSION:\n 1. No evidence of acute intra-abdominal pathology.\n 2. Normal appearance of the large and small bowel, post resection and\n anastamosis. No features to suggest colitis or enteritis.\n 3. Atrophic kidneys with multiple renal cysts as described.\n\n" }, { "category": "Radiology", "chartdate": "2174-10-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1212458, "text": ", MED 8:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute process\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for acute process\n CONTRAINDICATIONS for IV CONTRAST:\n chronic kidney disease\n ______________________________________________________________________________\n PFI REPORT\n PFI: Suboptimal scan due to patient motion in the scanner. With this\n limitation in mind, no acute intracranial process is seen.\n\n" }, { "category": "Radiology", "chartdate": "2174-10-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1212457, "text": " 8:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute process\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for acute process\n CONTRAINDICATIONS for IV CONTRAST:\n chronic kidney disease\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf 10:12 PM\n PFI: Suboptimal scan due to patient motion in the scanner. With this\n limitation in mind, no acute intracranial process is seen.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Altered mental status.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered.\n\n COMPARISON: CT head and MR .\n\n FINDINGS: This scan is suboptimal due to patient motion in the scanner. With\n this limitation in mind, there is no evidence of acute hemorrhage, large acute\n territorial infarction or large masses. Small hypodensity is seen in the left\n basal ganglia similar to prior, likely old lacune. Ventricles and sulci are\n slightly prominent, likely age related. There is no shift of midline\n structures. There is moderate mucosal thickening in the bilateral maxillary\n sinuses. Mucosal thickening is seen in the ethmoid air cells.\n\n IMPRESSION: Suboptimal scan due to patient motion in the scanner. With this\n limitation in mind, no acute intracranial process is seen.\n\n" }, { "category": "Radiology", "chartdate": "2174-10-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1211737, "text": " 3:40 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Is there a new infiltrate or pulm edema?\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with h/o chronic abd pain, diarrhea admitted w/ worse sx, no\n cause found. Now w/ new rales and dropped sats.\n REASON FOR THIS EXAMINATION:\n Is there a new infiltrate or pulm edema?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: Chest x-ray .\n\n FINDINGS: Cardiac silhouette is upper limits of normal in size, and\n demonstrates left ventricular configuration. Aorta is tortuous without\n change. Pulmonary vascularity is normal. Within the lungs, a small linear\n opacity in the lingula is consistent with linear atelectasis. A questionable\n poorly defined opacity has developed at the left base partially obscuring the\n mid portion of the left hemidiaphragm contour. PA and lateral chest\n radiographs would be helpful for more complete evaluation of this region, in\n order to exclude a developing pneumonia at this site.\n\n\n" }, { "category": "ECG", "chartdate": "2174-10-27 00:00:00.000", "description": "Report", "row_id": 149798, "text": "Baseline artifact. Probable sinus rhythm with atrial ectopy. Left axis\ndeviation. Late transition with small R waves in the anterior leads consistent\nwith possible infarction. Non-specific ST-T wave changes. Compared to the\nprevious tracing of ST-T wave changes are less and Q waves are more\nprominent in the anterior leads.\n\n" } ]

[ { "category": "Echo", "chartdate": "2203-11-19 00:00:00.000", "description": "Report", "row_id": 101027, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Shock.\nHeight: (in) 60\nWeight (lb): 135\nBSA (m2): 1.58 m2\nBP (mm Hg): 102/52\nHR (bpm): 84\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 and RA cavity sizes.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). TDI E/e' >15, suggesting PCWP>18mmHg. No resting\nLVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic\nfunction.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: 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: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed by telephone with\nthe houseofficer caring for the patient.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size and\nregional/global systolic function (LVEF>65%). Tissue Doppler imaging suggests\nan increased left ventricular filling pressure (PCWP>18mmHg). The right\nventricular cavity is mildly dilated with borderline normal free wall\nfunction. The diameters of aorta at the sinus, ascending and arch levels are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic stenosis or aortic regurgitation. Normal\nmitral valve morphology with trivial mitral regurgitation. There is no mitral\nvalve prolapse. The pulmonary artery systolic pressure could not be\ndetermined. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with normal regional\nand global systolic function. Mild right ventricular cavity enlargement with\nlow normal free wall motion. Increased PCWP.\nIs there a history to suggest pulmonary embolism or other acute pulmonary\nprocess?\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": "2203-11-18 00:00:00.000", "description": "Report", "row_id": 301401, "text": "Sinus rhythm. Compared to the previous tracing bifascicular block has resolved.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2203-11-18 00:00:00.000", "description": "Report", "row_id": 301402, "text": "Sinus rhythm. Right bundle-branch block with left posterior hemiblock. Compared\nto the previous tracing of bifascicular block is new and the rate is\nslightly increased.\nTRACING #1\n\n" } ]

[ { "category": "ECG", "chartdate": "2141-03-17 00:00:00.000", "description": "Report", "row_id": 116256, "text": "Atrial fibrillation/flutter. Since tracing #1, the rate is more rapid. There is\notherwise, no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2141-03-17 00:00:00.000", "description": "Report", "row_id": 116257, "text": "Atrial fibrillation/flutter with a relatively rapid ventricular response. No\ndiagnostic change compared to the previous tracing of .\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2141-03-16 00:00:00.000", "description": "Report", "row_id": 116258, "text": "Atrial fibrillation with somewhat rapid ventricular response. Since the\nprevious tracing of atrial fibrillation is a new rhythm. The rate is\nsomewhat faster. Otherwise, no significant change.\n\n" }, { "category": "ECG", "chartdate": "2141-03-20 00:00:00.000", "description": "Report", "row_id": 116218, "text": "Sinus tachycardia\nSupraventricular extrasystoles\nLeft ventricular hypertrophy\nNonspecific ST-T wave changes\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2141-03-20 00:00:00.000", "description": "Report", "row_id": 116219, "text": "Baseline artifact. Sinus rhythm. Left ventricular hypertrophy. Since the\nprevious tracing of rapid atrial fibrillation and ST-T wave changes are\nnow absent.\n\n" }, { "category": "Radiology", "chartdate": "2141-03-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 903501, "text": " 1:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: HYPOTENSION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 y/o M with fever and hypotension\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW CHEST\n\n INDICATION: Fever and hypotension.\n\n COMPARISON: , and .\n\n FINDINGS: Single bedside AP upright chest exam demonstrates mild cardiomegaly\n and a tortuous aorta. Pulmonary vasculature is slightly more prominent than\n previously. Small bilateral pleural effusions have also increased slightly in\n the interval. Patient is status post sternotomy. Previously visible dialysis\n catheter is no longer seen. There are sutures in the right lung apex and\n pleural thickening is again noted.\n\n IMPRESSION: Worsening mild CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 904446, "text": " 3:53 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o mass, mass effect\n Admitting Diagnosis: HYPOTENSION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 y/o M with mental status changes\n REASON FOR THIS EXAMINATION:\n r/o mass, mass effect\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status change.\n\n COMPARISON: .\n\n NON-CONTRAST HEAD CT SCAN: There is no evidence of acute intracranial\n hemorrhage or shift of the normally midline structures. The ventricles and\n sulci are prominent, consistent with involutional change. There is malacia of\n the left cerebellum, consistent with prior infarction, unchanged. There is\n hypodensity of the cerebral periventricular white matter, consistent with\n chronic microvascular ischemia. The -white matter differentiation is\n preserved. Chronic changes are again identified within the frontal air cells\n the left sphenoid air cell with soft tissue thickening and sclerosis of the\n surrounding bone. A left orbital prosthesis is again noted.\n\n IMPRESSION:\n 1. No evidence of intracranial hemorrhage.\n 2. Old left cerebellar infarction.\n 3. Soft tissue thickening and sclerosis involving the frontal and left\n sphenoid sinus, likely representing a chronic infectious process.\n\n Findings were discussed with Dr. at the time of interpretation.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-28 00:00:00.000", "description": "TUNNELED W/O PORT", "row_id": 904369, "text": " 7:31 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: Please place tunnelled HD catheter\n Admitting Diagnosis: HYPOTENSION;TELEMETRY\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1750 CATH,HEMO/PERTI DIALYSIS LONG *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 y/o M ESRD on HD, currently has temp L IJ line\n REASON FOR THIS EXAMINATION:\n Please place tunnelled HD catheter\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Temporary dialysis line, please convert to permanent.\n\n TECHNIQUE/FINDINGS: After informed consent was obtained, the previously\n placed temporary left IJ catheter was prepped and draped in sterile fashion.\n The Seldinger technique was used to remove this catheter over an Amplatz wire\n after which the tract was dilated and a 15-French sheath advanced into the\n SVC.\n\n 1% lidocaine was then used to create a subcutaneous tract after which this was\n dilated and placement of a 14.5-French dual lumen catheter was performed.\n Using fluoroscopic guidance, the catheter was then advanced through the peel-\n away sheath into the proximal right atrium without difficulty.\n\n The catheter was sutured in place with 0-6 silk suture, both ports freely\n aspirated and infused.\n\n IMPRESSION: Conversion of a temporary to permanent left IJ catheter, 19 cm\n tip to cuff, tip in the proximal right atrium, ready for use.\n\n" }, { "category": "Radiology", "chartdate": "2141-03-17 00:00:00.000", "description": "RP FEMORAL VASCULAR US RIGHT PORT", "row_id": 903032, "text": " 7:32 PM\n FEMORAL VASCULAR US RIGHT PORT Clip # \n Reason: please eval for hematoma, fluid collection, avf.\n Admitting Diagnosis: HYPOTENSION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with ESRD s/p failed renal transplant with multiple groin\n line. Now with swelling in the area.\n REASON FOR THIS EXAMINATION:\n please eval for hematoma, fluid collection, avf.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage renal disease status post multiple groin line attempts.\n Swelling in the area.\n\n scale, color, and pulse Doppler examination of the right femoral vessels\n was performed. Markedly turbulent, increased flow is seen in the right\n femoral vein with arterialization of the venous waveform demonstrated on pulse\n Doppler examination. There is a large groin hematoma measuring at least 18.5\n x 7.9 x 8.3 cm.\n\n IMPRESSION:\n 1. Findings consistent with an AV fistula of the right femoral vessels.\n 2. Right groin hematoma.\n\n This was communicated to Dr. at 11:15 p.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-22 00:00:00.000", "description": "NON-TUNNELED", "row_id": 903604, "text": " 8:41 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please place temporary HD line\n Admitting Diagnosis: HYPOTENSION;TELEMETRY\n Contrast: OPTIRAY Amt: 5CC\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1752 CATH,HEM/PERTI DIALYSIS SHORT *\n * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with ESRD on HD\n REASON FOR THIS EXAMINATION:\n Please place temporary HD line\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 69-year-old man with end-stage renal disease on\n hemodialysis, needs a temporal hemodialysis catheter placement.\n\n PROCEDURE/FINDINGS: The procedure was performed by Dr. and Dr.\n . Dr. , the attending radiologist was present and supervising\n throughout the procedure.\n\n After the risks and benefits were explained to the patient, written informed\n consent was obtained. The patient was placed supine on the angiographic\n table. Ultrasound confirmed the left internal jugular vein was patent and\n compressible. The left neck was prepped and draped in the standard sterile\n fashion. 5 cc of 1% lidocaine was applied for local anesthesia. Under\n ultrasonographic guidance, a 21-gauge needle was used to access the left\n internal jugular vein. Hard copy ultrasound images were obtained before and\n after venous access documenting vessel patency. A 0.018 guidewire was placed\n through the needle under fluoroscopic guidance with the tip in the superior\n vena cava. The needle was exchanged for a 4- French micropuncture sheath. The\n wire was exchanged for a 0.035 short guidewire. However, it was\n difficult to pass the wire into the SVC. Therefore, a Glidewire was used to\n advance through the sheath with the tip in the inferior vena cava. The\n micropuncture sheath was exchanged for a long BriteTip vascular sheath with\n the tip in the inferior vena cava. The wire was exchanged for a 0.035 \n guidewire with the tip in the inferior vena cava. The vascular sheath was\n removed. The left IJ the venous access was dilated by using 12-French\n dilator. A hemodialysis catheter with the VIP port was then placed over the\n wire with the tip in the right atrium. The wire was removed. Three lumens were\n flushed and the line was secured with skin with sutures.\n\n The patient tolerated the procedure well and there were no immediate\n complications.\n\n IMPRESSION: Successful placement of a nontunneled hemodialysis catheter with\n VIP port through left internal jugular vein with the tip in the right atrium.\n The line is ready to use.\n (Over)\n\n 8:41 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please place temporary HD line\n Admitting Diagnosis: HYPOTENSION;TELEMETRY\n Contrast: OPTIRAY Amt: 5CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2141-03-18 00:00:00.000", "description": "R FEMORAL VASCULAR US RIGHT", "row_id": 903087, "text": " 9:28 AM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: Please eval for avf, pseudoaneurysm.\n Admitting Diagnosis: HYPOTENSION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with ESRD s/p failed renal transplant with avf on ultrasound\n yesterday. Held pressure for 20 mins please eval if avf is resolved.\n REASON FOR THIS EXAMINATION:\n Please eval for avf, pseudoaneurysm.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: AV fistula seen on femoral ultrasound yesterday. Held pressure for\n 20 minutes.\n\n COMPARISON: Femoral vascular ultrasound from .\n\n FEMORAL VASCULAR ULTRASOUND: Grayscale, color, and Doppler son of the\n right common femoral artery and vein were performed. Again demonstrated is\n pulsatility of the right common femoral venous waveform with markedly elevated\n velocities of 180 cm/s consistent with an arteriovenous fistula.\n Redemonstrated within the right medial groin is a heterogeneous collection\n measuring at least 8.9 x 6.0 x 3.0 cm. These findings are consistent with a\n hematoma which appears more organized than on prior exam.\n\n IMPRESSION:\n\n 1. Arteriovenous fistula persists. This finding was discussed with Dr. at\n 9 pm, .\n\n 2. Large right groin hematoma.\n\n\n\n\n\n\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2141-03-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 902914, "text": " 7:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate\n Admitting Diagnosis: HYPOTENSION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with altered mental status and hypotension\n\n REASON FOR THIS EXAMINATION:\n assess for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 68-year-old man with altered mental status and hypertension.\n\n CHEST, UPRIGHT AP VIEW: Comparison is made to . The patient\n is status post sternotomy. The tip of the central venous line terminates at\n the cavoatrial junction in a similar location. Cardiac and mediastinal\n contours are unchanged. The lungs are clear. However, there is evidence of a\n small right subpulmonic effusion, new since the prior study. There is also\n similar fullness of the pulmonary vessels bilaterally, consistent with\n pulmonary venous hypertension.\n\n IMPRESSION:\n\n 1. Probable new small right pleural effusion.\n\n 2. Similar mild pulmonary venous hypertension.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-03-19 00:00:00.000", "description": "Report", "row_id": 1449277, "text": "S:\"I WOULD LIKE TO SIT IN THE CHAIR FOR A WHILE.\"\n\nO:CV: PT NOW IN SR RATE CONTROLLED C LOPRESSOR AND CARDIZEM. HR 80'S. BP 113/61. R GROIN HEMATOMA NO CHANGES.PALP PEDAL PULSES.\n\nRESP: LS CLEAR O2 SATS 90'S ON ROOM AIR. DENIES SOB.\n\nGI: PT HAS GOOD APPETITE ATE 80% OF ALL MEALS. PT HAS HAD TWO LOOSE BM'S TODAY. PT USES COMMODE.\n\nGU: HEMODIALYSIS DEPENDENT PT DOES NOT VOID. PT HAVING HEMODIALYSIS CATH PLACE IN A.M PT SHOULD BE NPO AT MIDNIGHT. PT DUE FOR DIALYSIS MONDAY. K 5.1.\n\nA: PT STABLE HR AND BP NOW.\n\nP: TO FOLLOW LYTES, HCT. PT CO.\n\n" }, { "category": "Nursing/other", "chartdate": "2141-03-20 00:00:00.000", "description": "Report", "row_id": 1449278, "text": "CCU NPN\n\nCV: NSR WITH HR 85-93 REMAIN ON LOPRESSOR AND CARDIAZEM. SBP 90-120 MAP'S 66-74. DENIES PAIN.\n\nRESP; RA SATS 97-100% BS CL/DIMINISHED. DENIES SOB. APPEARS COMFORTABLE\n\nGI: REMAINS NPO FOR PERM DIALYSIS PLACEMENT. ADB SOFT NON TENDER. NO STOOL THIS SHIFT\n\nGU: MAKES NO URINE. NEXT DIALYSIS RUN MONDAY.\n\nSKIN: R GROIN SITE HEMATOMA STABLE. GROIN SOFTENING. PULSES 3+/2+ FT WARM\n\nNEURO: ALERT OREINTED X2. MAE FOLLOWS COMMNADS. NO SLEEPERS OR PAIN MEDS NEEDED. SLEPT OVERNOC\n\nID: TEMP MAX 100.4\n\nLABS: BS 124,120 NO SSI NEEDED.\n\n\nA/P: 68 YR OLD WITH ESRD FAILED RENAL TRANSPLANT ADM FOR HYPOTENSION DURING DIALYSIS. TRANSF TO CCU. ? SEPSIS. COURSE C/B RAPID A-FIB NOW CONTROLLED ON LOPRESSOR AND CARDIAZEM. ALSO HAD HEMATOMA AND AV FISTULA OF R GROIN AFTER CL REMOVED. 3 UNITS PRBC'S OVER WEEKEND, NOW WITH STABLKE HCT'S. PLAN TODAY PERM CATH PLACEMENT. ? REPEAT R GROIN U/S. C/O TODAY\n" }, { "category": "Nursing/other", "chartdate": "2141-03-18 00:00:00.000", "description": "Report", "row_id": 1449275, "text": "S:\"I just want to get better.\"\n\nO:CV:AFIB HR 90'S-100'S. PT RECEIVED LOPRESSOR TODAY AT 0800 50 MG HR DID NOT DECREASE PT THEN RECEIVED INCREASED DOSE OF 50MG PO AT 1300 HR DID NOT COME DOWN PT'S DOSE IS NOW INCREASED TO 75MG PO TID PT HAD BEEN TAKING 100MG PO TID AT HOME PRE ADMISSION. PT'S NEXT DOSE DUE @ MIDNIGHT PT NEED AN INCREASE IN LOPRESSOR BEFORE THAT TIME. BP HAS BEEN 120/63 TO 84/53 BASELINE 100'S. MAP'S 60'-70'S.\n\nRESP: RA O2 SAT'S 100%. RR REG PT APPEARS COMFORTABLE.\n\nGI: ABD SOFT PT DID TRY TO HAVE BM NO LUCK. PT SAID HE DID NOT FEAL CONSTIPATED. TOLERATING DIET WELL.\n\nGU: PT ANURIC THREE TIMES A WEEK DIALYSIS PT. LAST HD TX . PT IS (+) 480CC FOR THE DAY.\n\nSKIN:R GROIN HEMATOMA CONFIRMED C ULTRASOUND TODAY. OUTLINED . PT HAD CENTRAL LINE DC'D FROM R GROIN \n\nNEURO: A+OX3. PT SLEEPING MOST OF THE DAY. PT C/O PAIN IN R GROIN AREA AND IN PT HAS BEEN GETTING MORPHINE FOR PAIN C GOOD EFFECT. PT GETS IRRITATED AT TIMES WHEN WOKEN UP.\n\nID: AFEBRILE CONTACT PRECAUTIONS /MRSA/C-DIFF LAST HOSP STAY. PT ON VANCOMYCIN BEING DOSED C DIALYSIS.\n\nENDO: PT ON SS INSULIN.\n\nA:68YP MALE ESRD ON DIALYSIS FAILED KIDNEY TRANSPLANT + IVDU + HEP C + PPD. PT ADMITTED FOR HYPOTENSION ? ETIOLOGY OF HYPOTENSION ? BE LINE SEPSIS FROM HEMODIALYSIS ACCESS.\n\nP: TO MONITOR HR PT NEED INCREASE IN LOPRESSOR. MAINTAIN LOW POTASSIUM DIET PT'S K 5.1 WILL NOT HAVE HD UNTIL MONDAY. TO MONITOR R FEM HEMATOMA. FOLLOW HCT'S.\n\n" }, { "category": "Nursing/other", "chartdate": "2141-03-19 00:00:00.000", "description": "Report", "row_id": 1449276, "text": "NURSING PROGRESS NOTE 7P-7A\nS: \"I WANT TO GO TO THE KITCHEN TO GET SOMETHING TO EAT\"\n\nO: NEURO: PT. ALERT, DISORIENTED TO TIME AND PLACE DURING NOC. NEEDS FREQUENT ORIENTATION TO TIME AND PLACE. MOVING ALL EXTREMITES, TURNS SELF IN BED. SLEPT IN LONG NAPS, GIVEN TRAZADONE FOR SLEEP.\n\nCV: HR 95-97 SR NO VEA NOTED. HEART RATE REMAINS LEVATED DESPITE LOPRESSOR AND CARDIZEN ADDITION. DENIES C/O CHEST PAIN. RIGHT GROIN HAS SMALL HEMATOMA, FIRM, TENDER TO TOUCH. PALP PEDAL PULSES.\n\nRESP: LUNG SOUNDS CLEAR, ON ROOM AIR. DENIES C/O SOB.\n\nGI: FEELS HUNGRY, ATE 2 BOWLS OF CEREAL DURING NOC. + BOWEL SOUNDS, NO BM OVERNIGHT. ABD SOFT.\n\nGU: DOES NOT VOID, ON HEMODIALYSIS (SCHEDULED FOR MONDAY ). QUINTON CATH INTACT VIA LEFT SC. BUN/CR PENDING THIS AM.\n\nSKIN INTACT.\n\nENDO: SUGARS STABLE, NO SSRI REQUIRED.\n\nID: TEMP MAX 99.4 PO. ON , MRSA PRECAUTIONS\n\nA/P: HYPOTENSIVE FOLLOWING HEMODIALYSIS, ? LINE SEPSIS. FOLLOW CULTURES, LYTES, HCT. SCHEDULED FOR HEM ON MONDAY, ? TRANSFER TO FLOOR\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nA/P; HYPOTENSIVE FOLLOWING HEMODIALYSIS, ? LINE SEPSIS. FOLLOW CULTURES\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-03-18 00:00:00.000", "description": "Report", "row_id": 1449274, "text": "CCU NPN\n\nCV: ON DILTIAZEM GTT @ 15MG. RECEIVED LOPRESSOR PO 25MG PROGRESSIVE DROP IN HR 65-79. DILTIAZEM GTT DROPPED TO 10MG AND MD . ORDERED GIVEN BY DR TO D/C DILTIAZEM GTT AND OBSERVE HR. @ 2330 HR BACK UP TO 100-102 AFIB. DR . PT GIVEN LOPRESSOR 10MG. HR BACK DOWN TO 95 A-FIB. WILL GIVE AN ADDITIONAL LOPRESSOR IV DOSE IF HR ^. SBP 100-120, MAPS > 60. CK 64 K+ 4.8 MG 1.3 MG REPLACED WITH 2 GM MAG SULFATE.\n\nRESP: RA SATS 98-100%. RR-REG APPEARS COMFORTABLE. BS CL/DIMINISHED IN BASES.\n\nGI: ABD SOFT NON TENDER. + BS TOL PO'S AND MEDS. CARAFATE D/CD CON'T ON PPI'S\n\nGU: BUN 34 CREAT 6.5. HAS HEMODIALYSIS CATH VIA LSC. LAT DIALYSIS \n\nSKIN/ HEME: R GROIN + HEMATOMA, OUTLINED AND EVALUATED WITH MD PRESENT. ( PT HAD CL D/CD FROM R GROIN ON DAYS ) REPEAT HCT 30.2 U/S OF R GROIN COMPLETED. + HEMATOMA + A/V FISTULA NOTED. PRESSURE HELD BY MD. 1 UNIT PRBC'S GIVEN. SBP STABLE\n\nNEURO; ALERT, DOZING INTERMITTENTLY. ORIENTED TO PERSON AND YEAR. FOLLOWS COMMNADS. PT HAD SOME CONFUSION...WANTING TO GET UP OOB, DIFFICULTY UNDERSTANDING RATIONALS FOR CARE. MD HAS SEEN PT AND STATES THIS BEHAVIOR IS NO DIFFERENT FROM PAST DAYS. MAE. MORE COMPLIENT AND CALM AS EVE PROGRESSED.\n\nID: AFEBRILE WBC 7.8 ON CONTACT PRECAUTIONS FOR VRE AND MRSA ,\n\nLABS: BS 211 COVERED BY 4 U REG, 0200 BS 88\n\nCOMFORT: MSO4 FOR R GROIN DISCOMFORT. TRAZADONE @ HS WITH GOOD EFFECTS.\n\nA/P: 68 YR OLD ESRD, FAILED RENAL TRANSPLANT, + IVDU, HEPC + PPD ADM FOR HYPOTENSION ASSOCIATED WITH HEMODIALYSIS. ? ETIOLOGY FOR HYPOTENSION. INITIAL THOUGHT ? SEPSIS. BLD CULT PENDING. ICU ADM C/B RAPID A-FIB/A FLUTTER REQUIERING LOPRESSOR/ DILATIAZEM. NOW RATE CONTROLLED WITH LOPRESSSOR. ALSO C/B R FEMORAL HEMATOMA. FOLLOW HCT'S. ADDRESS FURTHER RATE CONTROL ISSUES. CON'T PER NSG JUDGEMENT\n" }, { "category": "Nursing/other", "chartdate": "2141-03-16 00:00:00.000", "description": "Report", "row_id": 1449270, "text": "TSICU Nursing Admit Note\nPt admitted from ED, verbal report from RN. Hx VRE, C-diff, Hep C, zoster. ESRD s/p failed transplant in . Pt transfered to ICU bed and connected to monitors. Pt appears to be a frail elderly man, poor historian. Pt is alert and oriented, moves all extremities. HR irregular, PACs vs atrial fibrillation. Lungs CTA, eupnic. MBP > 60 by cuff. Abdomen soft, NT, + BS. Peripheral pulses weakly palpable. Pt does not void. Skin intact.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-17 00:00:00.000", "description": "Report", "row_id": 1449271, "text": "TSICU Nursing Progress Note\nPlease see transfer note for ROS.\n\nPt. to be transfered to CCU this am. Continue to monitor VS. Possible dialyasis in the am.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-17 00:00:00.000", "description": "Report", "row_id": 1449272, "text": "Nursing Note 6:30a-7a\nPt received from TSICU @ 0630. A+Ox3, no c/o c-pain sob. Afeb, Tele AF HR 102-112, NBP 86/66 MAP 69. LSC, sats>95%. Pt is on contact precautions for +VRE. Please see careview and transfer note for all objective data. Pt is called out pending bed availability.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-17 00:00:00.000", "description": "Report", "row_id": 1449273, "text": "CCU 0700-1900\nRESP:- Remains on room air, Sa02 96-100%, bilateral air-entry heard to all ling fields diminished at the bases. RR 16-20 when settled but did increase when agitated with pain. Not coughing/expectorating sputum.\n\nCV:- Heart rate a problem to control all day, initially in A-fib, 120s to 140s, given bolus of IV diltiazem which did control the rate for short periods. However Diltiazem drip commenced as rate increasing to 140s-160s, initially started at 5mg/hr, increased to max dose of 15mg/hr. Hypotensive eariler in the morning, mainly due to cuff position, but withstood all medications. HR settled for short period this afternoon, but became agiated with pain from rt groin site, heart rate up to 160s, ECG taken found to be A-flutter, bolused with 10mg/dilt, no improvement, given adensoine 6mg then 12mg X2 no improvement. Then given 10mg IVP lopressor with good effect. SBP satisfactory throughout. Rate currently 100 bpm. Femoral line removed as ? heamatoma, for ultra sound scan later. peripherally warm to touch. pedal pulses weak but palpable. Had 2x units of during HD, Hct impoved to 32.\n\nNEURO:- A&O x3, generally, having times of agiation and confusion due to rt groin site. Moving all limbs within limits of bedrest. has periods when he is calling out in pain and asking for help dispite reassurance and explination of care from nursing and medical staff.\n\nPAIN:- Has been as issue this afternoon, Rt femoral line site causing pain, Given 650mg PO tylenol. given bolus'of morphine with no effect, becoming increasingly agitated and shouting out. Given 2mg hydromorphone with little effect. Femoral line removed, Mr states that he is still in pain but HR settled and has periods of calling out. Keeps moving around in the bed told to keep still as that will help the pain, but continues to shuffle around in the bed.\n\nGU:- HAd HD today, no urine output.\n\nGI:- Taking good amount of oral diet today. Abndomen soft. Bowels open X2 loose golden stool, complaining of abdominal pain, Drs . Stool Guaic negative. Bowel sounds heard.\n\nENDO:- glocose elevated, today requiring sliding scale insulin, not given 1800 dose as not eating at that time, also needing lots of pain meds and anti arrythmics.\n\nID:- Rt femoral line removed as in pain, ? hematoma at the site. No other signs of infection. Afebrile during the day.\n\nFAMILY:- NO enquires as yet from family during the day.\n\nSKIN:- Pressure areas intact, barrier cream applied to sacral area. Shuffling self around the bed, even though told to keep still. Offered wash but refused.\n\nPLAN:- For bolus' of metoprolol if rate increases'. Needs ultra sound scan of Rt groin at . Needs lytes and hct checking, will need IV to try, difficult stick. To continue to give full explination of care and reassurance.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2108-08-06 00:00:00.000", "description": "Report", "row_id": 1340503, "text": "CCU Nursing Progress Note 1900-0700\nS: \"I really hope I can get my pacemaker fixed today. This line in my leg is becoming a nuisance\".\n\nO: Please see careview for complete VS/additional objective data.\n\nMS: AAOx3. Pleasant and cooperative. MAE. PEARL. Denies pain . Slept with minimal interruption.\n\nCV: Hemodynamically stable. VVI transvenous temp pacing wire via R femoral site set at 70 bpm. Ventricular Sensing at 2 MV/ 3.5 MA. Threshold 0.6 - 0.3 MA. Site remains CDI. No hematoma or ooze. NIBP 116-158/70. MAPs>85. Pt remains on antihypertensive regimen of Norvasc/ Irbesartan. Pt tolerating well. INR last pm following Vit K dose from prior shift 2.4. HO notified. Instructed to follow . Repeat INR this am 1.9. Goal for PPM placement <2.0. HCT stable. K+ 3.8. Awaiting orders for repletion. Remaining electrolytes wnl.\n\nResp: Remains off all supplemental O2. RR 14-23. O2 sats 96-97%.\n\nGI/GU: Obese. +BS. No stool. NAS/ cardiac diet. Tolerating well. NPO after midnight for ? PPM placement. Voiding 75-300cc cyu via urinal. -2L LOS. BUN/Cr 21/1.1.\n\nID: Afebrile. Tmax 98.2 axillary. WBC 11.7. Vancomycin dose to be given en route to EP.\n\nSkin: Intact. No breakdown.\n\nSocial: No calls or visitors .\n\nA/P: VSS. INR improved and at goal <2.0. Scheduled for PPM after existing PPM malfunctioned d/t ruptured wire. Vanco dose to be given prior to EP intervention. Cont supportive care. Keep updated in POC.\n\n" }, { "category": "Nursing/other", "chartdate": "2108-08-05 00:00:00.000", "description": "Report", "row_id": 1340501, "text": "CCU Nursing Progress Note 1900-0700\nS: \"I got a pretty good amount of sleep\".\n\nO: Please see careview for complete VS/ additional objective data.\n\nMS: AAOx3. Pleasant and cooperative. Received Tylenol #3 on prior shift for pain mgmt. Declined use . Remains painfree until early this am. Pt c/o of vague back pain. Heat pack applied to area with resolution of discomfort. No further complaint. MAE. PEARL. Restful sleep per pt.\n\nCV: Hemodynamically stable. Vpaced. VVI temp wire set at 70 bpm. R femoral site CDI. Difficulty aspirating blood from venous sidearm. Able to flush w/o difficulty. Threshold .6/ 8 MA. Pt experienced a single episode of bradycardia w/ HR to 38 at 0558. Pt asymptomatic. Likely positional. no further incidence. No vea. HR 70-98. NIBP 97-136/70. MAP>74. K+ this am 3.5. Currently undergoing repletion. HCT and remaining electrolytes wnl. INR 3.7 last pm. Pt received 5 mg po Vitamin K. Repeat INR this am 5.4. LFTs added on to am labs. Results still pending.\n\nResp: LS cta. Pt denies SOB. RR 14-25. o2 sats 96-97% off all supplemental O2.\n\nGI/GU: Abdomen obese. Good appetite per report. +BS. No stool . Voiding 100-150cc cyu via urinal. Bun/Cr 25/1.2. Pt remains negative 1L LOS.\n\nID: Afebrile. Tmax 98.1 axillary. WBC 11.0. No antibiotic regimen at present.\n\nSkin: Skin stable. Pt moving side to side.\n\nSocial: No calls or visitors .\n\nMisc: No DVT prophylaxis. Ordered for pneumoboots. Initial pair malfunctioning. Awaiting replacement via distribution.\n\nA/P: 53 yo male w/ cardiac history s/p PPM failure. Temp wire placed. Scheduled for interogation Monday am. INR remains elevated following Vit K . Cont to follow. Clot active in BB for ? FFP to improve INR preprocedure. Hemodynamically stable. Continue electrolyte repletion. Follow electrolytes. Cont supportive care. Cont current medical mgmt. Keep pt updated in POC.\nA/P:\n" }, { "category": "Nursing/other", "chartdate": "2108-08-05 00:00:00.000", "description": "Report", "row_id": 1340502, "text": "CCU Nursing Progress Note\nS-\"I feel better today, no dizziness.\"\nO-Neuro alert and oriented x3, very pleasant and cooperative. MInimal c/o back ache with tylenol #3 x2 with good effect.\nCV-VSS temp pacer atached with low threshold .4 rate 70/mA 8. VVI. Perm pacer VVR with rates up to 120's with activity in bed. Still having intermittant high SBP 180's on norvasc/ lopressor on hold until perm pacer lead repaired. INR still elevated at 3.2 received Vit K 5mg po. Recheck INR at 10pm and again at 7am.\nResp-LS clear RA sat 95%.\nID-afebrile.\nGI-appetite good no bm\nGU-voiding urinal qs.\nSkin- intact with dry feet.\nA/P-stable with temp/perm pacer awaiting pacer lead replacement.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2108-08-04 00:00:00.000", "description": "Report", "row_id": 1340499, "text": "CCU Progress Note:\n\nS- \"My back hurts me. I've been in bed too long!\"\n\nO- see flowsheet for all objective data.\n\ncv- Pt admitted to CCU for temp pacer wire placement due to perm pacer failure- temp wire placed via R fem- dsg D&I- no hematoma- pacer set @ 70- mA 11 threshold of .6 noted- Prior to temp wire, Pt had long pauses with pacing spikes but no capture- rate 30's- hemodynamically stable- Once wire inserted & sleeping, V paced rhythm noted @ rate of 70 until awake & moving- HR up to high 90's low 100's- Pt's underlying rhythm is A fib with occ paced beats noted from perm pacer- B/P 133-170/84-113 MAPs 102-126- norvasc 10mg given @ 0500- Hct 41.1 this am- other labs pending.\n\nresp- lung sounds essentially clear- diminished @ bases this am- resp even, non-labored- SpO2 95-97% on room air.\n\nneuro- A&O X3- moving all extremities- pleasant & cooperative- follows command- has Hx spinal bifida- (+) paraparesis.\n\ngi- abd obese- (+) bowel sounds- taking Po without incident- no BM.\n\ngu- voiding clear yellow urine qs- U/A sent to lab- need CVS for culture- (-) 850cc since 12am.\n\nskin- Pt has chronic leg cellulitis- R leg dsg done by VNA when home- small black area .9cm long by .4cm wide noted- no oozing- cleaned with saline, then open to air- skin dry & flakey- lotion applied- small growth noted on buttock- Pt states it is a cyst & he has had it for years- no redness or oozing noted.\n\ncomfort- c/o low back pain- states has arthritis & cannot lie in bed too long- med with tylenol #3 X2 this shift with good effect.\n\nA- permanent pacemaker failure requiring insertion of temp wire\n\nP- maintain present medical management- ? addition of another antihypertensive for B/P control- medicate for back pain while in bed- plan is to have new perm pacer placed on Monday- offer emotional support to Pt & keep him updated on plan of care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2108-08-04 00:00:00.000", "description": "Report", "row_id": 1340500, "text": "CCU Nursing Progress Note\nS-\"I feel so much better now with the pacemaker working.\"\nO-Neuro alert and oriented x3, very pleasant and cooperative. c/o lower back ache from arthritis, receiving tylenol #3 x2 with good effect.\nCV-HR 70-110 V paced, temporary pacer set rate 70/MA 6 threshold .3, permanent pacer also firing v paced with rates up to 110. Right groin Underlying rhythm AF. Scheduled for lead replacement on Monday. Intermittant hypertensive SBP 120-180's on Norvasc 10mg po and Irbesartan 150mg QD.\nResp-LS clear and slightly diminshed at bases. On RA sats 95%.\nID afebrile\nGU voiding small amounts after lasix.\nGI-appetite good, no bm\nSkin-poor hygiene with foot care, unable to wash feet. Toes were dry, caked with old skin and very long toe nails curling back. Foot care given. No cellulitis noted or open wounds on leg.\nSocial-single man with services at home, uses a cane to get around, recently broke his patella and was using crutches-? causing pacer lead to break. His brothers were in to visit.\nCode Status- Full\nA/P-Continue current medical management and keep pt and family aware of POC as discussed in multi disciplanary rounds.\n\n\n" }, { "category": "ECG", "chartdate": "2108-08-07 00:00:00.000", "description": "Report", "row_id": 182003, "text": "Demand electronic ventricular pacing with indeterminate underlying cardiac\nrhythm. Compared to the previous tracing of cardiac rhythm now\nventricular paced.\n\n" }, { "category": "ECG", "chartdate": "2108-08-03 00:00:00.000", "description": "Report", "row_id": 182004, "text": "Probable junctional rhythm or slow regular atrial fibrillation (dig toxcity)\nExtensive ST-T changes suggest myocardial infarct\nLow QRS voltages in precordial leads\nNo electrocardiographic signs of pacemaker fuction - consider non-functioning\npacemaker\n\n" }, { "category": "Radiology", "chartdate": "2108-08-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 921954, "text": " 7:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infiltrates\n Admitting Diagnosis: PACEMAKER FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with complete heart block s/p pacer failure, also with\n leukocytosis.\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON .\n\n HISTORY: Status post pacer failure with leukocytosis, question infiltrate.\n\n FINDINGS: The heart size continues to be moderately enlarged. Pacemaker and\n femoral line with leads projecting over the right ventricle are unchanged.\n There is no focal infiltrate or effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2108-08-03 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 921926, "text": " 10:05 PM\n CHEST (SINGLE VIEW); CHEST FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: TEMP PACER IN CCU\n Admitting Diagnosis: PACEMAKER FAILURE;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n FLUOROSCOPY FILM ON \n\n HISTORY: Temporary pacer in CCU.\n\n FINDINGS: This is a single cone-down view of the chest showing a pacer wire\n overlying the cardiac silhouette.\n\n\n" }, { "category": "Radiology", "chartdate": "2108-08-03 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 921934, "text": " 11:34 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Fractured pacer lead? Position of new pacer leads?\n Admitting Diagnosis: PACEMAKER FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with complete heart block s/p pacer failure\n REASON FOR THIS EXAMINATION:\n Fractured pacer lead? Position of new pacer leads?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON AT 00:02\n\n HISTORY: Complete heart block status post pacer failure.\n\n FINDINGS: The single lead pacemaker is seen with the lead projecting over the\n presumed location of the right ventricle. There is also a femoral line with\n the lead coiled in the right atrium with the tip extending into the presumed\n right ventricle. There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2108-08-06 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 922167, "text": " 11:11 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Evaualte for pneumothorax\n Admitting Diagnosis: PACEMAKER FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with complete heart block s/p pacer failure, now with new\n pacemaker placed via left axillary vein into more septal position\n REASON FOR THIS EXAMINATION:\n Evaualte for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY \n\n COMPARISON: .\n\n INDICATION: Pacemaker placement.\n\n Previous radiographs have demonstrated a left-sided permanent pacemaker with\n single lead in the right ventricle. There is now a second lead present, with\n a more superior course than the preexisting right ventricular lead. This\n probably also terminates within the right ventricle, but coronary sinus\n location is not excluded based on this single projection. Dedicated lateral\n radiograph would be helpful in this regard.\n\n Cardiac silhouette is upper limits of normal in size. Pulmonary vascularity\n is normal. There is new partial right lower lobe atelectasis as well as a\n small right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2108-08-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 922284, "text": " 8:52 AM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for lead placement, lung fields.\n Admitting Diagnosis: PACEMAKER FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Pt wiht old RV apex lead that is capped and new lead in more septal position.\n\n REASON FOR THIS EXAMINATION:\n Please evaluate for lead placement, lung fields.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of lead placement.\n\n PA and lateral upright chest radiograph compared to the previous film from\n .\n\n Two pacemaker leads are presumably in the right ventricle, the previous lead\n is in the standard apical position and the new one is ending more medially and\n superior than usual, most probably close to the septum. The coronary sinus\n location is not excluded based on this single projection. The lateral chest\n radiograph is limited due to patient's arm obscuring the field of view.\n The heart size is top normal but stable. There is no pulmonary vasculature\n congestion or pulmonary infiltrates. The right lower lobe atelectasis has\n remarkably improved.\n\n IMPRESSION: New pacemaker lead terminates in medial and superior position,\n most likely near the septum but the coronary sinus location cannot be\n excluded. Additional lateral chest radiograph with the patient's arm up is\n recommended for precise evaluation of the location. These findings were\n discussed with Dr. .\n\n\n" } ]

[ { "category": "Physician ", "chartdate": "2106-03-18 00:00:00.000", "description": "Intensivist Note", "row_id": 559451, "text": "TITLE: SICU ADMISSION/PROGRESS NOTE\n SICU\n HPI:\n 78/F s/p fall with subsequent confusion, aphasia and facial droop.\n CT confirmed SDH. . Intubated on arrival.\n Chief complaint:\n respiratory failure\n PMHx:\n CVA ,AAA with repair2002,HTN,DVT2002, Ruptured appy\n ,Hyperlipidemia\n : Coumadin,atenolol,folic acid,simvastatin,citracal,centrum,CA\n Current medications:\n Influenza Virus Vaccine 2. Morphine Sulfate 3. Pneumococcal Vac\n Polyvalent\n 24 Hour Events:\n EXTUBATION - At 11:15 PM\n status, extubated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.4\nC (99.3\n HR: 71 (55 - 86) bpm\n BP: 178/59(81) {137/46(69) - 189/99(114)} mmHg\n RR: 12 (11 - 25) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 12 mL\n 50 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12 mL\n 50 mL\n Blood products:\n Total out:\n 680 mL\n 120 mL\n Urine:\n 680 mL\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n -668 mL\n -71 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 20 cmH2O\n Plateau: 17 cmH2O\n SPO2: 93%\n ABG: ////\n Ve: 10 L/min\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL, sluggish\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: )\n Abdominal: Soft, Non-distended, Non-tender\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 Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Follows simple commands, (Responds to: Tactile\n stimuli), No(t) Moves all extremities, (RUE: Weakness), (LUE:\n Weakness), (RLE: No movement), (LLE: No movement), Sedated\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Assessment and Plan: 78F s/p fall on COumadin with large R SDH.\n Neurologic: large R SDH, nonoperative. morphine gtt\n Cardiovascular: no intervention\n Pulmonary: , extubated overnight\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: Foley for comfort\n Hematology: no labs\n Endocrine: no sugars\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley, peripheral IV\n Wounds: none\n Imaging: none\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:51 PM\n 20 Gauge - 02:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments: Pt is \n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 29 minutes\n" }, { "category": "Respiratory ", "chartdate": "2106-03-17 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 559414, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\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 weaned on PSV back on A/C to rest over night will resume\n weaning trial in AM\n" }, { "category": "Nursing", "chartdate": "2106-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559383, "text": "Pt fell at home and was having MS changes. Was brought to outside\n hospital where CT of head showed large SAH with midline shift. Pt\n transfer to , neuro evaluated but feels pt is not a surgical\n canidate. Pt transferred to SICUb to be made CMO. Awaiting pt son to\n fly in from . Son is to arrive roughly around 2200. Emotional\n support offered to pt and pt family. Father involved with last\n right and Wednesday. POC: Extubate pt when so arrives, monitor\n respire status, continue to keep pt comfortable. Continue to offer\n emotional support to pt and pt family\n" }, { "category": "Respiratory ", "chartdate": "2106-03-17 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 559413, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\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 made CMO awaiting for family member to arrive from to\n extubate,SDH.\n" }, { "category": "Nursing", "chartdate": "2106-03-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 559549, "text": "Pt fell at home and was having MS changes. Was brought to outside\n hospital where CT of head showed large SAH with midline shift. Pt\n transfer to , neuro evaluated but feels pt is not a surgical\n candidate. Pt transfer to SICUb to be made CMO. Pt family was waiting\n for additional family member to arrive last evening. Once family\n member arrived, pt was extubated and placed on a morphine drip. At\n 0400 on the 26^th of pt nurse went into the room to check\n comfort level and noticed pt eyes were open. Nurse then did neuro exam\n to find pt was answering to yes/no questions and knew her name, PERL,\n and pt was following commands. Nurse turned off morphine drip and\n informed family.\n This morning pt is easily arousable to voice, opens eyes, follows\n commands, speech is garbled at times to yes and no question. Gag is\n intact but cough is weak. PERL, tongue is midline, and as morning has\n progressed smile has become more midline. Family was in this morning\n to discuss plan of care with neuro team. Current Plan of care is\n to reverse CMO order, keep DNR/DNI order. Pt is to have PT/OT and\n speech and swallow consult. Social Worker is involved as is Case\n Management to start rehab planning. Pt is to come back to in \n weeks to have Burr holes placed to drain the blood. Family is\n currently aware of plan.\n" }, { "category": "Physician ", "chartdate": "2106-03-18 00:00:00.000", "description": "Intensivist Note", "row_id": 559533, "text": "TITLE: SICU ADMISSION/PROGRESS NOTE\n SICU\n HPI:\n 78/F s/p fall with subsequent confusion, aphasia and facial droop.\n CT confirmed SDH. . Intubated on arrival.\n Chief complaint:\n respiratory failure\n PMHx:\n CVA ,AAA with repair2002,HTN,DVT2002, Ruptured appy\n ,Hyperlipidemia\n : Coumadin,atenolol,folic acid,simvastatin,citracal,centrum,CA\n Current medications:\n Influenza Virus Vaccine 2. Morphine Sulfate 3. Pneumococcal Vac\n Polyvalent\n 24 Hour Events:\n EXTUBATION - At 11:15 PM\n CMO status, extubated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.4\nC (99.3\n HR: 71 (55 - 86) bpm\n BP: 178/59(81) {137/46(69) - 189/99(114)} mmHg\n RR: 12 (11 - 25) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 12 mL\n 50 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12 mL\n 50 mL\n Blood products:\n Total out:\n 680 mL\n 120 mL\n Urine:\n 680 mL\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n -668 mL\n -71 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 20 cmH2O\n Plateau: 17 cmH2O\n SPO2: 93%\n ABG: ////\n Ve: 10 L/min\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL, sluggish\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: )\n Abdominal: Soft, Non-distended, Non-tender\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 Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Follows simple commands, (Responds to: Tactile\n stimuli), No(t) Moves all extremities, (RUE: Weakness), (LUE:\n Weakness), (RLE: No movement), (LLE: No movement), Sedated\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Assessment and Plan: 78F s/p fall on COumadin with large R SDH.\n Neurologic: large R SDH, nonoperative. morphine gtt off now that pt\n has awakened and is following commands; NuSu at bedside discussing\n plans with the family\n Cardiovascular: restart home meds\n Pulmonary: CMO, extubated overnight, now maintaining her airway\n Gastrointestinal / Abdomen: NPO for now\n Nutrition: NPO for now, possible Speech and Swallow\n Renal: Foley\n Hematology: check labs\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley, peripheral IV\n Wounds: none\n Imaging: none\n Fluids: maintenance fluids while NPO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:51 PM\n 20 Gauge - 02:52 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: H2\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: PENDING discussion with family at present\n Disposition: Transfer to floor\n Total time spent: 29 minutes\n" }, { "category": "Nursing", "chartdate": "2106-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559610, "text": "Pt noted to have mental status deterioration prior to shift change.\n She was brought for a stat head CT and per neuro surgery PA \n and Attending there was no changes from AM CT of head. Patient no\n longer following commands, she moves left arm more than the right,\n PERRL but right eye is slightly more sluggish than left, she is\n nonverbal but moans. Family called by , MD to inform on current\n condition, left message with family. Patient is on NS 75/hr, lopressor\n and hydralazine for BP goal less than 140mmHg. , MD transfer\n patient to 9.\n" }, { "category": "Nursing", "chartdate": "2106-03-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 559611, "text": "Pt fell at home and was having MS changes. Was brought to outside\n hospital where CT of head showed large SAH with midline shift. Pt\n transfer to , neuro evaluated but feels pt is not a surgical\n candidate. Pt transfer to SICUb to be made CMO. Pt family was waiting\n for additional family member to arrive last evening. Once family\n member arrived, pt was extubated and placed on a morphine drip. At\n 0400 on the 26^th of pt nurse went into the room to check\n comfort level and noticed pt eyes were open. Nurse then did neuro exam\n to find pt was answering to yes/no questions and knew her name, PERL,\n and pt was following commands. Nurse turned off morphine drip and\n informed family.\n This morning pt is easily arousable to voice, opens eyes, follows\n commands, speech is garbled at times to yes and no question. Gag is\n intact but cough is weak. PERL, tongue is midline, and as morning has\n progressed smile has become more midline. Family was in this morning\n to discuss plan of care with neuro team. Current Plan of care is\n to reverse CMO order, keep DNR/DNI order. Pt is to have PT/OT and\n speech and swallow consult. Social Worker is involved as is Case\n Management to start rehab planning. Pt is to come back to in \n weeks to have Burr holes placed to drain the blood. Family is\n currently aware of plan.\n Pt noted to have mental status deterioration prior to shift change.\n She was brought for a stat head CT and per neuro surgery PA \n and Attending there was no changes from AM CT of head. Patient no\n longer following commands, she moves left arm more than the right,\n PERRL but right eye is slightly more sluggish than left, she is\n nonverbal but moans. Family called by , MD to inform on current\n condition, left message with family. Patient is on NS 75/hr, lopressor\n and hydralazine for BP goal less than 140mmHg. , MD transfer\n patient to 9.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n ACUTE SUBDURAL HEMATOMA\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 50 kg\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH: CVA\n Additional history: CVA/TIA, aneursym, DVT, PNA.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:155\n D:57\n Temperature:\n 99.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 28 insp/min\n Heart Rate:\n 85 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 60% %\n 24h total in:\n 968 mL\n 24h total out:\n 595 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 10:45 AM\n Potassium:\n 3.5 mEq/L\n 10:45 AM\n Chloride:\n 107 mEq/L\n 10:45 AM\n CO2:\n 27 mEq/L\n 10:45 AM\n BUN:\n 20 mg/dL\n 10:45 AM\n Creatinine:\n 1.0 mg/dL\n 10:45 AM\n Glucose:\n 94 mg/dL\n 10:45 AM\n Hematocrit:\n 26.5 %\n 10:45 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n foley, right hand 20G PIV\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:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2106-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559497, "text": "At start of shift, patient was intubated and only withdrawing to\n painful stimuli. She would move her extremities on the bed but nothing\n to command. PERRL at 3-4mm with brisk reaction. She would not open\n her eyes to tactile or verbal stimuli. The family was waiting\n for patient\ns son to arrive from out of state before she was to be\n extubated and placed on a morphine gtt and made comfort measures only.\n Patient was successfully extubated at 2315 and placed on morphine gtt\n of 2mg/hr. Patient would open eyes to verbal stimuli at this time but\n did not track, did not follow commands, continued to move extremities\n on bed and pupils were unchanged. Patient\ns neurological status\n remained unchanged until 0400 assessment when patient opened her eyes\n to verbal stimuli and began to track. She also began verbalizing and\n following simple commands (opening mouth for mouthcare, squeezing hands\n bilaterally). Morphine gtt was shut off and neurosurgery was paged and\n resident came to assess patient and noted above changes. Dr. \n spoke with attending MD and informed of dramatic changes. Per Dr.\n , discontinued morphine gtt but no other orders given. Informed\n both SICU resident and neurosurg residents that patient had no meds\n ordered and no labs ordered. No orders given at this time. RN also\n asked if the family should be contact and was told that the\n neurosurgery team would speak to them in the AM. Patient\n spokesperson and daughter, , called at 0445 and I updated her on\n her mothers current condition. Plan is to monitor neuro status q1h,\n assess patient for pain/comfort, monitor VS and keep SICU and\n neurosurgery teams aware of any and all changes.\n" }, { "category": "Nursing", "chartdate": "2106-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559473, "text": "At start of shift, patient was intubated and only withdrawing to\n painful stimuli. She would move her extremities on the bed but nothing\n to command. PERRL at 3-4mm with brisk reaction. She would not open\n her eyes to tactile or verbal stimuli. The family was waiting\n for patient\ns son to arrive from out of state before she was to be\n extubated and placed on a morphine gtt and made comfort measures only.\n Patient was successfully extubated at 2315 and placed on morphine gtt\n of 2mg/hr. Patient would open eyes to verbal stimuli at this time but\n did not track, did not follow commands, continued to move extremities\n on bed and pupils were unchanged. Patient\ns neurological status\n remained unchanged until 0400 assessment when patient opened her eyes\n to verbal stimuli and began to track. She also began verbalizing and\n following simple commands (opening mouth for mouthcare, squeezing hands\n bilaterally). Morphine gtt was shut off and neurosurgery was paged and\n resident came to assess patient and noted above changes. Dr. \n spoke with attending MD and informed of dramatic changes. Per Dr.\n , discontinued morphine gtt but no other orders given. Informed\n both SICU resident and neurosurg residents that patient had no meds\n ordered and no labs ordered. No orders given at this time. RN also\n asked if the family should be contact and was told that the\n neurosurgery team would speak to them in the AM. Patient\n spokesperson and daughter, , called at 0445 and I updated her on\n her mothers current condition. Plan is to monitor neuro status q1h,\n assess patient for pain/comfort, monitor VS and keep SICU and\n neurosurgery teams aware of any and all changes.\n" }, { "category": "Physician ", "chartdate": "2106-03-18 00:00:00.000", "description": "Intensivist Note", "row_id": 559580, "text": "TITLE: SICU ADMISSION/PROGRESS NOTE\n SICU\n HPI:\n 78/F s/p fall with subsequent confusion, aphasia and facial droop.\n CT confirmed SDH. . Intubated on arrival.\n Chief complaint:\n respiratory failure\n PMHx:\n CVA ,AAA with repair2002,HTN,DVT2002, Ruptured appy\n ,Hyperlipidemia\n : Coumadin,atenolol,folic acid,simvastatin,citracal,centrum,CA\n Current medications:\n Influenza Virus Vaccine 2. Morphine Sulfate 3. Pneumococcal Vac\n Polyvalent\n 24 Hour Events:\n EXTUBATION - At 11:15 PM\n CMO status, extubated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.4\nC (99.3\n HR: 71 (55 - 86) bpm\n BP: 178/59(81) {137/46(69) - 189/99(114)} mmHg\n RR: 12 (11 - 25) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 12 mL\n 50 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12 mL\n 50 mL\n Blood products:\n Total out:\n 680 mL\n 120 mL\n Urine:\n 680 mL\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n -668 mL\n -71 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 20 cmH2O\n Plateau: 17 cmH2O\n SPO2: 93%\n ABG: ////\n Ve: 10 L/min\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL, sluggish\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: )\n Abdominal: Soft, Non-distended, Non-tender\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 Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Follows simple commands, (Responds to: Tactile\n stimuli), No(t) Moves all extremities, (RUE: Weakness), (LUE:\n Weakness), (RLE: No movement), (LLE: No movement), Sedated\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Assessment and Plan: 78F s/p fall on COumadin with large R SDH.\n Neurologic: large R SDH, nonoperative. morphine gtt off now that pt\n has awakened and is following commands; NuSu at bedside discussing\n plans with the family\n Cardiovascular: restart home meds\n Pulmonary: CMO, extubated overnight, now maintaining her airway\n Gastrointestinal / Abdomen: NPO for now\n Nutrition: NPO for now, possible Speech and Swallow\n Renal: Foley\n Hematology: check labs\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley, peripheral IV\n Wounds: none\n Imaging: none\n Fluids: maintenance fluids while NPO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:51 PM\n 20 Gauge - 02:52 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: H2\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: PENDING discussion with family at present\n Disposition: Transfer to floor\n Total time spent: 29 minutes\n" }, { "category": "General", "chartdate": "2106-03-18 00:00:00.000", "description": "Generic Note", "row_id": 559565, "text": "TITLE: BEDSIDE SWALLOW EVALUATION\n Pt seen at bedside for PO trials. Exam notable for\n increased WOB w/ thin liquid, swallow delay, possible aspiration on\n other liquid boluses, increasing fatigue and need for repeated oral\n suctioning w/ return of bolus material. Recommend that pt remain NPO w/\n repeat evaluation tomorrow. Please see Web OMR or hard copy chart for\n complete note.\n , SLP/Student\n Pager #\n 15:22\n" }, { "category": "General", "chartdate": "2106-03-18 00:00:00.000", "description": "Generic Note", "row_id": 559459, "text": "TITLE: Respiratory Care\n Pt extubated at 2316 on .\n" }, { "category": "Nursing", "chartdate": "2106-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559465, "text": "Initially patient was intubated and only withdrawing to painful\n stimuli. She would move her extremities on the bed but nothing to\n command. PERRL at 3-4mm with brisk reaction. She would not open her\n eyes to tactile or verbal stimuli. The family was waiting for\n patient\ns son to arrive from out of state before she was to be\n extubated and placed on a morphine gtt. Patient was successfully\n extubated at 2315 and placed on morphine gtt of 2mg/hr. Patient would\n open eyes to verbal stimuli at this time but did not track, did not\n follow commands, continued to move extremities on bed and pupils were\n unchanged. Patient\ns neurological status remained unchanged until 0400\n assessment when patient opened her eyes to verbal stimuli and began to\n track. She also began verbalizing and following simple commands\n (opening mouth for mouthcare, squeezing hands bilaterally). Morphine\n gtt was shut off and neurosurgery was paged and resident came to assess\n patient and noted above changes. The resident spoke with attending MD\n and informed of dramatic changes. Per resident discontinued\n morphine gtt but not other orders given. Informed both SICU resident\n and neurosurg residents that patient had no meds ordered and no labs\n ordered. No orders given at this time. I also asked if the family\n should be contact and was told that the neurosurgery team would speak\n to them in the AM. Patient\ns spokesperson and daughter, , called\n at 0445 and I updated her on her mothers current condition. Plan is to\n monitor neuro status q1h, assess patient for pain/comfort, monitor VS\n and keep SICU and neurosurgery teams aware of any and all changes.\n" }, { "category": "ECG", "chartdate": "2106-03-17 00:00:00.000", "description": "Report", "row_id": 242115, "text": "Sinus bradycardia, rate 55. Axis is 0 degrees. Non-specific ST-T wave\nchanges diffusely throughout the tracing. Left ventricular hypertrophy.\nCannot rule out anteroseptal myocardial infarction of indeterminate age\nbut these changes can also be seen with left ventricular hypertrophy alone.\nNo previous tracing available for comparison. Clinical correlation is\nsuggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2193-05-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238050, "text": " 5:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with stroke\n REASON FOR THIS EXAMINATION:\n ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Woman with stroke, question of pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the appearance of the chest\n radiograph is unchanged. On the single view, a left pectoral pacemaker with\n normal course of the wires is noted. The lung volumes are normal. There is\n moderate cardiomegaly and tortuosity of the thoracic aorta but no evidence of\n acute lung disease such as pulmonary edema or pneumonia. No pneumothorax. No\n pleural effusions.\n\n\n" }, { "category": "ECG", "chartdate": "2193-05-07 00:00:00.000", "description": "Report", "row_id": 304416, "text": "No significant change compared to tracing #1.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2193-05-07 00:00:00.000", "description": "Report", "row_id": 304417, "text": "Sinus rhythm. Atrial sensing with ventricular pacing. The paced beats are\nunusual and may indicate fusion beats versus biventricular pacing or could\nbe a variant. No previous tracing available for comparison. Clinical\ncorrelation is suggested.\nTRACING #\n\n" } ]

[ { "category": "Radiology", "chartdate": "2106-04-11 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 961912, "text": " 4:57 PM\n BILAT LOWER EXT VEINS PORT; UNILAT UP EXT VEINS US LEFT Clip # \n UNILAT UP EXT VEINS US RIGHT\n Reason: r/o DVT\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man histroy of massive PE on anticoagulation, was hemodynamically\n unstable requiring blood transfusions. Need to assess for clot\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER AND UPPER EXTREMITY VEINS, PORTABLE\n\n INDICATION: 79-year-old man, history of massive PE on anticoagulation. Assess\n for clot.\n\n BILATERAL LOWER EXTREMITY VEINS: Grayscale and color Doppler ultrasounds were\n performed. There is normal compressibility, color flow, Doppler signal within\n the common femoral, superficial femoral and popliteal veins bilaterally.\n\n IMPRESSION: No evidence of DVT in the lower extremities.\n\n BILATERAL UPPER EXTREMITIES.\n\n Grayscale and color Doppler ultrasounds were performed. There is normal\n compressibility, color flow and Doppler signal within the internal jugular\n vein, subclavian, axillary, brachial veins as well as the cephalic and basilic\n vein bilaterally.\n\n IMPRESSION: No evidence of DVT in the upper extremities.\n\n" }, { "category": "Radiology", "chartdate": "2106-04-11 00:00:00.000", "description": "GI BLEEDING STUDY", "row_id": 961841, "text": "GI BLEEDING STUDY Clip # \n Reason: 79 YR OLD MALE WITH BRBPR, RECENT NEGATIVE EGD/CSCOPE, CAPSU\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 14.8 mCi Tc-m RBC ();\n HISTORY: 79 YR OLD MALE WITH BRBPR, RECENT NEGATIVE EGD/CSCOPE, CAPSU\n\n INTERPRETATION: Following intravenous injection of autologous red blood cells\n labeled with Tc-m, blood flow and dynamic images of the abdomen for 160\n minutes were obtained. A left lateral view of the pelvis and bilateral obliques\n view of the abdomen were also obtained.\n\n Blood flow images show normal distribution within the vasculature.\n\n Dynamic blood pool images show a focal area of uptake in the right lower abdomen\n that becomes apparent at approximately 40 minutes. This focus of uptake becomes\n more apparent during the 60-90 minute series and is essentially unchanged\n thereafter.\n\n\n IMPRESSION: Single focus of tracer uptake in the right lower abdomen that likely\n represents a focus of bleeding, the location of which cannot be determined due\n to its static nature.\n\n\n\n , M.D.\n , M.D. Approved: TUE 3:32 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": "Nursing/other", "chartdate": "2106-04-11 00:00:00.000", "description": "Report", "row_id": 1573215, "text": "MICU-7 Nursing Note 7A-7P:\n\n79 y.o. male admitted from Hosp where he presented from home with c/o melanotic stool x2. Diagnosed with lower GIB, transported to for management. Recent admit for treatment of MRSA pneumonia.\n\nPMH: severe COPD, home O2 @ 3L NC continuously. HTN, BPH, A-fib (one known episode) CAD, hx 1.5ppd smoker quit 12yrs ago, appy, laminactomy, partial hip replacement, bowel resection for SBO, hx klebsiella, Pseudamonas, MRSA, VRE, bilat LE lymphedema x20yrs, recent dx PE on Coumadin @ home.\n\nFull Code/Contact Precautions\n\nAllergy: Amoxicillin\n\nNeuro: Alert & oriented x3, pleasant and cooperative with care. Denies pain. Moves all extremities strongly. PERL. OOB to recliner with 1 assist and walker.\n\nCV: NSR/BBB rate 70's, no ectopy noted. BP 110-140/40-50 via cuff. Lopressor 12.5, Captopril 25mg begun today. INR 3.4. Baseline HCT=28.Dropped to 24.7 @ 1000 labs. Transfused 2 units PRBC, 4 units FFP, 1mg Vit K IV. US of all extremites ordered to r/o DVT. Possible placement of IVC filter discussed.\n\nResp: Exp wheezes throughout. Prolonged expiratory time. SOB upon exertion. O2 3L NC. SAT 97-99%. RR 15-25. Albuterol/Atrovent nebs Q6hr. Prednisone taper. No cough noted.\n\nGI: No stools this shift. Plan bowel prep with Mag citrate tonight for possible scope tomorrow. Tolerating clear liquids. Glucose 86-126, no insulin coverage required. Oral thrush treated with antifungal lozenges.\n\nGU: Voiding clear yellow urine per urinal. Lasix 20mg IV x1.\n\nSkin: Redness, tenderness of coccyx. Skin remains intact. Yeast around peri area was being treated at home with miconazole poweder; tx continued here. R arm edematous, bilateral LE lympedema; thigh-length hose in place.\n" }, { "category": "Nursing/other", "chartdate": "2106-04-12 00:00:00.000", "description": "Report", "row_id": 1573216, "text": "PT. REMAINS A FULL CODE AT THIS TIME.\n\nPT. REMAINS ON CONTACT PRECAUTIONS FOR +MRSA, AND +VRE.\n\nPT. HAS ALLERGIES TO AMOXICILLIN.\n\nPT. REMAINS A/A/O AND DENIES ANY PAIN OR DISCOMFORT AT THIS TIME. PT. REMAINS AFEBRILE, MAE'S, AND FOLLOWS ALL COMMANDS.\n\nPT. REMAINS NSR 60-80'S WITH NO NOTED ECTOPY. B/P HAS RANGED 120-140'S/60-70'S. PULKSE ARE WEAK BUT PALPABLE. PT. HAS GROSS LYMPH EDEMA AND AT PRESENT HAS BILAT THIGH HIGH STOCKINGS ON AT THIS TIME. PT. HAS RECEIVED OVER THE PAST 24HRS 4 UNITS OF PRBC'S FOR DROPPING HCT DOWN TO 24.1, AND 4 UNITS OF FFP FOR ELEVATED INR OF 3.9. AM LABS ARE PENDING THIS AM. PT. HAS Q6HRS HCT'S ORDERED. PT. HAD U/S OF ALL FOUR EXT'S YESTERDAY WHICH WAS NEGATIVE. PT. WILL BE SCHEDULED FOR GREEN FILLED FILTER FOR TODAY.\n\nPT. HAS REMAINED ON 3L/MIN VIA N/C OF O2. LUNGS HAVE EXHIBITED CLEAR UPPER TO EXP. WHEEZES THROUGHOUT. PT. CONTINUES ON HIS INHALERS AND NEUB TX'S. RESP RATE REMAINS CONTROLLED AND O2 SATS REMAIN >97%.\nPT. HAD BEEN ON COUMADIN THERAPY FOR RESOLVING P.E. BUT WITH REVERSING HIS PT. WILL BE PROBABLE REQUIRE GREEN FILLED FILTER AND HEPARIN THERAPY.\n\nPT. REMAINS NPO, BUT HAVE SIPS OF CLEAR LIQUIDS AND ICE CHIPS WITH MEDS. PT'S ABD. IS OBESE, AND SOFT. BOWEL SOUNDS ARE EASILY AUDIBLE IN ALL QUADRANTS AND BOWEL PREP OF MAG CITRATE WAS TAKEN WITHOUT INCIDENT. PT. HAS BEEN TO THE COMODE CHAIR SEVERAL TIMES FOR BROWN/MELENA GUAIC POSITIVE FORMED STOOL, TO NOW CLEARING TO LIQUID PINKISH/BROWN, STOOL. PT. WILL HAVE COLONSCOPY TODAY TO EVALUATE FOR SOURCE OF BLEED.\nPT. CONTINUES TO VOID VIA URINAL FOR FREQUENT SMALL AMT'S OF CLEAR YELLOW URINE.\n\nSKIN EXHIBIT REDDENED COCCYX/PERINEUM REGION. BARRIER CREAM APPLIED AND PT. HAS BEEN TURNED FREQUENTLY AS WELL OOB CHAIR AND COMODE. ALL PIV'S TO EACH ARM REMAIN INTACT, SECURED, AND FUNCTIONING WELL.\n\nPLAN FOR PT. TODAY INVOLVES HAVING COLONSCOPY, TO EVALUATE POSSIBLE SOURCE OF BLEEDING. PT. WILL MOST LIKELY REQUIRE GOING TO I.R. FOR PLACEMENT OF GREEN FILLED FILTER, AND HAVE HEPARIN GTT STARTED DUE TO RESOLVING P.E. VS. G.I. BLEED. PT. WILL ALSO REQUIRE Q6HRS HCT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2106-04-12 00:00:00.000", "description": "Report", "row_id": 1573217, "text": "respiratory care\npt seen for neb Tx.BS clear with mild Exp.wheezes.Alb/atr neb given fair effect.O2 sats and vitals acceptable.Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2106-04-12 00:00:00.000", "description": "Report", "row_id": 1573218, "text": "Nursing Note: 0700-1900\nNo significant events.\n\n\n79 yo male admitted from Hosp with lower GIB. Has had recent significant hx of unresolving PNA and PE. Admitted to and received Red Tag study which was unremarkable for active bleed. Pt had colonoscopy a few weeks ago with a polyp removal and will be rescoped tomorrow to determine souce of bleed. PMH: PNA, PE, copd with home O2 @ 3L, Htn, Afib, CAD, small bowel resection, lower extrem lymphedema X 20 yrs.\n\n\nNEURO: A&O X 3, pleasant/cooperative. Up in chair entire shift. Denies pain/discomfort. MAE. One assist up to commode.\n\nRESP: O2 @ 3L n/c; LS initially ronchorous with exp wheezes; receiving MDIs/nebs. No cough noted or reported. SOB with exertion. Continues on prednisone.\n\nC/V: HR 80s, SR, no ectopy. NBP 110s-130s; receiving Captopril, Lopressor on sched dosing. Started Heparin gtt for recent PE. Serial Hcts stable at 30. Possible filter placement in IR but will scope first. Lymphedema to bilat lower extrems.\n\nGI/GU: Clr liq and later NPO for scope tomorrow. Continued bowel prep today secondary to continued dark stool. Abdomen obese. Voiding via urinal in adequate amounts.\n\nENDO: SS coverage when required.\n\nID: Afebrile; receiving Bactrim PO.\n\nDISPO: Full code; will remain in MICU for scope tomorrow; heparin gtt.\n" }, { "category": "Nursing/other", "chartdate": "2106-04-11 00:00:00.000", "description": "Report", "row_id": 1573213, "text": "PT ARRIVED IN MICU AT 0630 FROOM NUCLEAR MED. PT 3, MAE, FOLLOWING COMMANDS. DENIES ANY PAIN. NO ACTIVE BLEEDING IN NUCLEAR MED OR ON ARRIVAL IN MICU. VSS. PT FULL CODE. PT TO BE EVALUATED BY MICU TEAM.\n" }, { "category": "Nursing/other", "chartdate": "2106-04-11 00:00:00.000", "description": "Report", "row_id": 1573214, "text": "Nursing MICU NOTE 7P-7A\n\nREPORT GIVEN FROM ER TO NURSE. MICU NURSE TO MEET ER NURSE WITH PT IN NUCLEAR MED FOR RED TAG SCAN AT 0125. NURSE AND PT HAVE REMAINED IN NUCLEAR MED THROUGH OUT NIGHT. PT YET TO BE SEEN BY MICU TEAM AND ATTENDING. PT TO BE CONT TO BE MONITOR IN NUCLEAR MED THIS AM BY MICU NURSE AND ADMISSION INTO MICU.\n" }, { "category": "Nursing/other", "chartdate": "2106-04-15 00:00:00.000", "description": "Report", "row_id": 1573225, "text": "1900-0700 rn notes micu\n\n79y.o male with pmh COPD on O2 at home, Afib, CAD,recently diagnosed PE, admitted d/t low GI bleed, red tag study unremarkable, pt had colonoscopy with polyp removal a few weeks ago. repeat colonoscpy in unit that shown small ulceration in colon compatible with postpolypectomy site.\n\nfull code\n\nneuro: A/Ox3, and cooperative, uses walker to ambulate from chair to bed with assistent, minimal SOB notes.pt has bilt LE lymphedema x20years.\n\nresp: NC 3L, sat 97%,LS clear, at time wheezing, cont nebs tx.\n\ncv: HR 80-90's, several episoded tachy to 115-120, cont diltiasem Po, metoprolol, Captopril MD d/t BP 108/45. cont Heparin gtt 1200unit/hr, start on Coumadin at 5/22. morning labs pending.\n\ngi/gu: pt voids adequite amouht urine. ABD obese, soft, BS+, no stool.\ntollerate po diet well.\n\nid: contact for MRSA/VRE, stoolx1 pos for C.diff, start on flagyl PO. afebrile.\n\nplan: cont monitoring resp/cardio status\n follow PTT\n c/o to floor.\n" }, { "category": "Nursing/other", "chartdate": "2106-04-15 00:00:00.000", "description": "Report", "row_id": 1573226, "text": "Nursing Progress Note 0700-1900\n*Full code\n\n*Allergies: Amoxicillin\n\n*Access: 2 Larm PIV's\n\n** Please see admit note/FHP for admit info and hx.\n\nNeuro: A&Ox3, ambulating w/ PT, tolerated good (fatigued quickly) but was able to work well w/ PT and was up to commode and then ambulated and then to chair (assist w/ walker). No c/o pain.\n\nCardiac: NSR w/o ectopy, HR 82-99, SBP 107-142. Gave diltiazem and metoprolol, held captopril d/t decreased SBP. Hct stable this AM 30.3. Remains on hep gtt therapeutic @ 1200U/hr, remaining therapeutic (93.2) w/ AM labs, next check w/ AM labs. Coumadin increasing this evening to 5mg from 2.5mg.\n\nResp: 2L NC most of shift, trying on RA, goal sats>92%. On o2 when sleeping @ home, will attempt this here as well. This shift o2sat 93-97, rr 21-28, LS wheezy @ times, nebs and INH for treatment @ this time.\n\nGi/Gu: tolerating reg diet, +BS, stool x1 this shift brown/loose/guiac pos, abd obese/non-tender. voiding adequate amts in urinal, yellow/clear. FSBG 167, covered per RISS.\n\nID: Afebrile, wbc 8.5, cx's (+) for C.diff, MRSA, and VRE (contact precautions). Currently only on bactrim and flagyl. Skin w/ bilat LE lymphedema x20years, compression stockings on. Coccyx red/purple treated w/ aloe vesta cream, sitting on foam cushion while in chair.\n\nPsychosocial: Calls from fam/friends in room, no visitors today. Pt still awaiting room on floor (may need private d/t infections), may just go to rehab soon or discharged home.\n\ndispo: monitor resp status, monitor temp, monitor for s/s of bleeding, start high dose of comadin tonight, cont med regimen and abx, cont icu care @ this time.\n" }, { "category": "Nursing/other", "chartdate": "2106-04-14 00:00:00.000", "description": "Report", "row_id": 1573222, "text": "1900-0700 rn notes micu\n\n79 y.o male with pmh COPD, on O2 at home AF, CAD recent diagnosed with PE, admitted d/t low GI bleed,red tag study unremarkable.pt had colonoscopy with polyp removal a few weeks ago. had colonoscopy agiamn that shown small ulceration in colon compatible with postpolypectomy site.\n\n\nevents: in the begging of shift c/o cold, start having chills, temp up to 101.3, urine and blood cx sent, given tylenol. put on bear hugger blanket. Cxray done,unremarkable.pt became tachycardic 106-109, given fluid bolus 500ccx1 NS.\n\nneuro: A/Ox3, and cooperative, start having SOB after back to bed from chair, that resolved after neb and MDI.pt with lymphedema x20years.\n\nresp: NC 3-4L, nebs tx given for wheezing with good effect. Sat 96-97%,\n\ncv:HR 80's, NSR, no ectopy. SBP stable 100-130/60, cont Diltiasem Po, Captoprile PO. cont heparin 1200u/hr, PTT at 2100 77, morning PTT pending. HCT 29.4(last 33.1), baseline HCT 28.\n\ngi/gu: voids adequate amount urine. ABD soft/obese, BS +, pt has loose brown stoolx3, quaiac neg. stool for C.diff sent.pt taking meds PO and on liquid diet, tollerate good.\n\nid: contact , temp , pan cx sent, WBC up 13.4(7.0).\n\naccess: recieved with 1piv, IV RN placed 2nd piv.\n\nskin: red unbroken skin on coccyx area, cream barrier apllied.\n\nplan: cont monitoring resp/cardio status\n follow HCT, sighs of bleeding, cont Heparin per SS.\n monitoring temp\n c/o to floor\n\n" }, { "category": "Nursing/other", "chartdate": "2106-04-14 00:00:00.000", "description": "Report", "row_id": 1573223, "text": "Resp: Pt remains on 3 lpm n/c with no distress. Pt ordered for Atr nebs Q8, Alb Q4 prn and tx once by RT, RN administered nebs x2 noc. will cotninue to follow and treat.\n" }, { "category": "Nursing/other", "chartdate": "2106-04-14 00:00:00.000", "description": "Report", "row_id": 1573224, "text": "Nursing Progress Note 0700-1900\n*Full code\n\n*Allergies: Amoxicillin\n\n*Access: 2 Rarm PIV's\n\n** Please see admit note/FHP for admit info and hx.\n\nNeuro: Pt A&Ox3 following commands, ambulated to chair w/ assist of walker, tolerated chair all day, no c/o pain.\n\nCardiac: NSR w/o ectopy, HR 69-90, SBP 100-115, held captopril and diltiazem for decreased BP (held MD's). Hct this AM stable @ 29.4, repeat this afternoon pending, next w/ AM labs. PTT x2 therapeutic early this AM, next w/ AM labs. Hep gtt remains @ 1200U/hr, cont coumadin, hep gtt off when INR therapeutic (1.4 this AM).\n\nResp: 2L NC, no c/o difficulty breathing, maintained sat w/ ambulating. LS w/ exp wheezing upper/diminished lower, treating w/ standing and PRN nebs. This shift, o2 sat 95-96 w/ goal >92 (on o2 @ home when sleeping @ night), rr 18-25.\n\nGI/GU: reg low sodium diet, tolerating well, +BS, no stool this shift, voiding urine yellow/clear, about 20-30cc/hr average. FSBG 163-148, covered per RISS.\n\nID: temp 97.2-97.7, wbc 13.4 this AM from 7.0 yesterday. Bactrim @ this time, pan cx results from last night still pending. Coughing up perulent sputum, sent for cx.\n\nPsychosocial: very pleasant, calls fam/friends, visited today by son and pt's wife. still awaiting bed (called out).\n\nDispo: cont to monitor resp status, monitor FSBG, still awaiting bed on floor, cont med regimen (hold bp meds if BP low, may want to consult MD's first), cont icu care @ this time.\n\nResp:\n" }, { "category": "Nursing/other", "chartdate": "2106-04-13 00:00:00.000", "description": "Report", "row_id": 1573219, "text": "Nursing Progress notes 1900-0700\nreview carevue for additional data\n\nevents: No significant events.\n\n79 y o male with multiple medical problem with low gi bleed, Red Tag study unremarkable for any active bleed, awaiting scope in am to see any active bleed, patient had colonoscopy a feew weeks ago with a polyp removal.\n\nNeuro: Alert, pleasant, oriented x3 and following commands, Patient MAE and normal strength in UE and LE lymphedema x20 yrs. Patient able to use bed side commode with assistance. denies any pain.\n\nResp: Continued on o2 3L on nasal canula, breathing normal but SOB with exertion. receiving MDI's and nebs, bilateral lung sounds clear to coarse and diminished at the base. spontaneous cough strong and unproductive. continues on prednisone.\n\nCv; Nsr,without ectopy, SBP 110-130's,continued on po lopressor and captopril. heparin gtt continued for PE and titarated as per ptt, next due at 0800. HCt stable in 30s.\n\nGi/GU: Npo from midnight for scope in am, abd obese and Bs present. Magnesiumcitrate given last night for bowel prep and stool is getting cleared and frequent liquid stool. voiding urine in urinal and small frequent urine adequate amount.\n\nEndo; Insulin on ss\nSkin: coccyx very sore and red due to frequent stool and aole vesta cream applied.\nSocial: no calls from family.\n\nPlan: Scope in Am\n ? filter placement in IR for PE\n Heparin gtt and titarate as per ss\n Series of HCt and watch for bleeding.\n series HCt and watch for bleeding.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2106-04-13 00:00:00.000", "description": "Report", "row_id": 1573220, "text": "Resp: Pt rec'd on 3 lpm n/c. Bs auscultated reveal bilateral clear apecies, with diminished bases, no wheezes noted. Nebs administered as ordered alb/atr. Pt says, \"he feels better following tx\". Will continue to monitor and treat.\n" }, { "category": "Nursing/other", "chartdate": "2106-04-13 00:00:00.000", "description": "Report", "row_id": 1573221, "text": "events: colonscopy done which reveladed sm ulceration compatible with postpolypectomy site with no active bleed.\n\nneuro: a+ox3. +mae noted.\ncv: monitor shows nsr with no ectopy noted. heparin resumed post procedure. will need ptt checked ~2100. plan to start po coumadin this evening. also will resume po dose of dilt.\nresp: ls with exp wheezes throughout. sob with minimal exertion noted. tol nebs/mdi's.\ngi: abd soft and obese. +bs noted. liquid clear stool with flecks (heme-). diet advanced to clears post colonscopy and tolerated well.\ngu: voiding via urinal without difficulty.\nskin: peri area reddened, nystatin powder applied. aloe protective barrier cream appllied to bottom. ble lymphedema-> stockings removed x1hr and reapplied.\nendo: remains on fingersticks q6hr with riss.\ni-d: afebrile. remains on bactrim for pcp slow steroid taper.\nheme: hct checks -> will need to be checked @ 2100.\naccess: piv. iv rn attempted to place 2nd, however unsuccessful. dr aware. will reattempt later this evening when pt returns to bed.\npsy-soc: pt spoke with wife via telephone. dr spoke with pt and updated on status and plan of care. c/o to floor awaiting bed availabilty.\n" }, { "category": "ECG", "chartdate": "2106-04-10 00:00:00.000", "description": "Report", "row_id": 192434, "text": "Sinus bradycardia. Right bundle-branch block. Compared to the previous tracing\nof ST segment in the inferolateral leads has resolved and the rate is\nslower.\n\n" }, { "category": "Radiology", "chartdate": "2106-04-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 962215, "text": " 8:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with COPD, HTN, hypothyroidism, recent PE, and GIB, now\n with fever and chills\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever and chills, rule out infiltrate. History of COPD,\n hypertension, hypothyroidism and recent PE and gastrointestinal bleeding.\n\n COMPARISON: Chest CT from and chest radiograph from , , \n and .\n\n TECHNIQUE AND FINDINGS: A portable frontal chest radiograph was obtained in\n semi-upright position.\n\n As compared to , there has been mild further improvement in\n bilateral opacities, suggestive of sequelae after right upper and bilateral\n lower lobes consolidations previously described as resolving aspiration\n pneumonitis. No new focal consolidation or infiltrate is seen. The lateral\n costophrenic angles remain sharp. Heart size is normal.\n\n CONCLUSION: No new focus of pneumonia. Progressively resolving bilateral\n parenchymal opacities, consistent with resolving aspiration pneumonitis.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2145-09-27 00:00:00.000", "description": "Report", "row_id": 1532242, "text": "TSICU Nursing Progress Note\nNeuro - Pt x3. Pupils unequal (s/p bilateral cataract surgery), reactive. Bilateral eyes swollen shut. Conversing appropriately throughout shift. Able to make needs known. C/o pain in left wrist (fracture), initially difficut to control. Now with pain score down from 10 to 5 with 2 mg dilaudid in divided doses over 6 hours.\n\nCV - NSR with rate in 60s, no ectopy. BP stable by cuff. Peripheral pulses palpable.\n\nResp - Lungs CTA, dim in bases. 50% face tent with O2 sats generally > 95%, occ dips to 90% when sleeping, quickly return to normal when awakened. Strong cough with encouragement.\n\nGI - Abdomen soft, NT, ND. + BS. Tolerating ice chips. No c/o nausea. No BM.\n\nGU - Adequate UOP via foley.\n\nEndo - Regular insulin per sliding scale.\n\nHeme - HCT decreased to 30, stable over last 2 levels.\n\nA - Neuro status stable on serial exams. Pain under better control.\n\nP - Continue serial exams. CT this AM. Monitor serial HCTs. Continue pain meds, assess for pain control.\n" }, { "category": "Nursing/other", "chartdate": "2145-09-27 00:00:00.000", "description": "Report", "row_id": 1532243, "text": "7p-2230\nSEE CAREVUE FOR ASSESSMENT AND VITAL SIGNS.\n\nNEURO: PT NEUROLOGICALLY INTACT. MAE. APPROPRIATE.\n\nCV: STABLE BP AND HR.\n\nRESP: SATS 95-97% ON 4L NC.\n\nGI: CLEAR LIQUIDS TOLERATED. NPO FROM MIDNIGHT TONIGHT FOR OR TOMORROW. +BS.\n\nGU: FOLEY WITH GOOD URINE OUTPUT.\n\nENDO: SSI. NO COVERAGE REQUIRED. BS 106 @ .\n\nSKIN: MULTIPLE BRUISED AREAS. EYE SWELLING SIGNIFICANTLY REDUCED IN LAST 24HRS.\n\nPLAN: TRANSFER TO 2 (209)\n NPO FROM MIDNIGHT. OR TOMORROW.\n MONITOR COLOUR/WARMTH/SENSATION TO L ARM.\n\n" }, { "category": "Nursing/other", "chartdate": "2145-09-26 00:00:00.000", "description": "Report", "row_id": 1532240, "text": "T/SICU NPN: Nursing Admission Note\n is a 83 year old woman admitted to the T/SICU at 0700 from the EW. Pt is s/p fall in middle of night. Pt found face down in bathroom by daughter. Pt has no recall of incident; actually,\npt thought she fell down the stairs. Tox screen negative.\n\nInjuries are as follows:\n facial fractures--bilateral orbit roof fracture and left\n retro-orbital hematoma eye lacerations(two)\n s/p right canthotomy(in EW)\n Small right parietal SDH SAH\n splenic laceration(grade 3)\n left distal radius fracture\n L2 compression fracture(old)\n\nPMH: hx a-fib(came in ?a-fib then converted to NSR)\n angina(reports several episodes/year--starts in left chest radiating to jaw)\n hypercholesteremia\n hx carpal tunnel--wears wrist splints at night\n\nPSH: s/p right THR(s/p fall)\n s/p right TKR\n s/p cataract surgery\n\nAllergies: ASA Morphine\n\nMedications: atenolol 50mg qd\n zocar 20mg qhs\n nitroquik 0.4mg prn\n fosomax 70mg per week(q sunday)\n tramadol 50mg qd\n\nPsychosocial: retired in last year lives in daughter-- and grand-daughter live with pt(d/t housing issues) pt has second daughter-- who lives in is Health Care Proxy.\n\nSystem Review:\n\nNeuro: awake alert oriented x 3 answering questions/conversation appropiate speech normal moving all extremities to command decreased mobility of LUE d/t fracture intact gag/cough pupils\nright pupil 2-3mm brisk reaction left pupil 4-5mm irregularly shaped\nnon-reactive right eye swollen--able to partially open eye\nleft eye moves lid but unable to open c/o frontal headache throughout day continues on dilantin no seizure activity c-spine/t-l-s cleared\nby Dr. \n\nCVS: HR 60-70's NSR with no ectopy NBP 140>>100's started on iv lopressor 5mg q4hr skin warm/dry +palpable pedal pulses\nleft arm splinted c/o numbness in fingers on/off +palpable radial pulse fingers warm to touch with good capillary refill ortho md\nin to evaluate\n\nRespiratory: RR 12-20's lungs clear strong dry cough sao2's drifting to low 90's% on room air 2L NC added then changed to 50% face tent(d/t nasal fx) sao2 > 97%\n\nRenal: foley patent and draining clear yellow urine 25-120cc/hr\nK+ 3.5 IVF changed to NS with 20meq KCL at 100cc/hr MG+ 1.7 2gms magnesium sulfate repleted\n\nGI: abdomen: soft +bs +flatus remains NPO c/o nausea with dry heaves x 1 medicated with 12.5mg anzemet for relief on protonix\n\nEndocrine: FS qid last FS 156 covered with 2u regular insulin sq\n\nHeme: serial Hct's q6hrs Hct's 36.6>>34.8 PLT 235 INR 0.9 on pneumoboots\n\nID: tmax 99.8 WBC 10.9 no antibiotics\n\nSkin: left lid lacerations sutured by plastics scant amount of bloody fluid cleaned with NS bacitracin applied eyes ecchymotic\nright more swollen than left left heel with ~quarter size superficial sk\n" }, { "category": "Nursing/other", "chartdate": "2145-09-26 00:00:00.000", "description": "Report", "row_id": 1532241, "text": "T/SICU NPN: Nursing Admission Note\n(Continued)\nin tear cleaned with NS and covered with DSD left arm splinted--resplinted by ortho md at 1700\n\nComfort: c/o left arm pain/finger numbness and frontal headache\npain scores up to 10 for left arm medicated initially with 25mcg iv fentanyl for sedative effect/thus less c/o pain several hours later\npain on the rise again medicated with total of .5mg iv dilaudid pain scores down to 5 and pt dozing on/off at 1700 left arm splint replaced and pt extremely uncomfortable and demanding that splint be removed ortho md up to evaluate/re-evaluate splint circulation intact to LUE medicated for total of .375mg of iv dilaudid with gradual relief and falling off to sleep\n\nPsychosocial: daughters in for visits updated on clinical situation and questions answered\n\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2145-09-27 00:00:00.000", "description": "Report", "row_id": 200473, "text": "Sinus rhythm. No change since the previous tracing of .\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2145-09-26 00:00:00.000", "description": "Report", "row_id": 200474, "text": "Sinus rhythm. Left ventricular hypertrophy with repolarization\nabnormalities. No change since the previous tracing of .\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2145-09-26 00:00:00.000", "description": "Report", "row_id": 200475, "text": "Sinus bradycardia\nPossible left atrial abnormality\nNonspecific intraventricular conduction delay\nLeft ventricular hypertrophy with ST-T abnormalities\nConsider also biventricular hypertrophy\nNo previous tracing available for comparison\n\n" }, { "category": "Radiology", "chartdate": "2145-09-26 00:00:00.000", "description": "L WRIST(3 + VIEWS) LEFT", "row_id": 926443, "text": " 5:31 AM\n WRIST(3 + VIEWS) LEFT Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p fall down stairs\n REASON FOR THIS EXAMINATION:\n trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall downstairs. Evaluate for trauma.\n\n There are no prior studies for comparison.\n\n LEFT WRIST, THREE VIEWS: Overlying cast material obscures detail. There is a\n fracture of the left distal radius, with dorsal angulation. Overlying cast\n material obscures the left distal ulna, but there may be a fracture at this\n locale as well. No other definite fractures are identified. The bones are\n demineralized.\n\n IMPRESSION: Colles fracture of the distal left radius.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-09-28 00:00:00.000", "description": "OL WRIST, AP & LAT VIEWS IN O.R. LEFT", "row_id": 926701, "text": " 2:08 PM\n WRIST, AP & LAT VIEWS IN O.R. LEFT; UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # \n Reason: ORIF OF LEFT WRIST\n Admitting Diagnosis: FACIAL TRAUMA,INTRACEREBRAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Left wrist intraoperative study performed on .\n\n HISTORY: ORIF of left wrist fracture.\n\n FINDINGS: Six fluoroscopic images from the operating room demonstrate\n interval placement of a volar plate and multiple pins as well as two\n percutaneous pins fixating a comminuted distal radius fracture. There is also\n a fracture of the ulnar styloid. There is some widening of the scapholunate\n interval. Please refer to the surgical report for further details.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-09-26 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 926434, "text": " 4:37 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Trauma.\n\n There are no prior studies for comparison.\n\n SUPINE AP CHEST: A trauma board obscures detail. The heart size is normal.\n The mediastinal contours are normal. There appears to be mild pulmonary\n vascular prominence. No consolidation or pneumothorax visualized. No pleural\n effusion.\n\n SUPINE AP PELVIS: A trauma board obscures detail. A dynamic hip screw\n transfixes the right proximal femur. Femoral heads are rounded and well\n seated in the acetabuli. No diastasis of the pubic symphysis. The sacrum is\n not well visualized. Bowel gas is normal.\n\n IMPRESSION: No definite acute traumatic injury visualized.\n\n" }, { "category": "Radiology", "chartdate": "2145-09-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 926435, "text": " 4:51 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p fall down stairs\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKXa SUN 5:43 AM\n Small right posterior subdural hematoma and subdural blood along the left side\n of the falx.\n Subarachnoid hemorrhage.\n\n Multiple facial fx to be described in facial ct. roofs of both orbits\n involved.\n retroorbital hematoma on the left with slight proptosis of the left eye.\n Pneumocephalus rel to left orbital roof fx.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall downstairs.\n\n There are no prior studies for comparison.\n\n NON-CONTRAST HEAD CT SCAN: There is a small subdural hematoma in the right\n occipital region. There is also a small amount of subdural blood along the\n left side of the falx cerebri superiorly. There is hypodensity of bifrontal\n sulci as well as hyperdensity within the left sylvian fissure and within a\n right occipital sulcus, all consistent with subarachnoid blood. The\n ventricles and cisterns are normal. There was no shift of the normally\n midline structures. The -white matter differentiation of the brain is\n preserved. Blood fills the left maxillary sinus, most of the ethmoid air\n cells and the left sphenoid air cell, as well as layering posteriorly within\n the right sphenoid air cell. The mastoid air cells are clear. There are\n several facial fractures, including fractures of the roof of the orbits\n bilaterally. There is pneumocephalus present within the left frontal extra-\n axial space related to the fracture of the orbit at this locale. There are\n fractures of the right lamina papyracea, lateral wall of the left orbit as\n well as medial and lateral walls of the left maxillary sinus. Please refer to\n the facial bone report of the same day.\n\n Blood is seen within the retro orbital intraconal fat on the left side. There\n is also proptosis of the left globe, slightly.\n\n IMPRESSION:\n 1. Small right posterior subdural hematoma. Also, a small amount of subdural\n blood along the left side of the cerebri.\n 2. Subarachnoid blood in the locales described in the body of the report.\n 3. Multiple fractures involving the roof of both orbits, the right lamina\n papyracea, the lateral wall of the left orbit as well as the medial and\n lateral walls of the left maxillary sinus. There are bilateral nasal\n fractures present. Please refer to the facial bones report of the same day.\n (Over)\n\n 4:51 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: trauma\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Retro orbital, intraconal, hematoma on the left, and slight proptosis of\n the left globe.\n\n The findings were discussed with the surgical resident at the conclusion of\n the exam, Dr. .\n\n 5. Small foci of pneumocephalus related to fracture of the left orbital roof.\n\n" }, { "category": "Radiology", "chartdate": "2145-09-26 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 926436, "text": " 4:51 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p fall down stairs\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKXa SUN 5:48 AM\n No cervical spine fracture. Multilevel changes. Fractures involving left\n max sinus better seen on facial and head ct.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall. Evaluate for fracture.\n\n There are no prior studies for comparison.\n\n TECHNIQUE: Contiguous axial images through the cervical spine were obtained\n without IV contrast. Coronal and sagittal reformatted images were generated.\n\n CT OF THE CERVICAL SPINE WITHOUT CONTRAST: No fracture of the cervical spine\n is identified. The cervical vertebral body heights and alignment are\n maintained. There is intervertebral disc space narrowing at multiple levels,\n greatest at C6/7. The prevertebral soft tissues are normal. Though CT does\n not provide intrathecal detail comparable to that of MRI, the central spinal\n canal appears patent. There may be mild disc protrusions at C3/4, C4/5 and\n C5/6. The largest appears to be at C3/4, causing perhaps mild-to-moderate\n central canal stenosis.\n\n The patient is post right thyroidectomy. There are nodular-appearing\n structures within the left lobe of the thyroid gland.\n\n Multiple facial fractures including those of the left maxillary sinus are\n visualized though they are better appreciated on the CT head and facial bones\n of the same day.\n\n IMPRESSION:\n 1. No cervical spine fracture.\n 2. Cervical spondylosis, with mild-to-moderate central canal stenosis at 3/4.\n 3. Post right thyroidectomy.\n 4. Left maxillary sinus fracture is better appreciated on the head and facial\n bones CTs of the same day.\n\n" }, { "category": "Radiology", "chartdate": "2145-09-26 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 926437, "text": " 4:52 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please recon spine - s/p trauma\n Field of view: 42.5 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p fall down stairs\n REASON FOR THIS EXAMINATION:\n please recon spine - s/p trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKXa SUN 6:09 AM\n 1.5 cm y shaped splenic laceration, without free fluid around the spleen or in\n the abdomen.\n L2 compression fx (50%) of undetermined acuity.\n ?Bursa vs. necrotic node in lat right axilla.\n Abnormal periesophageal lymph nodes.\n schlerotic lesions of left humeral head and T11.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall downstairs. Evaluate for trauma.\n\n There are no prior studies for comparison.\n\n TECHNIQUE: Contiguous axial images through the chest, abdomen and pelvis were\n obtained following the administration of 130 cc of IV Optiray contrast.\n Coronal and sagittal reformatted images were generated.\n\n CT OF THE CHEST WITH CONTRAST: There is no evidence of aortic injury. There\n is atherosclerosis of the aorta. There are coronary artery calcifications. No\n pleural or pericardial effusion. There is no pneumothorax. No consolidations\n or noncalcified pulmonary nodules visualized. There is a calcified granuloma\n of the right middle lobe. There are mild dependent changes within the lungs.\n The central airways are patent. There is a fluid- containing structure with a\n hyperdense rim and a possible septation within the right axilla measuring 3.1\n x 1.7 cm in transverse dimensions. This likely represents the subcoracoid\n bursa; a similar structure is seen on the other side. No pathologically\n enlarged lymph nodes of the left axilla, mediastinum or hila. The patient is\n post-right thyroidectomy. There is a small 5-mm soft tissue structure\n posterior to the esophagus (series 2, image 9) which may represent a\n diverticulum.\n\n CT OF THE ABDOMEN WITH CONTRAST: The liver, gallbladder, pancreas and adrenal\n glands are normal. There is a 1.5-cm Y-shaped hypodensity within the spleen\n that is indeterminate in nature. A laceration is not entirely excluded. There\n is no free fluid surrounding the spleen or surrounding traumatic injury. The\n kidneys enhance symmetrically and excrete normally. The stomach, small and\n large bowel loops are normal. There is no free air or free fluid in the\n abdomen. The aorta is of normal caliber, and the proximal celiac, SMA and \n are patent. No other notable mesenteric or retroperitoneal lymph nodes.\n\n CT OF THE PELVIS WITH CONTRAST: There is a Foley catheter within the bladder,\n (Over)\n\n 4:52 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please recon spine - s/p trauma\n Field of view: 42.5 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n and air within the bladder likely related to instrumentation. The uterus and\n rectum are normal. There is sigmoid diverticulosis, without evidence of\n diverticulitis. No free fluid in the pelvis, and no pathologically enlarged\n pelvic or inguinal lymph nodes. There is a 1.4 cm cyst of the left ovary.\n\n BONE WINDOWS: There is hardware of the right hip, with beam hardening\n artifact limiting detail. The iliac wings are thin, without a definite\n fracture identified. The iliac wings are extremely thin, but no definite\n fracture is identified. There is a sclerotic lesion of the left humeral head,\n measuring 2.1 cm, likely an old enchondroma. There is also a sclerotic lesion\n within the T11 vertebral body superiorly.\n\n Multiplanar reformatted images were essential in delineating the anatomy in\n this case. In addition, the sagittal reformatted images demonstrate a\n compression fracture at L2. There does not appear to be any retropulsed\n fragments present. The vertebral body height is decreased by about 50%\n centrally. The acuity is indeterminate as there are no prior studies for\n comparison.\n\n IMPRESSION:\n 1. 1.5-cm splenic hypodensity, without free fluid surrounding the spleen.\n Given that there is no surrounding traumatic injury, the lesion is unlikely to\n be a splenic laceration. The lesion is not a mass.\n\n 2. L2 compression fracture, of indeterminate acuity. The vertebral body\n height is decreased by about 50% centrally. No definite acute features.\n\n 3. Post right thyroidectomy.\n\n 4. Sclerotic lesion of the left humeral head, likely an old enchondroma.\n Sclerotic focus of the T11 thoracic vertebral body, benign in appearance.\n\n 5. 1.4 cm cyst of the left ovary. Pelvic US is recommended if this finding\n has not been shown to be stable.\n\n The findings were discussed with Dr. at the conclusion of the exam.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-09-26 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 926438, "text": " 4:52 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p fall down stairs\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKXa SUN 6:31 AM\n Fx of rooves of both orbits, both laminae papricea, lateral wall of left\n orbit, floor of left orbit, left zygomatic arch, medial and lateral walls of\n left maxillary sinus and bilat nasal fx.\n\n Left retroorbital hematoma, with slight proptosis of left eye. Hematoma\n situated btw left medial rectus and optic nerve.\n\n Left inferior rectus approaches floor of orbit fx defect but doesn't def.\n cross into it.\n\n Pneumocephalus rel to orbital roof fx on left, air in right orbit.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Facial fractures. Please assess.\n\n There are no prior studies for comparison.\n\n TECHNIQUE: Contiguous axial images through the facial bones were obtained\n without contrast. Coronal reformatted images were generated.\n\n CT OF THE FACIAL BONES WITHOUT CONTRAST: There are multiple extensive facial\n fractures, including the roof of both orbits, the junction of the right lamina\n papyracea with the orbital rim, bilateral nasal fractures, the lateral wall of\n the left orbit, the left lamina papyracea, the medial and lateral walls of the\n left maxillary sinus and the left zygomatic arch. The left orbital floor is\n also fractured, and the left inferior rectus approaches but does not\n definitely cross the fracture defect. The globes appear rounded and intact\n bilaterally, though there is slight proptosis of the left orbit. There is a\n left retro-orbital hematoma present, which appears situated between the optic\n nerve and the medial rectus muscle in the coronal plane. There is\n opacification of the left maxillary sinus and most of the ethmoid air cells as\n well as the left nasal cavity, and the sphenoid air cell on the left related\n to the fractures. There is marked soft tissue swelling about the left side of\n the face and above both orbits.\n\n IMPRESSION:\n 1. Multiple facial fractures as described.\n 2. Fracture of both orbital roofs, resulting in pneumocephalus on the left\n side. There is air in the roof of the right orbit.\n 3. Retroorbital hematoma on the left, situated between the medial rectus\n muscle and optic nerve. There is slight proptosis of the left eye.\n 4. Fracture of the floor of the left orbit with herniation of fat, where the\n (Over)\n\n 4:52 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: trauma\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n inferior rectus approaches but does not definitely protrude through the\n fracture defect.\n\n Ophthalmologic consultation was recommended.\n\n Findings were relayed to the ED dashboard and were discussed with Dr. .\n\n NOTE ADDED AT ATTENDING REVIEW: There is also a bubble of gas at the superior\n left sphenoid sinus. The integrity of the cortex at this location is suspect\n and a tiny fracture cannot be excluded.\n\n In addition, the fracture of the posterolateral left orbital wall has a\n displaced fragment. This displaced fragment forms a wedge and impinges\n directly upon the lateral rectus muscle. Dr. was notified of this\n finding at the time of review.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-09-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 926535, "text": " 7:57 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: FELL DOWN STAIRS; F/U TO SDH; PRE-OP\n Admitting Diagnosis: FACIAL TRAUMA,INTRACEREBRAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p fall down stairs with SAH, subdural and multiple facial\n fractures.\n REASON FOR THIS EXAMINATION:\n F/U CT\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall downstairs with subarachnoid and subdural\n hemorrhage and multiple facial fractures, followup CT.\n\n COMPARISON: CT dated .\n\n TECHNIQUE: MDCT acquired images of the head were obtained without IV\n contrast.\n\n FINDINGS: Multiple bilateral foci of subarachnoid hemorrhage are again\n demonstrated and do not appear significantly changed compared to the previous\n study. Subdural hemorrhage layering along the falx on the left is also again\n demonstrated and not significantly changed. Subdural hemorrhage overlying the\n right posterior parieto-occipital lobe is also again demonstrated and may be\n slightly increased in extent compared to the previous exam. The ventricles\n are stable in size. There is no shift of normally midline structures. The\n basal cisterns appear patent. Left retrobulbar hemorrhage is again\n demonstrated. Skull fractures are better characterized on the CT scan of\n of the facial bones. There is increased soft tissue swelling compared\n to the prior study.\n\n IMPRESSION: Multiple stable foci of subarachnoid hemorrhage and stable\n subdural hemorrhage layering along the falx on the left with subdural\n hemorrhage overlying the right parieto-occipital lobe, possibly slightly\n increased compared to the previous exam. Soft tissue swelling has increased\n compared to the prior study.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2121-11-14 00:00:00.000", "description": "Report", "row_id": 1537461, "text": "NURSING PROGRESS NOTE:\nSEE PREVIOUS NOTE:\nPT RECEIVED AT 0330 FROM THE TRAUMA SICU. PT RECEIVED INTUBATED/VENTED AND ON PROPOFOL DRIP AT 50MCQ. PT VERY SEDATED AND DROPPING BLOOD PRESSURE INTO THE 80'S. PROPOFOL WEANED TO 20MCQ AND BP CAME BACK UP TO THE 120'S.\nRESP: PT ON PRESSURE SUPPORT OF 12 AND 5PEEP 40% WITH MINIMAL SECRETIONS. PT HAS WHEEZES IN HER UPPER AIRWAYS. O2SAT'S IN HIGH 90'S TO 100%. PT HAS BEEN A FAILURE TO WEAN AND EXTUBATE X 3. PT WAS REINTUBATED AT 7PM IN THE TSICU.\n\nCV: PT IN NSR WITHOUT ECTOPY. BP WITHIN NORMAL LIMITS ON LOWER DOSE OF PROPOFOL. TEMP 98 PO.\n\nGI: PT NEEDS FEEDING TUBE OR NGT FOR PO MEDS. PT IS ON TPN FOR NUTRITION. ABD SOFT/DISTENDED WITH POS BOWEL SOUNDS. PT HAS COLOSTOMY AND IS PASSING FLATUS AND SM AMT'S OF LOOSE BROWN STOOL.\n\nGU: FOLEY CATH PATENT DRAINING ADEQUATE AMT'S OF CLEAR YELLOW URINE.\n\nSKIN: PT HAS ABDOMINAL INCISION AND IS OPEN TO AIR.\n\nENDO: ON SSRI.\n\nSOCIAL: HAVE NOT HEARD FROM ANY FAMILY MEMBERS SINCE ARRIVING TO THE MICU, PT IS FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-14 00:00:00.000", "description": "Report", "row_id": 1537462, "text": "Respiratory Care:\nPatient received from T-SICU, on ventilatory support (CPAP/PSV) after re-intubation for respiratory failure. ABG results determined a mild respiratory acidemia with excellent oxygenation.\n\nRSBI = 48.6 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-14 00:00:00.000", "description": "Report", "row_id": 1537463, "text": "Respiratory Care:\nPt remains on ventilatory support via ventilator. Pt received on PSV settings this a.m.; changed to A/C settings (please see carevue respiratory flowsheet for details in settings) when tracheostomy was placed. Pt placed with #8 Portex trach at bedside under visual bronchoscopy. There was difficulty placing the trach with a large amount of blood. Trach site continues to ooze blood; has drain sponges in place. Plan to continue to ventilate as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-12 00:00:00.000", "description": "Report", "row_id": 1537453, "text": "Respiratory Care:\nPt. remained on low level PS all night. ABG's well oxygenated with a slight respiratory alkalosis. B/S scattered, course crackles>>ETS small to moderate, thick, white. RSBI was 74 this a.m. (done on CPAP=0, ATC off). Pt. then started on SBT. Team to eval. for ? ext.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-13 00:00:00.000", "description": "Report", "row_id": 1537459, "text": "TRAUMA ICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: FOLLOWING AND NODDING APPROP THIS AM WHILE\n INTUBATED AND PROPOFOL OFF. CALM...AT TIMES\n SLEEPY/LETHARGIC. . SEEN BY\n NEUROLOGY TEAM...EXAM WNL. AROUND 5PM...\n DEVELOPED CONFUSION... ASKING \"WHEN IS THE\n TRAIN COMING?\" INCREASED WORK OF BREATHING\n . UPPER AIRWAY CONGESTION/WHEEZING. ALBUTEROL\n INHALER WITH NO CHANGE. STRONG PROD COUGH.\n RAISING SPUTUM TO YANKEUR.\n BECOMING INCREASINGLY RESTLESS. ATTEMPTING\n TO GET UP. EASILY REORIENTED INITIALLY..\n PT THEN LOOKING CONFUSED...INCREASED AGITATION.\n \"WHO HAS THE BABY?\" PULLED A LINE.\n ATTEMPTING TO GET UP REPEATEDLY.\n ATIVAN 1 MG IV TRIED WITH NO IMPROVEMENT...\n AND ? SLIGHT WORSENING OF AGITATION.\n SEEN BY SICU HO.\n\nCV: HR AND BP STABLE. LYTES REPLETED.\n\nRESP: THIS AM... SEE NEURO.\n GOOD SATS STILL.\n\nRENAL: LABS WNL. ADEQUATE UO.\n\nGI: TPN WITH LIPIDS CONTINUES. SOFT BROWN STOOL\n VIA COLOSTOMY. NO RECTUM. IV PROTONIX.\n\nHEME: STABLE. SC HEPARIN. BOOTS ON.\n\nENDO: INSULIN PER SLIDING SCALE.\n\nID: LOW GRADE TEMPS. WBC STABLE.\n ANTIBX'S D/C SEVERAL DAYS AGO.\n\nSKIN: NO NEW ISSUES.\n\nSOCIAL: SON IN MOST OF DAY.\n\nA: INCREASED WORK OF BREATHING AND INCREASED CONFUSION,\n AGITATION S/P EXTUBATION AND D/C'DING OF PROPOFOL\n DRIP.\nP: FOLLOW NEURO PLANS. LOW THRESHOLD TO REINTUBATE.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-12 00:00:00.000", "description": "Report", "row_id": 1537454, "text": "NPN 2300-0700\nNEURO: Sedated on propofol. Pt occasionally restless and fidgety, however hypotensive on greater than 30mcg/kg/ of propofol. Ativan ATC for ETOH withdrawal/anxiety. Nods to yes/no questions. Denies pain.\n\nRESP: Remained on CPAP + PS overnight. LS coarse, diminished at bases. RR high 20s-low 30s. Vent changed to 0PS/5PEEP in AM d/t ?extubation.\n\nCV: HR 60s-70s, SB no ectopy. BP 90s-140s/40s-60s. Lopressor ATC cont.\n\nHEME: H/H stable. Pboots, sq heparin cont.\n\nGI: Abd soft/distended. +Flatus in ostomy bag but no output. TPN cont.\n\nGU: Adequate u/o for shift. K+ repleted.\n\nID: Afebrile this shift. No abx at this time.\n\nENDO: No coverage per RISS.\n\nSKIN: Blisters to back pink and healing. Buttocks intact.\n\nSOCIAL: No contact from family overnight.\n\nASMT: Pt s/p hernia repair with ostomy re-site complicated by alteration in respiratory staus and mental status changes.\n\nPLAN: Cont to monitor vs, neuro checks, monitor resp status, ?extubate this AM, cont with scale if extubated.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-12 00:00:00.000", "description": "Report", "row_id": 1537455, "text": "Resp care\nPt remians on SBT t/o day. No new ABG's, no distress noted. RR in 20's with Vt's ~500cc's. BS coarse->clear, dimin. Sx sm white secretions. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-12 00:00:00.000", "description": "Report", "row_id": 1537456, "text": "TRAUMA ICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: SEDATED ON PROPOFOL. WAKES AGITATED..DIFFICULT\n TO SEDATE. HALDOL GIVEN IN PREPARATION OF ?\n EXTUBATING... PLAN TO EXTUBATE IN AM. HALDOL TO\n RESUME THEN. ATIVAN WEANING. NO C/O PAIN.\n NEUROLOGY TEAM CONSULTED. PLAN MRI OF HEAD.\n\nCV: HR AND BP LOW WITH PROPOFOL DRIP ON.\n IV LOPRESSOR HELD.\n\nRESP: WHITE FROTHY SPUTUM THIS AM.\n REPEAT CXR DONE.\n\nRENAL: LFT'S WNL WITH TBILI 1.0 GOOD UO.\n LYTES REPLETED.\n\nGI: TPN. NPO. COLOSTOMY WITH GAS..BUT NO STOOL\n X 2 DAYS OF NPO. IV PROTONIX.\n\nHEME: HCT STABLE. COAGS GOING UP. SC HEPARIN.\n BOOTS ON.\n\nENDO: INSULIN TAKEN OUT OF TPN. ON SLIDING SCALE.\n\nID: LOW GRADE TEMPS. WBC STABLE.\n ANTIBX'S D/C'D YESTERDAY.\n\nSKIN: ABD INCISIONS HEALING.\n STOMA HEALTHY.\n BACK BLISTERS HEALING.\n\nSOCIAL: SON AND DAUGHTER IN LAW VISITING.\n\nOTHER: OF ADDICTIONS TEAM CONSULTED PER\n FAMILY REQUEST. WILL FOLLOW UP WHEN PT .\n\nA: CONTINUES WITH AGITATION.\nP: WEAN AND EXTUBATE IN AM. FOLLOW MENTAL STATUS.\n MRI OF HEAD TONIGHT.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-13 00:00:00.000", "description": "Report", "row_id": 1537457, "text": "TSICU NPN 7P-7A:\n\nEV TO MRI HEAD. TOLERATED WELL. RIGHT SC TRIPLE LUMEN STARTED TO OOZE SPONTANEOUSLY AROUND THE SITE. RESOLVED WITH DRESSING CHANGE. LEFT RADIAL A-LINE LATER ON IN THE SHIFT, AFTER TURNING, ALSO STARTED TO SPONTANEOUSLY BLEED AROUND THE SITE. DRESSING REAPPLIED. PT TOLERATED WELL. VERY TACHYPNEIC ON CPAP 0/PSV 5 WITH 40 % AND DUE TO INCREASE IN SECRETIONS AND PT'S WORK OF BREATHING, PEEP INCREASED TO 5 PER DR. . PT TOLERATING THESE SETTINGS MUCH BETTER.\n\nNEURO: OPEN EYES TO VERBAL CUES INTERMITTENTLY AND WILL FOLLOW SOME SIMPLE COMMANDS. NODDING HEAD AT TIMES IN ANSWER TO QUESTIONS. MAE WEAKLY BUT PURPOSEFULLY. REMAINS SEDATED ON 30 MCG/KG/ OF PROPOFOL. ATIVAN 0.5MG IV ATC. HALDOL GIVEN DURING THE MRI SCAN FOR SEDATION WITH GOOD EFFECT. PERL 3MM.\n\nCV: SR WITH RARE PVCS. COLOR PALE. SKIN WARM AND DRY. PALP DP AND PT PULSES BILAT. GENERALIZED NON-PITTING EDEMA. BP STABLE. HYPERTENSIVE AT TIMES TONIGHT, ESPECIALLY WITH INCREASED RESP. DISTRESS.\n\nRESP; ORALLY INTUBATED. ETT SECURE AND EQUAL CHEST EXPANSION NOTED. LUNG SOUNDS COARSE WITH EXPIRATORY WHEEZING THROUGHOUT. SLIGHTLY DIMINISHED IN THE BASES. SUCTIONING LARGE AMOUNTS THICK YELLOW SECRETIONS.\n\nGI: ABD. SOFT ROUND. LLQ SURGICAL SITE WITH STAPLES INTACT. AREA IS ECCHYMOTIC AND FIRMER THAN SURROUNDING ABDOMINAL AREA. MULTIPLE BRUISED AREAS NOTED ON ABDOMEN. COLOSTOMY SITE RED, LOWER PORTION SLIGHTLY RETRACTED AND DARKER. +FLATUS, SMALL AMOUNT LIQUID BROWN STOOL, 2 FORMED SMALL STOOL ALSO NOTED IN BAG. + HYPOACTIVE BOWEL SOUNDS. NO VOMITING. NPO.\n\nGU: FOLEY WITH CLEAR YELLOW URINE. KVO AT 5CC/HOUR. REPLETED KCL AND MAGNESIUM\n\nENDO: COVERAGE WITH RISS REQUIRED.\n\nHEME: NO NEW ISSUES. CONTINUE WITH SQ HEPARIN, PNEUMO BOOTS. HCT 33.8.\n\nID: AFEBRILE. NO ABX COVERAGE. WBC FLAT.\n\nSKIN: BLISTERED AREAS ON BACK ARE HEALING AND DRY. SURGICAL INCISIONS OPEN TO AIR WITH NO DRAINAGE.\n\nSOCIAL: NO CONTACT WITH FAMILY OVERNIGHT.\n\nPLAN: CONTINUE WITH SLOW WEAN FROM VENTILATOR. ?ABILITY TO EXTUBATE THIS AM AS PLANNED DUE TO INCREASE IN PULMONARY SECRETIONS. CONTINUE TO MONITOR MENTAL STATUS CHANGES. PER NEUROLOGY REQUEST, LIMIT USE OF HALDOL. INCREASE ACTIVITY AS TOLERATED. LOPRESSOR FOR BP CONTROL.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-13 00:00:00.000", "description": "Report", "row_id": 1537458, "text": "RESPIRATORY CARE:\n\nPt remains intubated, minimally vent supported. Transported to and from MRI without event. Later in shift, pt had increased SOB, ^BP, and agitation. Added 5 of peep, symptoms seemed to subside. See flowsheet for further data.\nPlan: Maintain vent support.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-14 00:00:00.000", "description": "Report", "row_id": 1537460, "text": "T/SICU Nursing Progress Note\nS:\nO: Neuro: initially awake, very confused, trying to get out of bed. After intubation, sedated with propofol. Also received one dose of IM antipsychotic.\nCVS: stable heart rate and rhythm. Continues on iv lopressor\nRESP: reintubated at beginning of shift because of labored, dyspneic breathing. Intubation was somewhat difficult and required 3 passes and use of # 7 tube with a bougie. CXR verified tube placement post intubation. Suctioned for thick bloody secretions. ABG wnl. LLCurrently on psv of 12, 5 peep 40 %. Tidal volumes 550cc, rr rate 16-21.\nRENAL: urine output adequate. Weight today 85 kg.\nGI: belly soft with bowel sounds. Small amount of stool per colostomy. On tpn. Protonix for prophylaxis\nID: afebrile\nENDO: ssri\nHeme: bruising noted over abdomen and arms., pneumoboots in use\nSKIN: lips bleeding, midline incision open to air with ecchymosis, no drainage, Small abrasion on coccyx and forehead. AM care given.\nSocial: Son called and informed about intubation.\nA: Respiratory failure requiring reintubation.\nP: ??trach soon due to 3 failed extubation trials. ??feeding tube under fluoro. Transfer to MICU B due to bed management issues.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-10 00:00:00.000", "description": "Report", "row_id": 1537445, "text": "ROS:\n\nNeuro: alert oriented to self only. Agitated, haldol given. C/o incisional pain, dilaudid given. C/o nausea, dolasetron mesylate given. Slept b/t 2200 and 0200. Awakend for pulmonary toileting (resp acidosis via ABGs) then is agitated and restless. Followes commands, MAE x's 4. PEARRLA.\n\nResp: Sats 85->95%, Fio2 ^ to 80% to maintain sats. O2 NP also ^ temp to 6L, now back donw to 4 NP. Sats maintaining 95%. No resp distress noted. Tachypnic at times (associated w/agitation). = rise and fall of chest. ABGs = Resp acidosis which resolved w/pulomnary toileting.\n\nCV: RSR w/o ectopy. s1s2. Peripheral palpable w/ease. Has left radial ABP line, positinal and dampend at times. Has right subclavian MML being transduced for CVP = 4->10. No edema noted. Heparin SQ and P boots prophylacticly.\n\nGI: Abd soft, firmness around midline abd incision. Takes sips of clear liq thickend. Colostomy w/small amt soft brown stool. Active bowel sounds in all four quads of abd. Pepcid prophylacticly.\n\nGU: Foley patent draining clear dark yellow -> urine. UO dropped off, fluid bolus (500cc) given, with minimal responce.\n\nEndo: FSG covered w/RSSI\n\nID: Afebrile. ATB coverage vanco and levofloxin.\n\nLabs: Stable\n\nPlan: Continue w/pulmonary toileting. Frequent reorientation. Monitor ABGs. ?? transfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-10 00:00:00.000", "description": "Report", "row_id": 1537446, "text": "Resp care\nPt electively intubated for impending resp failure. #7.5 OET placed without difficulty. Taken to head CT. Results pending. BS coarse, dimin. Sx sm-mod thick tan secretions. ABG's acceptable. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-10 00:00:00.000", "description": "Report", "row_id": 1537447, "text": "TRAUMA ICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: OX1 ONLY THIS AM. INCREASING AGITATION, DESPITE\n ATIVAN/HALDOL. PLAN HEAD CT... ALSO INCREASED\n WORK OF BREATHING..WITH DROP IN SATS.\n INTUBATED. SEDATED. HEAD CT WNL.\n HALDOL PRN. NO C/O PAIN PER PT.\n\nCV: HR 50-60 SEDATED. BP LABILE WITH AWAKE/SEDATION.\n POTASSIUM REPLETED.\n\nRESP: SUCTIONED FOR THICK TAN/ YELLOW SECRETIONS.\n ABD WNL. NO PROBLEMS WITH SATS.\n\nRENAL: LABS WNL. ADEQUATE UO.\n\nGI: NPO. IVF AT 60. UNABLE TO PLACE OGT/NGT X 3\n PEOPLE ATTEMPT. PLAN TPN TONIGHT. REDISCUSS\n POSTPYLORIC TUBE TOMORROW. SOFT BROWN STOOL\n VIA COLOSTOMY...WITH + GAS. STOMA RED, WITH\n IMPROVED LOOKS SINCE FRIDAY.\n POUCH CHANGED. IV PROTONIX.\n\nHEME: LABS STABLE. SC HEPARIN. BOOTS ON.\n\nENDO: NO INSULIN PER SLIDING SCALE. (SOLUMEDROL X 3\n DOSES LAST WEEK.)\n\nID: AFEBRILE. WBC BACK UP TO 12.\n IV VANCO AND LEVOFLOXACIN TO CONTINUE UNTIL\n TOMORROW.\n\nCX: SPUTUM WITH G+R.\n\nSKIN: BLISTERS ON BACK FROM OLD EPIDURAL SITE..SEEN\n BY SICU MD'S. BENIGN.\n INCISIONS HEALING WELL.\n\nSOCIAL: SON AND WIFE VISITED AND UPDATED\n BY DR .\n\nA: INTUBATED FOR AIRWAY PROTECTION.\nP: FOLLOW SCALE AS ABLE. DISCUSS NUTRITION.\n REST ON VENT.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-11 00:00:00.000", "description": "Report", "row_id": 1537448, "text": "ROS:\n\nNeuro: Sedated on propofol, titrated to maintain adequate\n sedation, infusing at 45 mcg/kg/. On lower dose\n of propofol, followed commands w/all four\n extremities.PEARRLA. On ativan ATC for ETOH\n withdrawal.\n\n\nResp: Orally intubated and on vent. Mode changed to SIMV,\n 10x500,peep 5, ps 10, and 50% FIO2. Lungsounds\n coarse thoughout.Sx thick yellow via ETT.\n Sats 100%. No resp distress noted.= rise and\n fall of chest. ABG wnl this AM.\n\nCV: RSR w/o ectopy. S1S2. VSS. On metoprolol 5mg\n q 6 hr. Has left radial ABP. Has right subclavian\n MML w/distal port transduced for cvp = 4->8.\n Peripheral pulses palpable w/ease. Sub q heparin\n and P boots prophylacticly.\n\nGI: Abd soft round w/active BS thoughout. Colostomy\n w/gas, no stool this shift. Stoma red. Protonix\n prophylacticly. Abd incisions intact w/staples, no\n drainage.\n\nGU: Foley patent draining clear yellow urine in\n QS. Autodiuresing at the beginning of this shift.\n\nEndo: FSG did not require covered w/RSSI. Insulin in TPN.\n\nLabs: K = 3.6, repleted w/20 KCL. Other labs WNL.\n\nID: Tmax 100.5 on vanco and levofloxin.\n\nPlan: Wean, ? extubate.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-11 00:00:00.000", "description": "Report", "row_id": 1537449, "text": "Respiratory Care\nPt remain intubated and on vent support, BS coares, SX mod thick tan secreation.Pt vent mode was changed to SIMV with PS as a step to wean down to CPAP/PS.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-11 00:00:00.000", "description": "Report", "row_id": 1537450, "text": "TRAUMA ICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: SEDATED ON PROPOFOL DRIP. NO PRN'S GIVEN.\n AROUSABLE AT TIMES. ATIVAN 0.5 MG IV Q6\n CONTINUES.\n\nCV: HR LOW. BP LOWER WITH PROPOFOL....\n IV LOPRESSOR HELD. CVP STABLE.\n\nRESP: SUCTIONED FOR THICK SECRETIONS.\n TOLERATING PRESSURE SUPPORT.\n\nRENAL: CREATININE UP TO 1.1 FROM 0.6 YESTERDAY.\n GOOD UO.\n\nGI: TPN. IV PROTONIX. PASSING LARGE AMOUNTS\n GAS VIA COLOSTOMY. NO STOOL TODAY.\n\nHEME: STABLE. BOOTS. SC HEPARIN.\n\nENDO: BS UP. INSULIN IN TPN. 8 UNITS REGULAR INSULIN\n SC GIVEN.\n\nID: AFEBRILE. WBC STABLE. ANTIBIOTICS D/C'D.\n\nSKIN: BACK BLISTERS HEALING...OLD EPIDURAL SITE.\n STOMA RED AND VIABLE.\n 2 ABD INCISIONS DRY AND INTACT WITH STAPLES.\n\nSOCIAL: SON IN TO VISIT AND UPDATED.\n\nA: STABLE S/P REINTUBATION.\nP: SLOW WEAN. FOLLOW FOR MENTAL STATUS CHANGES..\n AGITATION.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-11 00:00:00.000", "description": "Report", "row_id": 1537451, "text": "Resp care\nPt remains on PSV. No vent changes made, no new ABG's. BS coarse->clear. Sm mod thick yellow secretions. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-11 00:00:00.000", "description": "Report", "row_id": 1537452, "text": "SICU NPN\nPt remains intubated and sedated in the ICU. Propofol titrated for sedation level. Pt tachypnic at times, suctioned for moderate ammt thick, white sputum. Sputum culture sent. Pt remains NPO with TPN, abd incisions CDI with staples. Good u/o via foley catheter. RISS for sugar coverage. Pt completed abx course today. son at bedside this PM, will return tomorrow. Pt continues with ATC ativan, no PRNs required. Plan to keep pt sedated/intubated overnight, consider wean/extubate when pt more comfortable/cooperative\n" }, { "category": "Nursing/other", "chartdate": "2121-11-09 00:00:00.000", "description": "Report", "row_id": 1537443, "text": "npn 1900-0700\n\nneuro:alert,oriented x 1,occasionally to year.somnolent but restless. given haldol x 2.ativan and narcotics held r/t somnolence.mae's equally,follows commands.pupils unequal,reported to house officer.no change in neuro exam noted otherwise.c/o pain to abd occasionally.\n\ncv:sbp 130-150s per a-line.sr 60-70s,occ pvcs.given 20meq kcl,2 gms magnesium sulfate this am.d51/2ns conts at 60ml/hr.cvp 2-3.\n\nresp:remained on 60% high flow face tent overnight.added 4lo2 per nc when continued to pull tent off.sao2 would drop to upper 80s% w/o mask.ls coarse.cough productive occ of thick drk bloody sputum.rr 24-38,tachypnea decreasing overnight.\n\ngi:abd soft,round.midline abd incision w/ staples approximated, ecchymotic,no drng,ota.LLQ old colostomy site w/ staples approximated, ecchymotic,small amt serosang drng,dsd.new stoma red.soft,formed brown stool w/ mod amt flatus.npo r/ rn report of difficulty swallowing thickened liquids.mouth very dry,oral care given freq.\n\ngu:u/o adequate,clear,yellow, to foley.\n\nskin:epidural blisters pink.covered w/ xeroform and tegaderm but ota r/t pt's restlessness.tape burns to L flank covered w/ duoderm.\n\nid:tmax 99.1 orally.conts on vanco and levaquin.\n\nendo:no coverage required overnight.\n\nsocial:no family contact overnight.\n\nplan:continue to monitor neuro status.cont pulm toilet.monitor and treat etoh withdrawal sx.oob again today.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-09 00:00:00.000", "description": "Report", "row_id": 1537444, "text": "T/SICU NPN\nBrief ROS\n Pt. remains confused and somewhat agitated at baseline. She frequently attempts to get OOB, \"I have to get out of this bed, I need to go upstairs to my bed...\" She has been busy getting in and out of bed today, the routine tires her somewhat so when the activity is complete she drifts off to sleep for a short nap. She moves all extremities equally with gd strength and purpose. She cooperates, even during her agitation. She does not want to be in the hospital. Her son and daughter in law visited, concerned over her confusion as it's not happened ever before(she's been hospitalized 4x in the past 18mos.). She has recieved haldol(total of 16mg this shift) and ativan(2mg all day) and also got 10cc oxycodone for pain. Pt. c/o incisional pain, abd. She is moving about in bed almost constantly, stress to abd.\n\nResp- Continues to remove face tent frequently so her O2 sat on nasal cannula has been 91-96%. Continues to have somewhat rapid resp rate and appears sl labored, esp with all her activity. Bilat BS with coarse bs. She has a productive strong cough.\n\nCV- Stable BP and HR all shift. Cont. on lopressor q6hr. Sinus, no ectopy noted. Skin warm and dry, periph pulses palpable. Gd color.\n\nGI- Taking a diet today, sml but successful. Tolerates liquids or solids, swallowing well. Abd soft. Colostomy producing mod to lrg amts of brown, formed stool. Flatus present.\n\nGU- Adequate amts of u/o via foley. Pt. feels she needs get OOB to urinate, despite foley. Seems to tire with exertion of getting OOB to chair to sit on pan, then she naps.\n\nID- Afeb.\n\nEndo- Following fs bs, not required coverage as yet.\n\nSkin- Generally intact but she has multiple sml areas over back. Appear to be blisters from tape of epidural, healing and open to air.\n\nMiscl- Family in twice today, concerned about confusion.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-14 00:00:00.000", "description": "Report", "row_id": 1537464, "text": "NPN 7a-7p\nNeuro: Pt. sedated on 20mcg of propofol. Increased from 20 to 22mcg as she seemed restless on the 20 with increased BP and moving legs. Does not follow commands but will respond to pain. Plan to keep pt. sedated until trach site heals. Is on serax which she is on at home and has been recommended from neuro for hx of dt's.\n\nResp: Had trach placed at bedside at 11:30am as she has failed extubtion three times-unclear why she fails extubation-? ENT consult per surgery. Somewhat difficult placement-moderate amount of bleeding in trachea. Pt. received fentanyl and vecuronium prior to procedure and had propofol throughout procedure. Have been suctioning moderate amounts of bloody sputum since trach placement. Plan to have minimal movement of trach/vent tubing to allow site to heal. Breath sounds coarse prior to suctioning and clear with suctioning and use of MDI's.\n\nCV: SBP generally 100's/60's. Increases with coughing or need to be suctioned. Aline somewhat positional. HR NSR 60's. No ectopy. Received 40kcl for K- 3.9.\n\nGI: NGT placed for po meds. Draining green bilious liquid. Abdominal incision C & D-no drainage-staples intact. Ostomy nurse came in to change ostomy bag-feel site is healing well and pt. can go on a Tuesday/Friday schedule for changing ostomy bag.\n\nGU: foley intact draining clear yellow urine approx 50-100cc/hr.\n\nID: tmax 99.7. on no antibiotics.\n\nSocial: Family in briefly to give consent for tracheostomy.\n\nA/P:\n-maintain sedation until trach site heals\n-change ostomy bag next Tuesday and Friday\n-call ostomy nurse for pt. teaching once she is and off sedation.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-14 00:00:00.000", "description": "Report", "row_id": 1537465, "text": "addendum\nPer patients son and his wife- and are to be the only visitors allowed in to see the patient. This is the patients wishes.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-15 00:00:00.000", "description": "Report", "row_id": 1537466, "text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nTHIS IS A 73Y/O F PT WITH 4 PRIOR PARASTOMAL HERNIA REPAIRS WHO UNDERWENT INCARCERATED PARASTOMAL REPAIR/PARTIAL COLECTOMY ON . PT HAD BEEN POST-OP AND TX TO FLLOR BUT ON POD # 3- PT NOTED TO HAVE INCREASED RESPIRATORY DISTRESS AND TACHYPNIA- REQURING EMERGENT INTUBATION AND TX TO UNIT FOR ASPIRATION PNA.\n\n- PT . FAILED SPEECH AND SWALLOW STUDY\n- REINTUBATED FOR MS CHANGES AND DECREASED OXYGENATION.\n FAILED EXTUBATION WITH SUBSEQUENT DIFFICULT REINTUBATION-\n 3 ATTEMPTS BEFORE SUCCESSFUL INTUBATION. BRONCH DONE- NEGATIVE.\n TRACHED, SEDATED.\n\nNEURO: PT IS ADEQUATELY SEDATED ON 20-256MCG/KG/ OF PROPOFOL. PT WILL AROUSE TO VERBAL STIMULI WHEN PROPOFOL IS LIGHTENED. DOES NOT FOLOW COMMANDS. ABLE TO MAE X 4 WITH PURPOSE AND WITHOUT DIFFICULTY. PERRLA, 2MM/BRISK. LOW GRADE TEMPS- 99. NO SEIZURE ACTIVITY NOTED. PLAN IS TO KEEP PT SEDATED UNTIL TRACH STOMA HAS HEALED.\n\nRR: TRACH IS SECURE, MIDLINE AND PATENT. BLEEDING FROM SITE. TRACH CARE DONE MULTIPLE TIMES. PT HAS INCREASED ORAL AND SECRETIONS. SUCTIONING Q 2-3 HOURS FOR THICK, BLOODY SECRETIONS. PT HAS NOXIOUS SMELLING SECRETIONS AND ORAL CAVITY- AGGRESIVE PULMONARY TOILIETING AND MOUTH CARE DONE. BBS= ESSENTIALLY COARSE THROUGHOUT ALL LUNG FIELDS. BILATERAL CHEST EXPANSION NOTED. PT ON CPAP/PS, RR 20'S, SP02 > OR = TO 95%, TV 400-500'S. STRONG COUGH EFFORT NOTED. CURRENT VENT SETTINGS ARE 12PS/40%/5.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR, WITH NO SIGNS OF ECTOPY NOTED. HR 70'S. SBP > OR = TO 90 WITH NO HYPERTENSIVE OR HYPOTENSIVE CRISIS NOTED. PALPABLE PULSES NOTED TO BILATERAL RADIAL AND DORSALS PEDIS. RT RADIAL ALINE IS SECURE AND PATENT. RECALIBRATED AND LEVELED DURING THE SHIFT. ALINE IS SLIGHTLY POSITIONAL- HAS GOOD WAVEFORM WHEN IN OPTIMAL POSITION. RT SCL CVL IS SECURE AND PATENT.\n\nGI: ABD IS SOFT, NON-DISTENDED. BS X 4 QUADRANTS. NGT IS SECURE AND PATENT- PROPER POSITIONING VERIFIED WITH AUSCULTATION OF 30CC/AIR. BILIOUS DRAINAGE. PT RECEIVING TPN. COLOSTOMY TO LLQ- BAG IS SECURE AND PATENT. STOMA PINK. STAPLES OTA, INTACT- NO DRAININAGE NOTED. EDGES ARE WELL APPROXIMATED AND HEALING NICELY. NO SIGNS OF REDNESS OR DRAINAGE TO THE AREA NOTED.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: SOME REDNESS AND SMALL ABRASION NOTED TO COCCYX. NO OTHER SIGNS OF BREAKDOWN NOTED.\n\nSOCIAL: NO CONTACT WITH FAMILY THIS SHIFT.\n\nPLAN: MAINTAIN SEDATION UNTIL TRACH HEALS. QUESTION OF PEG TUBE PLCMT. PLEASE SEE CAREVUE AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n" }, { "category": "Nursing/other", "chartdate": "2121-11-15 00:00:00.000", "description": "Report", "row_id": 1537467, "text": "Respiratory Care:\nPatient remains on ventilatory support (CPAP/PSV) with no parameter changes made throughout the night. Morning abg results revealed a mild mixed alkalemia,with excellent oxygenation.\n\nRSBI = 59.2 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-15 00:00:00.000", "description": "Report", "row_id": 1537468, "text": "Respiratory Care:\nPt continues to be mechanically ventilated via trach on PSV settings of ; no changes were made to settings throughout day. Suctioned for sm amts of secretions. Trach care given; trach tie changed & sight cleaned. Plan to continue ventilating as ordered & wean when tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-15 00:00:00.000", "description": "Report", "row_id": 1537469, "text": "CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFICS.\n\nNEURO: LIGHTLY SEDATED ON PROPOFOL AT 20 MCQ/KG/. PT IS TO STIMULI, OPENS EYES BUT DOES NOT FOLLOW COMMANDS. MOVES ALL EXTREMITIES WITH EQUAL STRENGTH.\nCV: T MAX 99.5. HR 70'S NSR WITH RARE PVC'S. SBP 96-130. FEET WARM WITH PALPABLE PULSES.\nRESP: PT ON CPAP WITH 5 PEEP AND 12 IPS. BS COARSE. SX FOR SM AMTS THICK YELLOW-WHITE SECRETIONS.\nGI: ABD SOFT AND NON-TENDER. STOMA PINK-RED WITH SM AMT SOFT BROWN STOOL. STARTED ON TF VIA NGT AT 20CC/HR. MINIMAL RESIDUALS.\nGU: CLEAR YELLOW URINE VIA FOLEY IN GOOD AMTS\nSOCIAL: FAMILY IN TO VISIT- SPOKE WITH RN ABOUT PRESENT PLAN OF CARE.\nA: HEMODYNAMICS AND RESP PARAMETERS MONITORED, PLAN TO KEEP PT UNTIL TRACH HEALED\nR: STABLE RESP STATUS, ADVANCE TF AS ORDERED\n" }, { "category": "Nursing/other", "chartdate": "2121-11-16 00:00:00.000", "description": "Report", "row_id": 1537470, "text": "Resp Care\nPt. remains on PSV overnight. IPS level weaned, currently tolerating well. Tidal volumes essentially unchanged with lower support ranging from 550-700cc with MV lpm.\nBs: coarse bilat.\nabgs: normal A/B with hyperoxia\nPossibly try trach mask today.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-16 00:00:00.000", "description": "Report", "row_id": 1537471, "text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT REMAINS SEDATED ON PROPOFOL GTT AT 20MCG/KG/. PT HAS BEEN GRIMACING WITH TURNS AND AT REST- GIVEN PRN DILAUDID FOR PAIN WITH THERAPEUTIC EFFECT. OPENS EYES SPONTANEOUSLY. DOES NOT FOLLOW COMMANDS, MAE X 4 WITHOUT DIFFICULTY AND WITH PURPOSE. PERRLA, 2MM/BRISK. LOW GRADE TEMPS- 99.1/PO. NO SEIZURE ACTIVITY NOTED.\n\nRR: TRACH IS MIDLINE AND SECURE. LESS BLEEDING TO THE SITE- STOMA IS PINK AND APPEARS TO BE HEALING NICELY. SECRETIONS HAVE CLEARED FROM BLOODY TO YELLOW. BBS= ESSENTIALLY COARSE THROUGHOUT ALL LUNG FIELDS. BILATERAL CHEST EXPANSION NOTED. RR 15-25, VENT CHANGES THROUGH THE EVENING- CURRENTLY AT CPAP/5PS/40%/5- NO INCREASED WOB NOTED. SP02 > OR = TO 95%. TV 500-600'S. POSSIBLE WEAN TO TRACH MASK TODAY.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR, HR 60-80'S WITH NO SIGNS OF ECTOPY NOTED. SBP > OR = TO 85. LOPRESSER DOSES HELD THIS PM FOR SBP < 90. NO HYPER OR HYPOTENSIVE CRISIS NOTED. PALPABLE PULSES NOTED TO BILATERAL RADIALS AND DORSALIS PEDIS. RT RADIAL ALINE IS SECURE AND PATENT, LEVELED AND RECALIBRATED DURING THE SHIFT. RT SCL CVL IS SECURE AND PATENT.\n\nGI: ABD IS SOFT, DISTENDED AND TENDER TO PALPATION. BS X 4 QUADRANTS. NGT IS SECURE AND PATENT. PROPER POSITIONING VERIFIED WITH AUSCULTATION OF 30CC/AIR. TF- IMPACT WITH FIBER RUNNING- GOAL RATE OF 60CC/HR, GASTRIC RESIDUALS HAVE BEEN MINIMAL. COLOSTOMY TO LLQ- STOMA PINK. GREEN-BROWN SOFT STOOL NOTED. PASSING FLATUS.\n\nGU: INDWELLING FOLEY CATHTER IS SECURE AND PATENT. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: SOME REDNESS NOTED TO COCCYX. NO OTHER SIGNS OF BREAKDOWN NOTED.\n\nSOCIAL: NO CONATCT WITH FAMILY THIS SHIFT.\n\nPLAN: WEAN TO TRACH MASK AND SEDATION AS PT WILL HOWEVER, TRACH SITE SHOULD BE PROTECTED AND PT SEDATED IF GETS TOO ANXIOUS IN ORDER FOR TRACH SITE TO HEAL. PLS. SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n" }, { "category": "Nursing/other", "chartdate": "2121-11-16 00:00:00.000", "description": "Report", "row_id": 1537472, "text": "Respiratory Care:\nPt on PSV 5/5 with FiO2 of 40% this a.m.; placed on trach mask for 4.5 hours; pt tolerated well then had increased secretions; increased RR & diaphoretic. ABG drawn & then placed back on ventilatory Support. Continue to ventilate as ordered & wean to trach mask again tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-16 00:00:00.000", "description": "Report", "row_id": 1537473, "text": "NPN 7a-7p\nNeuro: Pt. alert but diffiuclt to understand. Unclear if she is confused or not as it is difficult to make out her mouthing words and she was unable to write. Moving all extremities. Able to follow some commands. Propofol continues at 10mcg.\n\nResp: Was placed on a trach mask at 10:30am and did well until 14:30 when she became diaphoretic, tachpynic, and restless. She was placed back on the vent at PSV of 5 and 40% 5 PEEP. Sx frequently for moderate amounts of thick white/yellow sputum. Seems much calmer back on vent.\n\nID: Tmax 100.7. Has been diaphoretic most of the day. Surgery removed abdominal staples and pt. had some oozing of old blood-presume ruptured hematoma. Dry sterile dressing placed. No signs of infection at site-will continue to monitor.\n\nCV: HR 80's NSR. BP 120-140/80's. 120's when she is calm, increases with resp. distress. No ectopy. Aline is somewhat positional-is dampened at times but able to draw blood from line.\n\nGI: Tube feeds of impact with fiber at 60cc/hr. TPN will complete tonight. Dose was cut in at 4pm. will obtain blood sugar at 6 and 7. Colostomy intact. Due for bag change on Tuesday.\n\nGU: foley draining clear yellow urine approx 50-100cc/hr.\n\nSocial: son and daughter in law in to visit during day. Many questions answered about her care. They seem concerned about NGT feedings and are anxious for her to be able to have these stopped and for her to eat normally. Pt. is anxious to go home.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-17 00:00:00.000", "description": "Report", "row_id": 1537474, "text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nTHIS IS A 73 Y/O F PT WITH 4 PRIOR PARSTOMAL HERNIA REPAIR. ON , PT HAD INCARCERATED PARASTOMAL REPAIR/ PARTIAL COLECTOMY. HAD BEEN EXUTBATED IN THE PACU AND TX TO FLOOR BUT ON POD # 3, PT NOTED TO HAVE INCREASED RESPIRATORY DISTRESS AND TACHYPMIA REQUIRING EMERGENT INTUBATION AND TX TO UNIT FOR ASPIRATION PNA.\n\n . FALIED SPEECH AND SWALLOW STUDY\n REINTUBATED FOR MS CHANGES AND DECREASED OXYGENATION\n FAILED EXTUBATION WITH SUBSEQUENT DIFFICULT REINTUBATION\n 3 ATTEMPTS BEFORE SUCCESSFUL INTUBATION. BRONCH DONE- NEGATIVE\n TRACHED\n\nHOSPITAL COURSE COMPLICATED BY EPISODES OF ETOH PT IS NOTED TO DRINK DAILY.\n\nNEURO: PT LIGHTLY SEDATED ON 10MCG/KG/ PT GETS VERY RESLTESS AND AGITATED WHEN PROPOFOL IS TURNED OFF. PT OPENS EYES SPONTANEOUSLY AND INTERMITTENTLY OBEYS COMMANDS. LOW GRADE TEMPS- 100/PO. PERRLA, 3/BRISK. MAE X 4 WITH PURPOSE- NORMAL STRENGTH. NO SEIZURE ACTIVITY NOTED.\n\nRR: TRACHED. STOMA IS MIDLINE AND SECURE. PT ON CPAP/5/5/40% AND HAS BEEN COMFORTABLE THROUGH THE EVENING. WILL ATTEMPT TO TRY TRACH MASK TODAY. TV 500-600'S. RR 20-30- NO INCREASED WOB NOTED OR SOB. SP02 > OR = TO 95%. BILATERAL CHEST EXPANSION NOTED. BBS= ESSENTIALLY COARSE THROUGHOUT ALL LUNG FIELDS BUT DOES SEEM TO BE IMPROVING. SUCITONING FOR SMALL YELLOW, THICH SECRETIONS. PT HAS VERY STRONG COUGH EFFORT. FOUL SMELLING SECRETIONS. HAVE PROVIDED AGGRESSIVE ORAL CARE.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR, HR 70'S WITH NO SIGNS OF ECTOPY NOTED. SBP > OR = TO 100 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED. PALPABLE PULSES NOTED TO BILATERAL RADIAL AND DORSALIS PEDIS. RT ALINE IS SECURE AND PATENT- VERY POSITIONAL- WANT TO DC TODAY. REZEROED AND LEVELED DURING THE SHIFT. RT SCL CVL IS SECURE AND PATENT.\n\nGI: NGT IS SECURE AND PATENT. PROPER POSITIONING VERIFIED WITH AUSCULTATION OF 30CC/AIR. TF AT GOAL RATE OF 60CC/HR. MINIMAL GASTRIC RESIDUALS. BS X 4 QUADRANTS. PASSING FLATUS. COLOSTOMY CARE DONE- BAG CANGED DUE TO LEAK. STOMA IS PINK. BROWN LIQUID STOOL NOTED.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS.\n\nSOCIAL: NO CONTACT WITH FAMILY THIS SHIFT.\n\nPLAN: CONTINUE TO WEAN AS PT. TOLERATES- TRACH MASK TODAY. QUESTION OF A LINE DC. CONTINUE TO MONITOR. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n" }, { "category": "Nursing/other", "chartdate": "2121-11-17 00:00:00.000", "description": "Report", "row_id": 1537475, "text": "Resp Care\nPt. remains on vent with minimal support. VT's 400-600cc with MV 8-12lpm.\nBs: coarse sxn'd for mod. yellow thick\nPlan: Continue trach mask sprints\n" }, { "category": "Nursing/other", "chartdate": "2121-11-17 00:00:00.000", "description": "Report", "row_id": 1537476, "text": "Nsg Transfer Note 0700-1700\n\nThis is a 73 yo female with 4 prior parastomal hernia repairs. On pt had incarcerated parastomal repair/partial colectomy. She was postop and transferred to the floor but POD #3 she had increased resp distress and tachypnea requiring emergent intubation and was transferred to MICU for aspiration pneumonia.\nOn she was but failed the speech and swallow study\n she was reintubated for MS changes and decreased oxygenation\n she failed extubation and was a subsequent difficult reintubation. on she was trached.\nOther PMH is significant for Hep C, HTN, GERD, ETOH glasses wine/day.\nPt is presently on PSV 5 and PEEP 5 with RR 20-24 and O2 sat 98%. She was on a trach mask at 40% for 6 hours today before she got too tired to continue. She has had a large amt thin creamy secretions. She was able to clear them herself in the morning, but by afternoon she required suctioning to clear the secretions. BS are course bilat.\n\nCV - She continues to have a low grade fever of 100.1 po. HR 70's NSR and BP 130/70.\n\nGI - NGT replaced at 3pm with dobhoff tube for TF's. CXR pending. Abd soft and slightly distended. Colostomy red and moist and mod amt flatus and sm amt brown liquid stool. Midline incision with steristrips but oozing dark brown liquid. Surgical team looked at it and after extracting some more fluid - packed the area with a 4X4 and recovered the incision with dry 4x4's. They feel it could be a hematoma. LLQ incision is just below stoma and is clean and dry with steristrips still on.\n\nGU - Foley cath draining adequate amt cl yellow urine.\n\nEndocrine - Pt on sliding scale insulin coverage q 6 hours. Last BS at 12p was 186 and she recieved 8 units regular insulin.\n\nNeuro - Pt is alert and oriented x3. MAE actively. She is very anxious to go home but is happy to be leaving the ICU. PERL.\n\nSocial - Very involved son and daughter-in-law. and daughter do not have visiting rights per the son.\n\nSkin - No sign of breakdown to back or buttocks area.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-17 00:00:00.000", "description": "Report", "row_id": 1537477, "text": "Respiratory Therapy\nPt remains trached and on PSV. Long trach mask trial this morning tolerated well by pt for a few hours, then returned to vent this afternoon d/t fatigue. MDIs given as ordered to good effect. See resp flowsheet for specific vent data.\n\nPlan: continue weaning trials\n" }, { "category": "Nursing/other", "chartdate": "2121-11-05 00:00:00.000", "description": "Report", "row_id": 1537433, "text": "Resp Care\n\nPt was intubated on the floors for respiratory distress. Placed on A/C 600/14/100/5. Suctioned SM thick tan sputum. BS coarse\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-05 00:00:00.000", "description": "Report", "row_id": 1537434, "text": "Nursing Admission Note\nPt admitted from CC6, pt intubated emergently due to respitory distress. Pt underwent a perastomal hernis repair and reciting of stoam, on , became tachypneic duirng the night, treated with 02 therapy and lasix with some improvement, pt again became tachypneic with abd breathing and mental status changes with desaturation this afternoon, and required intubation.\nHX includes Colon CA since with parastomal herniations. Pt ois Hepititis C ps due to a transfusion in the past. other hx includes hypertension. Pt drinks 2-3 glasses of wine per day.\n pt has right subcalvian triple lumen and left radial arterial line placed on admission to TSICU\nReview of Systems\n pt is sedated on propofol, titrating to keep pt comfortable. pt occasionally becomes agited requiring increas doasge which causes hypotension. pt moving all extremities, not ot command. pt does open her eyes spontaneously when agitated. ptis restrained with soft limb restrainst on both hands.\n pt in NSR with no ectopy, initially pt hypertensive until adequately sedated. pt required fluid bolus for systolic pressure of 85 with CVP of 6. with good response. B/P has drifted down to 90, depending on rate of propofol. Hct is 34, INR 1.4. Lytes repleted. IVF at 100cc hr of LR.\n Pt sats initially 94-96 on 100% FIO2, with a PAO2 of 86. CXR showed a right main stem intubation, and ET tube was pulled back with good airation on both sides. Pt has been suctioned for mod amts of thick tan secretions.Sats have improved to 98-100% and last ABG on 60% FIO2 with 8 of peep PAO2 was 229. Sputum sent for culture.\nGI- NG tube inserted with minimal bilious drainage, abd is obese, soft ,distended with bowel sounds, stoma is red, no drainage, bag is intact.\n pt has had adequate u/o , urine is yellow to amber\nendo- pt received 2 units of reguslar insulin per ss for FS of 125.\nID- tmax 100.1, WBC 14.2. Pt started on vancomycin and levofloxin.\nskin- pt abd wound is open to air. and is clean and dry. pt has several ecchymotic areas over trunk and extremities. Pt skin on back was noted to have several blisters in the fold of her back where her epidural cathether had been D/C. Adaptic applied and DSD. compression sleeves on.\nsocial- pt son in to visit, bringing her clothes from CC6. son in briefly. He states that he is all she has . Nurse form CC6 states that pt lives alone , and son does not want pt husband or daughter to visit, that they are estranged. Valuables in safe. Admission packet given to him before he went home.\nA/ Pt has stabilized ,since intubation with improved ABG,infiltrate on CXR, question of aspiration. Pt requiring fluid bolus, and cont to have low grade temp. Cont to support hemodynamicsand resp status.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-06 00:00:00.000", "description": "Report", "row_id": 1537435, "text": "Resp: pt on a/c 14/600/+10/100%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral clear sounds with diminished bases. Suctioned for moderate amounts or rusty thick secretions. AM ABG\"S 7.45/40/99/29. Present vent settings a/c 14/600/+5/40%.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-06 00:00:00.000", "description": "Report", "row_id": 1537436, "text": "Nursing Progress Note. Please see CareVue for specifics.\n\nAssumed care of pt at 2345hrs.\n\nPt condition essentially stable.\n\nOn exam,\n\nResp:\nChest coarse to clear, scant secretions. Good cough. Ventilation per CareVue.\n\nHemodynamically:\nSR, normotensive. CVP remains ~.\n\nNeuro:\nPt on propofol and morphine prn. Obeys commands. Commenced on CIWA scale and lorazepam.\n\nEndocrine:\nNormoglycemic.\n\nFluids:\nLR at 100mls/hr.\n\nGI:\nAbd distended, soft, bowel sounds present. Passing flatus via colostomy. Stoma pink-red with old blood in bag (minimal amount). NGT output is baricat contrast.\n\nID:\nLow grade fever, no intervention necessary.\n\nRenal:\nDeclining urine output but team satisfied with volume.\n\nSkin:\nNoted blisters to lumbar area under dry dressing. No drainage. Pressure areas intact.\n\nSocial:\nNo contact from family.\n\nPlan:\nWatch pulmonary status- wean ventilation as tolerated.\nContinue to assess fluid volume status.\nNeeds social worker consult regarding circumstances of other family members.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-06 00:00:00.000", "description": "Report", "row_id": 1537437, "text": "TRAUMA ICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: AGITATED THIS AM. MORPHINE/ATIVAN GIVEN.\n LATER SON SAID PT HALLUCINATING YESTERDAY\n ON MORPHINE. CHANGED TO PO ROXICET..NONE\n NEEDED YET.\n ATIVAN 1 MG ATC SECONDARY TO ONE BOTTLE WINE\n PER DAY...PER SON.\n FOLLOWS COMMANDS. ORIENTED.\n\nCV: HR AND BP STABLE. LYTES REPLETED.\n IV LOPRESSOR 5 MG Q6 HOURS.\n\nRESP: EXTUBATED 2PM. WHEEZY...NEB GIVEN.\n INITIALLY WEAK COUGH. NOW STRONG ...BUT\n CONGESTED..AND NOT RAISING SPUTUM..SWALLOWS.\n RR HIGH 30-40... NC ADDED TO FACE TENT AS\n SATS LOW...\n\nRENAL: LYTES REPLETED. K PHOS INFUSING. ADEQUATE UO.\n IVF AT 70 CC/HR.\n\nGI: PROMOTE WITH FIBER BEGUN..THEN HELD FOR\n EXTUBATION... RESUME LATER.\n STOMA RED..AS BASELINE ATTENDING MD\n AND STOMA RN. POUCH CHANGED.\n PASSING LARGE AMOUNT GAS..AND LIQUID PINK\n FLUID. PO FAMOTIDINE BEGUN.\n\nHEME: HCT 27 COAGS WNL. PLT WNL.\n SC HEPARIN. BOOTS ON.\n\nENDO: BS STABLE.\n\nID: LOW GRADE TEMPS. IV VANCO GIVEN....LEVEL DUE\n IN AM.\n\nSKIN: ABD INCISION X2 OTA WITH STAPLES AND DRY AND\n INTACT. DRESSING INTACT TO OLD EPIDURAL\n SITE..BLISTERS.\n\nSOCIAL: SON AND DAUGHTER IN LAW... AND \n VISITED AND UPDATED.\n\nA: STABLE S/P EXTUBTION. AND OR.\nP: FOLLOW RESP STATUS. INCREASE DIET/OOB/TRANSFER\n WHEN STABLE.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-06 00:00:00.000", "description": "Report", "row_id": 1537438, "text": "SICU NPN Addendum\n3-7pm\nPt noted to have increase in WOB, upper airway stridor. SICU team notified and aware, in to eval pt. Pt placed on racimic epi neb, started on 24 hr course of solumedrol.\nPt also c/o pain, nausea. Dilauded 1mg IV X1 given, Dolasetron mesylate given with fair results.\nPt noted to have more blisters forming underneath straps, so straps removed, skin left OTA with A+D ointment on\n" }, { "category": "Nursing/other", "chartdate": "2121-11-07 00:00:00.000", "description": "Report", "row_id": 1537439, "text": "nsg note:\nneuro pt very confused oriented times 1 and occasionally times 2. very restless diaphoretic attempted to climb oob. given ativan as ordered q6 and twice prn. at 0020 given 2 mgs of haldol for continued agitation pt then slept and was calm rest of night although still confused. mae very strong.\n\ncv stable except hypertensive to 180's when very agitated hr nsr no ectpy. cvp 4 to 8.\n\nuo qs clear dark yellow. ivf at 70ccs per hr\n\n ng to lcs. draining sm amt of bilious fld clamped for famotidine with out any nausea.\nabd soft active bowel sounds. stoma red, scant ser/sang drainage in pouch.\n resp very strong cough raising and swallowing sputum sats >96 on 4lnps and face tent. rate 20's when calm up to 40's with agitation.\nwith pt sleeping co2 was 60 awake 53.\n\nskin: blisters on back not oozing covered with zeroform and dsd no tape applied.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-07 00:00:00.000", "description": "Report", "row_id": 1537440, "text": "TRAUMA ICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: IN AM... ALERT. ORIENTED X 3. AMBULATED SEVERAL\n SMALL STEPS OOB TO CHAIR. FEEDING SELF...\n SLIGHTLY RESTLESS. NO C/O PAIN. ATIVAN 1 MG Q6.\n THIS PM...BACK TO BED,,,SLEPT X 1/2 HOUR, AND THEN\n WOKE HIGHLY AGITATED. CONTINUED WITH AGITATION\n DESPITE SEVERAL DOSES OF HALDOL AND ATIVAN.\n LOT SATS AT THIS TIME...\n\nCV: HR AND BP STABLE.\n\nRESP: DROPS SATS WHEN AGITATED/RESTLESS. INHALERS\n GIVEN. STRONG PROD COUGH THIS AM.\n\nRENAL: LYTES REPLETED. ADEQUATE UO.\n\nGI: SEE FORMAL SWALLOW CONSULT. FAMOTIDINE.\n GAS VIA COLOSTOMY. ABD INCISIONS INTACT.\n STOMA STABLE.\n\nHEME: LABS WNL. SC HEPARIN. BOOTS ON.\n\nENDO: INSULIN PER SLIDING SCALE...BS GOING UP.\n\nID: AFEBRILE. IV VANCO GIVEN...TROUGH LEVEL TODAY 6.7\n IV LEVLFLOXACIN CONTINUES.\n\nSKIN: BLISTERS ON BACK,,, SLOW IMPROVEMENT...LEFT OTA\n AS NUMEROUS DRESSING ATTEMPTS/DUODERM/ETC NOT\n STAY ON PT...SECONDARY TO AGITATION.\n\nSOCIAL: SON IN MOST OF DAY.\n\nA: CONTINUES WITH RESP ISSUES, AND AGITATION.\nP: FOLLOW RESP STATUS. HALDOL PRN.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-08 00:00:00.000", "description": "Report", "row_id": 1537441, "text": "T-SICU NSG NOTE:\n PT VERY AGITATED, IN 4PT SOFT RESTRAINTS, HALLUCINATING, >24, ATIVAN 2MG NOT EFFECTIVE, 15MG IV HALDOL REQUIRED TO SETTLE PT PRESENT 17. SLEPT MOST OF NIGHT W/ OCC BURSTS OF AGITATION,\nPT DENIES PAIN.\n\nRESP- STRONG PRODUCTIVE COUGH, CLEARS, BS W/ INS WHEEZES, DIMINISHED IN BASES. SAO2 98-100% ON 50% FT AND 2LNC. TACHYPNEA 28-32.\n\nCVS- TM 98.6 AX, HR 70'S-80'S NSR, SBP 130'S. LYTES REPLETED. QTC .41-.44\n\nGI- TOL SOFT SOLIDS WHEN VERY AWAKE AND SEMI CALM. ABD SOFT, COLOSTOMY DRAINING SM AMT DK LIQ, LG AMTS OF FLATUS IN BAG.\n\nGU-FOLEY PATENT FOR DK YELLOW URINE IN ADEQ AMTS.\n\nSKIN- SM AMT RED BLISTERS IN MID BACK, USUALLY MOIST OCC VERY DIAPHORETIC.\n\nA: IMPROVED MENTAL STATUS FOLLOWING HALDOL\n\nP: MONITOR CVS/NVS PER ROUTINE, MONITOR RESP STATUS, ENC C+DB, ENC SOFT SOLIDS AS TOL, CONT HALDOL PRN.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-08 00:00:00.000", "description": "Report", "row_id": 1537442, "text": "See data, MD notes/orders. Neuro: Lethargic, oriented x2, follows commands, aggitated at times. To sleepy for po meds, did have thickend water that came back up in part via right nare trumpet that was placed to keep airway open. Pt had been observed to have obstructive apnea by nursing/RT. Pulm: 02 sats 98-100%, cxr improved as compared with film from . Lungs coarse bilaterally. Respitory rate 35-40 range, decreasing to high 20's while pt oob. Tachypnea recurred later in shift with abg's drawn and pa02 58. Pt placed on bipap which was tolerated for approximately 1 hour. Pt then placed on cool mist mask with fi02 95%. RR 24-27, pt appears comfortable and sleeping in long naps. CV: SR, sbp 90-100 range. GU: Uo 30-45cc/hr. Foley catheter changed for discomfort and leaking. GI: Abd obese, soft, bs +. Colostomy begining to put out small quantities of formed stool. Endo: SSC Soc: Son in to visit this afternoon. P: Continue to monitor mental status, hold sedation if possbile. Follow pulmonary status, abg's prn. Keep npo until more alert, thickend fluids/food - see swallow eval. Keep family upt to date on plan of care.\n" }, { "category": "Radiology", "chartdate": "2121-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 843910, "text": " 12:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: edema, effusion or other intrathoracic process\n Admitting Diagnosis: INCARCERATED PARASTOMAL HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman, POD1 dropped sats to 88% on 4L O2NC\n REASON FOR THIS EXAMINATION:\n edema, effusion or other intrathoracic process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73 y/o woman postoperative Day 1, desaturation.\n\n TECHNIQUE: Portable AP chest radiogrpah.\n\n Comparison is made with the prior chest radiograph dated .\n\n FINDINGS: Note is made of mild cardiomegaly, worsened compared to the prior\n study. Bilateral hilar vasculatures are slightly prominent. Note is made of\n multiple patchy parenchymal opacities in bilateral upper lobes, with platelike\n atelectasis in the left lung, gradually worsening compared to the prior study.\n Left-sided pleural effusion is noted. Platelike atelectasis in the left lower\n lobe is also noted. Pulmonary vasculature shows right upper lobe\n redistribution, worsened compared to the prior study.\n\n IMPRESSION: Worsening bilateral patchy opacities with platelike atelectasis,\n which may represent aspiration, aspiration pneumonia, or multifocal\n atelectases, atypical edema, or multifocal pneumonia. Please correlate\n clinically. New left pleural effusion. Mild cardiomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2121-11-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844789, "text": " 12:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for new changes\n Admitting Diagnosis: INCARCERATED PARASTOMAL HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p hernia repair, extubated 2 days ago and now w/\n SOB, tachypnea again\n REASON FOR THIS EXAMINATION:\n eval for new changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P hernia repair, intubated with shortness of breath and\n tachypnea.\n\n COMPARISON: Radiograph dated .\n\n AP SEMI-UPRIGHT VIEW CHEST: There is an ETT in satisfactory position. There is\n a right subclavian central venous line with its distal tip in the right\n atrium. Again noted are diffuse patchy opacities bilaterally with relative\n sparing of the right lower lung zones, unchanged compared to the prior study.\n There is a possible left small pleural effusion. No other interval change.\n\n IMPRESSION: 1) Subclavian central venous line with tip in the right atrium.\n Recommend retraction by several cm. 2) Bilateral patchy opacities with\n relative sparing of the right lower lobe that may be consistent with\n asymmetric pulmonary edema or aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2121-11-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 845048, "text": " 3:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post trach\n Admitting Diagnosis: INCARCERATED PARASTOMAL HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p hernia repair, extubated 2 days ago and now\n w/ SOB, tachypnea s/p trach\n REASON FOR THIS EXAMINATION:\n post trach\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post tracheostomy, shortness of breath, tachypnea.\n\n COMPARISON: One day previously.\n\n SINGLE VIEW CHEST, AP SUPINE: There has been interval placement of a\n tracheostomy tube which appropriately lies within the trachea. No pneumothorax\n or pneumomediastinum is identified. The right subclavian CVL tip appears to be\n extending into the region of the right atrium. The NG tube is terminating just\n within the stomach fundus. There has been interval improvement of the\n interstitial pulmonary opacities consistent with improving left ventricular\n heart failure. There is interval development of a retrocardiac right lower\n lobe opacity.\n\n IMPRESSION: 1. Interval placement of tracheostomy tube with appropriate\n positioning.\n 2. Right subclavian CV tip appears to extend into the proximal right atrium.\n 3. Interval improvement of predominantly upper lobe interstitial opacities\n consistent with improved left ventricular heart failure.\n 4. Retro- cardiac right lower lobe opacity consistent with atelectasis and/or\n aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2121-11-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 845168, "text": " 1:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate/effusions\n Admitting Diagnosis: INCARCERATED PARASTOMAL HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p hernia repair, extubated 2 days ago and now\n w/ SOB, tachypnea s/p trach\n REASON FOR THIS EXAMINATION:\n infiltrate/effusions\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: A few days post extubation, now with SOB.\n\n CHEST: A tracheostomy tube is present but not attached to the ventilator.\n The tip of the right subclavian vein catheter is unchanged since the prior\n chest x-ray. No infiltrates are seen. The costophrenic angles are sharp. No\n gross failure is present.\n\n IMPRESSION: No failure. No infiltrates.\n\n" }, { "category": "Radiology", "chartdate": "2121-11-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844300, "text": " 5:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?Tachypnea and SOB\n Admitting Diagnosis: INCARCERATED PARASTOMAL HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman, POD1 dropped sats to 88% on 4L O2NC ett pulled back with\n better aeration of lung\n REASON FOR THIS EXAMINATION:\n ?Tachypnea and SOB\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST COMPARED TO ONE DAY EARLIER.\n\n CLINICAL INDICATION: Tachypnea.\n\n There has been interval extubation and removal of the nasogastric tube. A\n central venous catheter remains in place, terminating in the region of the\n junction of the superior vena cava and right atrium. There is worsening\n opacity in the right upper lobe which contains air bronchograms. There is\n only mild volume loss with slight elevation of the minor fissure. There has\n been apparent interval development of a small left pleural effusion.\n\n IMPRESSION: Increasing right upper lobe opacity, concerning for pneumonia.\n\n Possible new small left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2121-11-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844336, "text": " 9:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate/pneumonia\n Admitting Diagnosis: INCARCERATED PARASTOMAL HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p hernia repair, extubated 2 days ago and now w/ SOB,\n tachypnea again\n REASON FOR THIS EXAMINATION:\n r/o infiltrate/pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post hernia repair. Extubated two days ago. Shortness of\n breath and tachypnea.\n\n PORTABLE AP CHEST, ONE VIEW: Comparison is made to study of , 17:15.\n There is a right subclavian line with tip in the inferior SVC/right atrial\n junction. There is no pneumothorax. There is slight interval improvement in\n aeration of the right upper lobe, although focal consolidation in this region\n remains. No other changes are noted.\n\n IMPRESSION: Slight improved aeration of the right upper lobe. No other\n changes identified.\n\n" }, { "category": "Radiology", "chartdate": "2121-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844026, "text": " 7:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?ETT placement\n Admitting Diagnosis: INCARCERATED PARASTOMAL HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman, POD1 dropped sats to 88% on 4L O2NC\n\n REASON FOR THIS EXAMINATION:\n ?ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST.\n\n INDICATION: Drop in oxygen saturation. ET tube placement.\n\n Comparison is made to the previous examination of the same day at 18:43 hours.\n\n FINDINGS: There has been interval repositioning of an ET tube, now in good\n position in the mid trachea. As a result, there is re-expansion of the left\n lobe of the lung with residual patchy opacities seen throughout the upper and\n mid zones. More focal opacity in the left lower lung zone remains, some of\n which may relate to a small effusion. Right upper lobe patchy opacity is\n stable. Right subclavian central venous line and NG tube are in stable\n position.\n\n IMPRESSION: Interval repositioning of ET tube, with re-expansion of collapsed\n left lung. Residual patchy opacity in the left lung, with small left effusion\n is noted. Stable appearance to right upper lobe opacity.\n\n" }, { "category": "Radiology", "chartdate": "2121-11-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844858, "text": " 5:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: effusion/infiltrate\n Admitting Diagnosis: INCARCERATED PARASTOMAL HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p hernia repair, extubated 2 days ago and now w/\n SOB, tachypnea again\n REASON FOR THIS EXAMINATION:\n effusion/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath. Status post hernia repair.\n\n PORTABLE AP CHEST, ONE VIEW: Comparison , 13:03. There is an ET tube\n 2 to 2.5 cm above the carina. There is a right subclavian line with tip in\n the inferior SVC/RA, unchanged.\n\n There are diffuse alveolar opacities, most marked in the upper lung zones,\n with relative sparing of the right lower lung zone. There may be a small left\n effusion. Appearances are slightly progressed since the prior examination.\n Differential includes asymmetric edema as well as pneumonia/aspiration.\n Clinical correlation is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2121-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844018, "text": " 6:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: new right tlc\n Admitting Diagnosis: INCARCERATED PARASTOMAL HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman, POD1 dropped sats to 88% on 4L O2NC\n\n REASON FOR THIS EXAMINATION:\n new right tlc\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: AP portable chest.\n\n INDICATION: Postop day #1 and drop of oxygen saturation.\n\n Comparison is made to the prior examination of the same day at 1:09 hours.\n\n FINDINGS: There has been interval placement of an ET tube with tip seen in\n the right main stem bronchus. There has been interval collapse of the left\n lung with right-to-left shift of the mediastinum. Previously noted patchy\n opacity in the right upper lobe is again noted, unchanged. An NG tube is seen\n coursing through the stomach and exits the field of view. A right subclavian\n central venous line has its tip at the SVC/RA junction. No right-sided\n pneumothorax. Expansion of the right lung is noted.\n\n IMPRESSION: Malposition of the ET tube in the right main stem bronchus, for\n which the clinical team is aware. No change to right upper lobe patchy\n opacity.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-11-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844922, "text": " 7:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: EVAL FOR ETT PLACEMENT\n Admitting Diagnosis: INCARCERATED PARASTOMAL HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p hernia repair, extubated 2 days ago and now w/\n SOB, tachypnea again\n REASON FOR THIS EXAMINATION:\n EVAL FOR ETT PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P hernia repair, intubated, follow up study.\n\n COMPARISON: Radiograph dated at 6 a.m.\n\n PA SUPINE VIEW CHEST: There is an ETT in satisfactory position. There is a\n right subclavian central venous line in the region of the distal SVC/RA. No\n interval change in bilateral patchy air space opacities with relative sparing\n of the right lower lobe. No evidence of pneumothorax.\n\n IMPRESSION: No interval change in bilateral patchy opacities with relative\n sparing of the right lower lobe consistent with asymmetric pulmonary edema or\n aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2121-11-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 844535, "text": " 11:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please assess for bleed, CVA.\n Admitting Diagnosis: INCARCERATED PARASTOMAL HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p colostomy resiting with confusion, delirium.\n REASON FOR THIS EXAMINATION:\n Please assess for bleed, CVA.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post colostomy. Confusion and delirium. Assess for hemorrhage.\n\n TECHNIQUE: Noncontrast head CT scan.\n\n FINDINGS: There are no preceding head imaging studies available for\n comparison.\n\n There is no intracranial hemorrhage, mass effect or shift of normally midline\n structures. A few punctate foci of diminished density are seen within the\n internal capsules bilaterally. These findings likely represent chronic lacunar\n infarcts. There is no major vascular territorial infarction. There is heavy\n atherosclerotic calcification of the cavernous portions of both internal\n carotid arteries. The surrounding osseous and soft tissue structures are\n normal aside from minimal right maxillary antral mucosal thickening as well as\n sclerosis of the posterior-superior aspect of the sinus bony margins. The\n latter finding presumably is postinflammatory in origin, and represents\n chronic inflammatory reactive sclerosis.\n\n CONCLUSION: No intracranial hemorrhage. Other findings as detailed above.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2121-11-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844061, "text": " 5:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate\n Admitting Diagnosis: INCARCERATED PARASTOMAL HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman, POD1 dropped sats to 88% on 4L O2NC ett pulled back with\n better aeration of lung\n REASON FOR THIS EXAMINATION:\n ?infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old woman, post-operative day 1, with hypoxemia. ? of\n infiltrate.\n\n COMPARISONS: Supine AP portable chest x-ray of at 7:30pm.\n\n TECHNIQUE: Supine AP portable chest x-ray.\n\n FINDINGS: The endotracheal and nasogastric tubes remain in satisfactory\n positions, and the tip of the right subclavian venous catheter remains at the\n cavoatrial junction. Since the prior study, the opacity at the left base is\n much improved. However, there is increasing intensity of the right upper lobe\n consolidation with air bronchograms, suggesting aspiration pneumonia as a\n possibility.\n\n IMPRESSION: 1) Improving left lower lobe opacity.\n 2) Somewhat increased right upper lobe opacity, suggesting pneumonic\n consolidation in this area, possibly due to aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2121-11-17 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 845332, "text": " 3:57 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval for dobhoff placement\n Admitting Diagnosis: INCARCERATED PARASTOMAL HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with dobhoff placement\n REASON FOR THIS EXAMINATION:\n eval for dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dobhoff placement.\n\n COMPARISON: .\n\n A Dobhoff tube has been inserted, and its tip overlies the gastric antrum. A\n nonspecific bowel gas pattern is present. Multiple surgical clips and coils\n are noted in the right and mid-pelvis. An ostomy disc projects over the left\n abdomen.\n\n IMPRESSION: Dobhoff tube in stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-11-12 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 844846, "text": " 9:26 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: eval for any process that may explain her change in MS..dege\n Admitting Diagnosis: INCARCERATED PARASTOMAL HERNIA\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p hernia repair, intubated. Cont to have altered mental\n status with neg CT earlier this week.\n REASON FOR THIS EXAMINATION:\n eval for any process that may explain her change in MS..degenerative? lacunes?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Mental status changes.\n\n TECHNIQUE: Multiplanar pre- and post-contrast T1-weighted images, axial T2-\n weighted, susceptibility and diffusion-weighted images were obtained. Some\n images are limited by patient motion.\n\n FINDINGS: There are foci of T2-hyperintensity in the left frontal white\n matter, probably related to small vessel disease. There is a small, old\n lacune in the right thalamus. On the diffusion-weighted images, there is no\n evidence of a recent infarct. There is no evidence of a mass or abnormal\n enhancement.\n\n There are foci of susceptibility effect, most likely related to hemosiderine,\n bilaterally in the lentiform nuclei and in both thalami. The one in the right\n lentiform nucleus is adjacent to the lacune. There is also a focus in the\n left frontal lobe anteriorly and the right occipital lobe. The brain stem is\n somewhat heterogeneous on the FLAIR and T2-weighted images, both of which are\n limited by motion, suggesting mild microvascular changes. The cerebellum is\n intact. The ventricles and sulci are normal in size.\n\n IMPRESSION\n\n 1. There are bilateral foci of susceptibility effect, most likely related to\n hemosiderine and microscopic old hemorrhages, primarily in the basal\n ganglia and thalami.\n\n 2. There is a small old lacune in the right putamine.\n\n 3. There are mild microvascular changes in the cerebral and cerebellar white\n matter.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-11-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844652, "text": " 10:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: cont to remain ventilator-dependent; eval for new changes\n Admitting Diagnosis: INCARCERATED PARASTOMAL HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p hernia repair, extubated 2 days ago and now w/\n SOB, tachypnea again\n REASON FOR THIS EXAMINATION:\n cont to remain ventilator-dependent; eval for new changes\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old woman status post hernia repair now with shortness of\n breath.\n\n COMPARISON: .\n\n AP CHEST: The right subclavian line tip is at the SVC-RA junction in good\n position. The endotracheal tube tip is approximately 3.5 cm from the carina in\n satisfactor position. Compared to the study of one day prior, the upper zone\n opacities have improved slightly. The rapid improvement suggests an aspiration\n event or asymmetric pulmonary edema.\n\n IMPRESSION:\n 1. Lines and tubes in satisfactory position.\n 2. Improvement in the patchy opacities of the upper lobes. The rapid\n improvement suggests aspiration versus asymmetric pulmonary edema and makes an\n infectious pneumonia less likely.\n\n" }, { "category": "Radiology", "chartdate": "2121-11-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844529, "text": " 10:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ETT placement and eval RUL opacity\n Admitting Diagnosis: INCARCERATED PARASTOMAL HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p hernia repair, extubated 2 days ago and now w/\n SOB, tachypnea again\n REASON FOR THIS EXAMINATION:\n eval for ETT placement and eval RUL opacity\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73 year old woman status post hernia repair, now with shortness\n of breath.\n\n COMPARISON: .\n\n PORTABLE CHEST: There has been intubated, and the endotracheal tube tip is\n approximately 3 cm from the carina. There is a right subclavian line whose\n tip is in the right atrium. There has been interval worsening of the right\n upper lobe opacity. Furthermore, there is opacification of the left upper lobe\n as well. There is a focal opacity seen in the left lower lobe. This\n constellation of findings raises the possibility of a multilobar pneumonia\n versus aspiration.\n\n Line tip position communicated to Dr. . Ramanavarpu.\n\n IMPRESSION:\n 1. Right subclavian line tip in the right atrium.\n 2. Multilobar pneumonia with aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2121-11-03 00:00:00.000", "description": "P ABDOMEN (SUPINE & ERECT) PORT", "row_id": 843653, "text": " 7:59 AM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: does pt have bowel obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with h/o para-ileostomy hernia repair presents with abdominal\n pain.\n REASON FOR THIS EXAMINATION:\n does pt have bowel obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN 2 VIEWS:\n\n HISTORY: Paraileostomy hernia repair with abdominal pain.\n\n Gas and fecal residue are present throughout the colon and there is no\n evidence for intestinal obstruction and no free intraperitoneal gas. No soft\n tissue masses. Degenerative changes are present in the lower lumbar spine and\n there are surgical clips in the pelvic cavity and radiopaque opacities\n overlying the right lower quadrant.\n\n IMPRESSION:\n\n No evidence for intestinal obstruction.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-11-03 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 843676, "text": " 9:58 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: any cardiopulmonry change or pathology that may contraindica\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman, pre-op for herniated stoma repair\n REASON FOR THIS EXAMINATION:\n any cardiopulmonry change or pathology that may contraindicate surgery\n ______________________________________________________________________________\n WET READ: AEBc MON 11:01 AM\n Slight LV enlargement and unfolding of the aorta. No evidence of acute\n cardiopulmonary disease.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n\n INDICATION: A 73-year-old woman, preoperative for herniated stoma repair.\n\n COMPARISON: Reports of the CTA of , and chest x-rays of\n and , as the images are not available at\n this time.\n\n TECHNIQUE: PA and lateral chest x-ray.\n\n FINDINGS: There is slight left ventricular enlargement. Other than slight\n unfolding of the thoracic aorta, the mediastinal and hilar contours are\n unremarkable. The pulmonary vascularity is normal, and the lungs are clear.\n There are no pleural effusions or pneumothorax. There is slight elevation of\n the right hemidiaphragm. The surrounding osseous structures and soft tissues\n are unremarkable.\n\n IMPRESSION: No evidence of acute cardiopulmonary disease.\n\n" }, { "category": "ECG", "chartdate": "2121-11-13 00:00:00.000", "description": "Report", "row_id": 309852, "text": "Baseline artifact in leads V4-V6. Sinus rhythm. Prominent limb lead\nQRS voltage - consider left ventricular hypertrophy. Tracing may otherwise be\nwithin normal limits, but baseline artifact makes assessment difficult. Since\nthe previous tracing of probably no significant change.\n\n" }, { "category": "ECG", "chartdate": "2121-11-05 00:00:00.000", "description": "Report", "row_id": 310057, "text": "Sinus rhythm, rate 79. Since the previous tracing of slight increase in\nST-T wave abnormalities are noted the lateral precordium.\n\n" }, { "category": "ECG", "chartdate": "2121-11-03 00:00:00.000", "description": "Report", "row_id": 310058, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , no significant change\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_\n\n" } ]

[ { "category": "Radiology", "chartdate": "2174-06-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825829, "text": " 5:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: postop film\n Admitting Diagnosis: S/P CATH;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman s/p cabg x2/IABP\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG.\n\n SINGLE VIEW OF THE CHEST: The exact position of the PA catheter is difficult\n to assess due to motion. This does not conclusively reach the main pulmonary\n artery. There is left basilar atelectasis. No pneumothorax. The\n endotracheal tube and NG tubes are in satisfactory position. There is a left\n chest tube and mediastinal drain. No vascular congestion or infiltrate.\n Median sternotomy wires.\n\n IMPRESSION: Further evaluation may be warranted to establish conclusively\n where the PA catheter terminates. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2174-06-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825877, "text": " 8:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG\n Admitting Diagnosis: S/P CATH;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman s/p cabg x2/IABP\n\n REASON FOR THIS EXAMINATION:\n s/p CABG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post-CABG.\n\n COMPARISON: .\n\n AP CHEST: The ET tube is approximately 5 cm above the carina. The Swan-Ganz\n catheter tip overlies the main pulmonary artery. The NG tube courses below\n the diaphragm. There is a left chest tube and mediastinal drain. The cardiac\n and mediastinal contours are stable. The lungs appear clear. There is a\n trace left pleural effusion. There is no pneumothorax. Osseous structures are\n unremarkable.\n\n IMPRESSION: Lines and tubes as described. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2174-06-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 826067, "text": " 9:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for CHF -\n Admitting Diagnosis: S/P CATH;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman s/p cabg x2/IABP rising PA numbers and decreased CI\n\n REASON FOR THIS EXAMINATION:\n evaluate for CHF -\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: History of CABG.\n\n PORTABLE AP CHEST: Status post CABG. The tip of the Swan-Ganz catheter\n overlies the proximal right main pulmonary artery. No pneumothorax. There are\n small bilateral pleural effusions and atelectasis in the left mid zone as well\n as at both lung bases.\n\n" }, { "category": "Radiology", "chartdate": "2174-06-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 826200, "text": " 3:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ASSESS FOR INFILTRATES/EFFUSIONS\n Admitting Diagnosis: S/P CATH;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman s/p CABG\n REASON FOR THIS EXAMINATION:\n ASSESS FOR INFILTRATES/EFFUSIONS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75 y/o woman status post CABG. Assess for infiltrates or pleural\n effusions.\n\n AP SEMI-UPRIGHT SINGLE VIEW OF THE CHEST: Compared to .\n\n FINDINGS: The patient is status post median sternotomy and CABG. There is\n interval removal of the Swan-Ganz catheter. There is a remaining right IJ\n cordis with tip in the right innominate vein. There is no evidence of\n pneumothorax. There are bilateral pleural effusions. They are probably small\n to moderate and are difficult to compare to the previous study due to\n different position. There is a persistent left retrocardiac opacity that\n could represent atelectasis but cannot exclude consolidation. The pulmonary\n vascularity is normal. There is no evidence of CHF.\n\n IMPRESSION:\n 1) Bilateral small to moderate pleural effusions difficult to compare to the\n previous study. The right pleural effusion may be slightly increased.\n 2) Worsening of the left retrocardiac opacity that could represent\n atelectasis or consolidation.\n 3) There is also persistent right retrocardiac patchy opacity also could\n represent atelectasis or consolidation.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2174-06-17 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 826678, "text": " 11:04 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: S/P CATH;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Short of breath.\n\n PA AND LATERAL CHEST: Removal of right IJ catheter since . There are\n technical differences and better inspiration, with equivocal change in the\n right pleural effusion, and left lower thorax opacification, presumably an\n effusion and atelectasis. No vascular congestion or infiltrates. The heart\n border is obscured, but may be borderline in size.\n\n IMPRESSION: Little interval change.\n\n" }, { "category": "Radiology", "chartdate": "2174-06-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825997, "text": " 12:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O EFFUSION\n Admitting Diagnosis: S/P CATH;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman s/p cabg x2/IABP\n\n REASON FOR THIS EXAMINATION:\n R/O EFFUSION\n ______________________________________________________________________________\n FINAL REPORT\n History of CABG.\n\n Status post CABG. Swan-Ganz catheter overlies proximal right main pulmonary\n artery. No pneumothorax. Opacity at the left base consistent with atelectasis.\n Possible associated small left pleural effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2174-06-16 00:00:00.000", "description": "Report", "row_id": 294490, "text": "Sinus rhythm. Ventricular premature beats. First degree A-V delay. Left atrial\nabnormality. Left axis deviation. Left bundle-branch block. Since the previous\ntracing of limb leads are now correctly applied.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2174-06-15 00:00:00.000", "description": "Report", "row_id": 294491, "text": "Reversal of right and left arm leads. Sinus rhythm. First degree A-V delay.\nLeft atrial abnormality. Ventricular premature beat. Left bundle-branch block.\nSince the previous tracing of atrial fibrillation is now absent and\nright and left arm leads have been reversed.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2174-06-14 00:00:00.000", "description": "Report", "row_id": 294697, "text": "Atrial fibrillation with an average ventricular response, rate 92. There is a\nleft bundle-branch block pattern with a very wide QRS complex seen. No previous\ntracing available for comparison. No previous tracing available for comparison.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-06-11 00:00:00.000", "description": "Report", "row_id": 1500088, "text": "CV: PT IN 1ST DEGREE AVB W/ BBB. 90-100'S. 2.5MG LOPRESSOR WAS ADMINISTERED FOR RATE W/ EFFECT. HR 90S. CO/CI WAS > 3.0 ON MILRINONE. D/C'D MIRINONE. CO/CI STILL > 3.0 THEN PT CONVERTED TO RAF 120-130'S. SBP DROP TO 80'S. MAPS 50'S. CI 2.11. NOTIFIED . GAVE 7.5MG LOPRESSOR IV, 500CC BOLUS NS, 2MG MAGNESIUM SUFATE, AND AMIO 150MG BOLUS. WILL START AMIODARONE INFUSION. STARTED NEOSYNEPHRINE GTT FOR HYPOTENSION W/ EFFECT. OCCASSION TO FREQUENT PVC'S. LYTES WNL.\n\nRESP: FINE BIBASILAR RALES. SPO2 99-100%. WEAN FIO2 FROM .75 FT TO 2L NP. SPO2 99-100%. ENCOURAGED PT TO . DOING IS 500-750CC.\n\nGU: MARGINAL UOP. HAS PATENT FOLEY. PT RECIEVED TOTAL 60MG IV LASIX W/ MILD RESPONSE. SEE FLOWSHEET.\n\nNEURO: EASILY AROUSABLE AND FOLLOWING COMMANDS. MAE. PT HAD C/O CT SITE PAIN. MEDICATED W/ 1 PERCOCET TAB X2. PT ALSO GIVEN 650MG TYLENOL.\n\nGI: HYPOACTIVE BS. TOLERATING CLEARS.\n\nENDO: INSULIN GTT D/C'D PER PROTOCOL.\n\nHEME: PLT'S 79. MINIMAL CT OUTPUT. POS AIR LEAK NOTED.\n\nPLAN: AMIODARONE INFUSION. WEAN NEO AS TOL. TITRATE TO BP PARAMETERS. MONITOR LYTES. ADVANCE DIET. MANAGE PAIN. ? HOLD ASA AND ZANTAC D/T PLT COUNT.\n" }, { "category": "Nursing/other", "chartdate": "2174-06-11 00:00:00.000", "description": "Report", "row_id": 1500089, "text": "7a-7p\n\nNEURO: AROUSES TO VOICE, ORIENTED X3. MAE AND FOLLOWS COMMANDS. PERCOCET FOR PAIN CONTROL WITH GOOD RELIEF. 25MCG'S OF PROPOFOL GIVEN FOR PROCEDURE (SEE CV).\n\nRESP: LS CLEAR WITH DIM BASES. O2 SATS 98% ON 3L NC. NEEDS ENCOURAGEMENT TO C&DB. CT PATENT S/S DRAINAGE. NO CREPITUS, INT AIR LEAK NOTED.\n\nCV: AFIB, 90-100'S. OCCASIONAL PVC NOTED. SBP 100-120'S. NEO GTT TITRATED OFF. AMIO GTT DECREASED TO 0.5MG/KG. CARDIOVERTED X1 WITH NO CONVERSION. ?REPEAT CARDIOVERSION TOMORROW. PAPABLE/DOLPPLER PEDAL PULSES LLE COOLER THEN RLE. SOME GENERALIZED EDEMA NOTED.\n\nENDO: ELEVATED BG'S TREATED SSRI.\n\nGI/GU: BS+. ABD SOFT AND NONDISTENDED. TOLERATING PO'S. NO BM OR FLATUS. NO LASIX TODAY, DIURESING MIN-MOD AMOUNTS OF YELLOW URINE SOME SEDIMENT NOTED.\n\nPLAN: CONTINUE AMIO GTT. INCREASE DIET AND ACTIVITY. ?CARDIOVERSION TOMORROW. HEMODYNAMIC MONITORING. MONITOR LABS. PULM TOILETING. PAIN CONTROL.\n" }, { "category": "Nursing/other", "chartdate": "2174-06-12 00:00:00.000", "description": "Report", "row_id": 1500090, "text": "Update\nO: cv status: remains in afib w labile co/ci's/svr. Excellent response to lasix 40 iv diurising copious amts clear urine.Distal pulses + faint palp + w doppler.\nresp status: 02 sats > 95% on np at 3lpm. bbs distant dimin bibas brth snds & clear ^ lobes. Coughing w/o raising sputum.\n\nneuro status: arous to voice oriented, follows simple commands mae. C/o incisional pain ^ w dbc exercises. Med for same w perc 1 tab x2, pt still uncomfortable and unable to rest for more than short perioids unitl ct's removed.Chest tubes dc by ho w/o incident and pt resting more comfortably.\n\ngi/endo: tol po liqs well. abd soft distended., hypoactive bowel snds +. riss per protocol\n\ngu status: as noted above. copious uop w lasix 40 iv x1.\n\nheme/id: tmax 100.wbc 11. hct stable at 33.\n\nA/P: ? start ace inhib ? captopril today for afterload reduction. Adv diet and activ as tol.\n" }, { "category": "Nursing/other", "chartdate": "2174-06-10 00:00:00.000", "description": "Report", "row_id": 1500085, "text": "NEURO: Propofol off. Pt opens eyes spontaneously, mae, has equally strong hand grasp. Pt nods head to question. Gave Morphine 2mg and 4mg ivp for w/effect.\n\nCV: Pt needed levophed gtt for periods of hypotension. Levo now off. Started iv nitro gtt for Sbp> 130's amd maps > 90. Low filling pressures. Recieved 2 L Lr. Pedal pulses are palpable. CO/CI good. See flowsheet. Milrinone @ .5mcg/k/min. Initially needed AV pacing d/t brady 1st degree avb. Pt also has LBBB. Now pt in 1st degree avb. hr 90-110. Occassional pvc's. Replete lytes as needed. IABP 1:1. Poor augmentation.\n\nRESP: Remained on Simv 5 peep, 5 ps, 40% Fio2. Changes were made according abg's. Lungs are clear bilat. Weaning attempts unsuccessful d/t lethargy and low resp drive r/t sedation.\n\nGU: Adequate Uop> Foley patent.\n\nHEME: Ct's w/ minimal serosang output.\n\nENDO: Started insulin gtt per protocol\n\nPLAN: Continue to wake and wean vent as tol. ? Wean and d/c IABP. Wean nitro gtt and milrinone. Monitor bs. Wean insulin gtt as tol.\n" }, { "category": "Nursing/other", "chartdate": "2174-06-10 00:00:00.000", "description": "Report", "row_id": 1500086, "text": "RESPIRATORY CARE:\n\n75 yo f s/p emergent cabg x2 . Pt remains intubated, vent supported. BS's diminished, though essentially clear. Sxing small amts clear secretions. Required increased vent support for acidosis. RSBI=118 this am, pt remains sedate- arrythmias noted. See flowsheet for further pt data.\nPlan: Wean vent support as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2174-06-10 00:00:00.000", "description": "Report", "row_id": 1500087, "text": "NEURO~SLEEPY. EASILY AROUSABLE. DC. MAE. MED PERCOCET ELIXIR & MORPHINE SULFATE FOR C/O INCISIONAL DISCOMFORT. EFFECTIVE. FAMILY IN VISITING ALL DAY.\n\nCARDIAC~1ST DEGEREE AB BLOCK W/ BBB. FREQ PVC'S. ELECTROLYTES WNL. LABILE BP TITRATING NITRO TO MAINTAIN MAP'S 60-90. CURRENTLY OFF. MILNIRONE @.3 UCG/KG/MIN. CI>2.6. RIGHT FEM IABP DC'D @ 1400, W/ MINIMAL BLEEDING. GOOD PAL PEDAL PULSES. FEET WARM.\n\nRESP~EXTUBATED W/O DIFFICULTY. CURRENTLY ON 75% OFM. GOOD POST EXTUBATION ABG. MAINTAINING SATS OF 98%. LUNGS CLEAR UPPER DIM IN BASES. NON PRODUCTIVE COUGH.\n\nGI/GU~GIVEN 10 MG REGLAN IV FOR NAUSEA W/ VOMITING. EFFECTIVE. U/O MINIMAL. AWARE. FOLEY IRRIGATED, PATENT.\n\nENDO~CONT ON INSULIN DRIP CURRENTLY @ 4 UNITS/HR. BG LEVELS Q 1 HR.\n\nA/P~FOLLOWING NORMAL POST OP COURSE. LABILE BP CONTROLED W/ NITRO.\nTO CONT AGGRESSIVE REHAB. MONITOR BG LEVELS Q/HR.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-06-09 00:00:00.000", "description": "Report", "row_id": 1500084, "text": "post op:\n\nrecieved from or at 1845. sedated on propofol. pearl. a-paced->changed to av paced d/t to long pr interval. levo ^ for bp support. milrinone & aprotinin infusing. iabp 1:1 good augmentation with poor unloading. see flow sheet. k+ & mgso4 given.\n" }, { "category": "Nursing/other", "chartdate": "2174-06-14 00:00:00.000", "description": "Report", "row_id": 1500094, "text": "RN progress note\nAAO x 3; depressed affect; pt states that she is \"discouraged\" about still \"feeling awful\". No focal deficits. Med w/ percocet 1 q 6h for ssternal pain.\n\nCV: afib, freq MF ectopy, PJC, PVC; HR 80-110. SBP 100-140 after lopressor started, 25 mg po BID. Heparin titrated MD ; PTT pennding from 0500.\n\nPulm: BS CTAb after . Occassional wheezy, non-productive cough. NP 2 L sats 95-99; RA sats 91-93.\n\nGI: abd soft, non=tender to palp, but pt has cc/o \"gas pains' intermittently all noc. Small soft brown BM x 2, heme neg; passing large amt flatus. Tol cl liqs, no N/V.\n\nGU: UOP adequate; 1000cc after lasix 40 mg IV @ . RF wnl.\n\nMS/derm: Skin intact w/ mullt small resolving hematomae. Sternum stable; wounds C/D.\n\nLabs: H/H stable; lytes repleted, wnl this am. PTT pending.\n\nP: to be seen by EP; ? cardioversion today. ? increase amio and/or lopressor. Increase DAT.\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-06-14 00:00:00.000", "description": "Report", "row_id": 1500095, "text": "NEURO: AWAKE AND ALERT; ABLE TO MOVE ALL EXT AND FOLLOW DIRESTIONS; PT MORE APP NOW; LESS APP IN AM W/ C/O NAUSEA AND JAW PAIN;\nCV: A-FIB W/ OCC PVC'S B/P STABLE; A-LINE AND CORD PULLED; WIRES D/C'D ON HEPARIN\nRESP: LSC SATS WNL ON 2L ABLE TO AMB AROUND BED W/ NO SOB\nGU: FOLEY D/C'D VOIDING VIA BEDSIDE COMMODE\nGI: C/O OF NAUSEA; PT DRY HEAVING IN EARLY AM; TX W/ ZOFRAN W/ EFFECT; INTERMITTENT NAUSEA THROUGH EARLY AFTERNOON; NO NAUSEA NOW; PASSING LOTS OF FLATUS; NO BM TODAY COLACE AND ASA HELD FOR GI UPSET\nENDO: BG TX PER SS;\nPLAN: CONT TO MONITOR GI STATUS; AMB AD LIB; ENC PO INTAKE D/T INC BUN FROM PM LABS; PREPARE FOR F2\n" }, { "category": "Nursing/other", "chartdate": "2174-06-14 00:00:00.000", "description": "Report", "row_id": 1500096, "text": "addedum: pt had episode of jaw pain and nausea; pa notified-ekg done labs drawn; no changes noted; pain stopped when partial removed; pa aware; pt stable at this time\n" }, { "category": "Nursing/other", "chartdate": "2174-06-15 00:00:00.000", "description": "Report", "row_id": 1500097, "text": "RN progress note\nNeurO: lethargic, cal, coop. no focal dificits. Med for sternal pain x 1 w/ percocet 1\n\nCV: afib, variable MF VEA; HR 70-90. SBO 90's-120's. Palp pulses.\n\nPulm: BS essentially CTAb, wheezy, non-productive cough. RA sats>95%.\n\nGI: anorexic w/ c/o dyspepsia after meds despite maaloxx w/ meds. Abd soft non-tender. nl BS. Small, heme neg BM NPO after MN, although needed sip g.ale & cracker w/ am amiodarone.\n\nGU: voids QS on BSC, mod response to lasix\n\nMS/derm: mult hematomae, eccymoses resolving. Sternum stable; wounds C/D.\n\nLabs: unable to draw am labs. Heparin adjusted specific MD order, now @ 1000u.\n\nP: EP to evaluate for cardioversion this am. Give meds, esp amio w/ food. Transfer 2\n" }, { "category": "Nursing/other", "chartdate": "2174-06-12 00:00:00.000", "description": "Report", "row_id": 1500091, "text": "7a-7a-p\n\nNEURO: ALERT AND ORIENTED. MAE AND FOLLOWS COMMANDS. APPEARS MUCH MORE ALERT TODAY. OOB TO CHAIR WITH 2 ASSIST. OK MD WITH PA LINE.\n\nRESP: LS CLEAR WITH DIM BASES. USING IS TO 750, NEEDS ENCOURAGEMENT. O2 SATS 97% ON 5L NC, HAD TO INCREASE O2 THIS AM FOR LOW SATS. PRODUCTIVE COUGH.\n\nCV: AFIB 80-90'S. INITIALLY ON NITRO GTT. TITRATED DOWN TO 1MCG/KG, STARTED ON PO CAPTOPRIL AND LABATOLOL GIVEN X1. TITRATING NITRO FOR SBP <130'S. WEAK BUT PAPABLE PEDAL PULSES. SOME GENERALIZED EDEMA NOTED. ? NEED FOR CARDIOVERSION TOMORROW. AMIO GTT @0.5. PACER WIRES UNABLE TO ASSESS THRESHOLDS D/T RATE AND AFIB. CI 1.8-2.0\n\nENDO: ELEVATED BG'S TREATED PER SLIDING SCALE.\n\nGI/GU: BS+. ABD SOFT AND NONDISTENDED. TOLERATING PO'S. AUTODIURESING MOD AMOUNTS OF C/Y/U. NO BM OR FLATUS.\n\nPLAN: TITRATE NITRO FOR SBP<130. CONTINUE AMIO GTT. INCREASE DIET AND ACTIVITY. MONITOR HEMODYNAMICS AND LABS. ?CARDIOVERSION TOMORROW.\n" }, { "category": "Nursing/other", "chartdate": "2174-06-13 00:00:00.000", "description": "Report", "row_id": 1500092, "text": "Update\nO: CV status: rate controlled afib w occ pvc's. Cont on ntg & captopril started tolerated well w much improved co/ci/svr in past 24hrs. Weaning ntg as tol ci>2. Distal pulses weak palp confirmed by doppler.\n\nResp status: bbs clear ^ lobes, diminsh bibas. Occ exp wheezes noted rll. alb/atr neb w cpt done . Exp wheeze resolved. Dbc w/o raising sput at this time. nc @ 5lpm wean as tol.\n\nNeuro status: more alert & conversant this pm. c/o mild incisional pain & med for same w perc 1 tab w releif of pain.Sleeping in long naps overnight.perl & mae spont.follows simple commands.\n\nGi status: tol po food and flds. passing flatus no bm yet. Endo-glucoses managed riss per protocol\nAbd soft slt distended non tender+ bowel snds.\n\nGu status:f/c w cl yellow urine.\n\nheme/Id: am hct 24.4 -> will repeat to confirm results. id: wbc dwn wnl @ 7.0 Afebrile.\n\nA/P: much improved co/ci/svr past 24hrs on captopril w adeq bp-> wean ntg as tol. Repeat hct to confirm results. Follow glucoses and rx per protocol. Bcpt, assess need for ongoing neb rx. ^ diet and activ as tol.? dc pa line later today if ci> 2 off ntg gtt.\n" }, { "category": "Nursing/other", "chartdate": "2174-06-13 00:00:00.000", "description": "Report", "row_id": 1500093, "text": "NEURO ALERT ORIENTED LETHARGIC AT TIMES EASILY AROUSABLE MOVES ALL EXTREMETIES NO DEFECITS NOTED\n\nC/V AFIB HR 90-120 CAPTORIL INCREASED TO 25MG TOL WELL AMIODERONE IV CHANGED TO PO CI > 2 PA DC/D HEP STARTED 700U 5PM PALP PULSES EPI WIRES INTACT\n\nRESP NC 4L SATS 98% LUNGS CLEAR DIMINISHED RA SATS 95% AT REST\n\nGU/GI TAKING ONLY SMALL AMTS POS LIQUIDS WITH SMALL AMT SOLIDS ABD SOFT FAINT BOWEL SOUNDS HEARD TO COMMODE X3 LARGE AMTS FLATUS NO STOOL MARGINAL URINE OUT\n\nPLAN INCREASE DIET AND ACTIVITY AS TOL\n" } ]

[ { "category": "Nursing", "chartdate": "2155-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341515, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Abdominal pain persists.\n Action:\n Morphine 2mg dosing.\n Response:\n States pain decreased and able to achieve periods of sleep.\n Plan:\n Morphine IV prn.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Decreased Hct; bloody sputum production but no hematemesis.\n Action:\n Received total of 7 PRBCs since admission.\n Response:\n Hct increased.\n Plan:\n Serial hct; endoscopy in AM.\n" }, { "category": "Nursing", "chartdate": "2155-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341562, "text": "76 year old male with MDS (transfusion dependent), h/o GIB due to\n peptic ulcer as well as multiple difficult to treat AVMs in his upper\n jejunum and duodenum ( radiation) and a Dieulafoy lesion in \n presents from heme onc clinic with hemetemesis. The patient was in\n his usual state of health this morning, presented to heme onc clinic\n for a scheduled blood transfusion and then developed nausea, and\n vomited bright red blood. He then developed epigastric pain, which has\n increased in intensity since that time. He received 2L of NS and 1\n unit of PRBC's in clinic and was transferred to the ED. He has not had\n a change in diet or medications, and has not recently used alcohol. He\n reports that though he has had GI bleeds in the past, he has never had\n large volume hemetemesis.\n .\n In the ED: The patient had continued hemetemesis (about 200 ccs out\n total). Three PIV's placed (18g, 20g, and 22g). Given 3 more liters\n of NS (for a total of 5L); a second unit PRBCs was hung just prior to\n transfer to the floor. There are varying reports regarding stool\n output: nursing documents both brown, guaiac positive stool as well as\n maroon grossly bloody stool. Of note, he is a very difficult\n crossmatch. He was given protonix IV, zofran, compazine and morphine.\n .\n On arrival to the MICU he is in distress, complains of epigastric\n pain, + nausea, and is actively spitting up bright red blood. He had a\n brown BM that was guaic positive\n Pain control (acute pain, chronic pain)\n Assessment:\n Abdominal pain persists.\n Action:\n Morphine 2mg dosing.\n Response:\n States pain decreased and able to achieve short periods of sleep.\n Plan:\n Morphine IV prn.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Decreased Hct; bloody sputum production but no hematemesis.\n Action:\n Received total of 7 PRBCs since admission.\n Response:\n Hct increased initially up to 29 but now down to 25.\n Plan:\n Protonix gtt; serial hct; endoscopy today.\n Other data and overall plan:\n Increased potassium of 7.4 with a repeat value of 7.3. Gave regular\n Insulin 10u, one amp D50, dose of Kayexalate. EKG done.\n Ordered for Calcium Gluconate 2gm, Mg Sulfate 2gm, Lasix 40mg.\n" }, { "category": "General", "chartdate": "2155-09-25 00:00:00.000", "description": "ICU Event Note", "row_id": 341695, "text": "Clinician: Attending\n Called at 9:30 PM by MICU housestaff for acute onset hemetemesis and\n BRBPR. On arrival pt was hypotensive on peripheral dopa with 4 PIV. We\n initiated wide open NS, blood 4 units on rapid transfuser, placed right\n groin line acutely for more vasopressors. GI, surgery, and IR\n consulted. Pt continued to have significant hemetemesis. Initiated on\n Neo and Levophed, intubated for airway protection and dyspnea. GI felt\n endoscopy would not be helpful and surgery fekt urgent embolization was\n best course of action. I personally spoke with IR fellow and Attg x 2\n to facilitate tx to Angio. Surgery is at bedside. Family called and\n updated on critical status\n Total time spent: 90 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2155-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341925, "text": "Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt received from OR s/p ex lap, antrectomy, repair of arteriotomy w/\n pericardial patch. BP unstable, tachycardic. Urine output low. Dark\n Red blood , clots suctioned from NGT & oral cavity\n Action:\n LSC TLC placed\n L Femoral Arterial Line placed\n Conts on Neo & Levo gtts\n 1unit PRBCs & 2units FFP given\n 1500cc total of Plasmalyte boluses\n Response:\n BP stabilized\n Pt remains anuric\n Plan:\n Maintain hemodynamic stability\n Titrate gtts as needed\n Cont to assess cardiac function w/ \n Cont to assess urine output\n Liver function abnormalities\n Assessment:\n Increasing liver enzymes & lactic acid, acidotic. Blood sugars\n trending down.\n Action:\n 1amp 50% Dextrose given\n D10 infusion ordered\n Pt hyperventilated\n Response:\n Blood sugars stabilized\n ABGs slightly improved\n Plan:\n Cont to assess LFTs Q6hrs\n Plan for OR tmrw to ?close abdomen\n Monitor FBS\n" }, { "category": "Nursing", "chartdate": "2155-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341849, "text": "Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt received from OR s/p ex lap, antrectomy, repair of arteriotomy w/\n pericardial patch. BP unstable, tachycardic. Urine output low. Dark\n Red blood , clots suctioned from NGT & oral cavity\n Action:\n LSC TLC placed\n L Femoral Arterial Line placed\n Conts on Neo & Levo gtts\n 1unit PRBCs & 2units FFP given\n 1500cc total of Plasmalyte boluses\n Response:\n BP stabilized\n Pt remains anuric\n Plan:\n Maintain hemodynamic stability\n Titrate gtts as needed\n Cont to assess cardiac function w/ \n Cont to assess urine output\n Liver function abnormalities\n Assessment:\n Increasing liver enzymes & lactic acid, acidotic. Blood sugars\n trending down.\n Action:\n 1amp 50% Dextrose given\n D10 infusion ordered\n Pt hyperventilated\n Response:\n Blood sugars stabilized\n ABGs slightly improved\n Plan:\n Cont to assess LFTs Q6hrs\n Plan for OR tmrw to ?close abdomen\n Monitor FBS\n" }, { "category": "Nursing", "chartdate": "2155-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341924, "text": "Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt received from OR s/p ex lap, antrectomy, repair of arteriotomy w/\n pericardial patch. BP unstable, tachycardic. Urine output low. Dark\n Red blood , clots suctioned from NGT & oral cavity\n Action:\n LSC TLC placed\n L Femoral Arterial Line placed\n Conts on Neo & Levo gtts\n 1unit PRBCs & 2units FFP given\n 1500cc total of Plasmalyte boluses\n Response:\n BP stabilized\n Pt remains anuric\n Plan:\n Maintain hemodynamic stability\n Titrate gtts as needed\n Cont to assess cardiac function w/ \n Cont to assess urine output\n Liver function abnormalities\n Assessment:\n Increasing liver enzymes & lactic acid, acidotic. Blood sugars\n trending down.\n Action:\n 1amp 50% Dextrose given\n D10 infusion ordered\n Pt hyperventilated\n Response:\n Blood sugars stabilized\n ABGs slightly improved\n Plan:\n Cont to assess LFTs Q6hrs\n Plan for OR tmrw to ?close abdomen\n Monitor FBS\n" }, { "category": "Nursing", "chartdate": "2155-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341605, "text": "76 year old male with MDS (transfusion dependent), h/o GIB due to\n peptic ulcer as well as multiple difficult to treat AVMs in his upper\n jejunum and duodenum ( radiation) and a Dieulafoy lesion in \n presents from heme onc clinic with hemetemesis. The patient was in\n his usual state of health thiis morning when, presented to heme\n onc clinic for a scheduled blood transfusion and then developed nausea,\n and vomited bright red blood. He then developed epigastric pain, which\n has increased in intensity since that time. He received 2L of NS and 1\n unit of PRBC's in clinic and was transferred to the ED. He has not had\n a change in diet or medications, and has not recently used alcohol. He\n reports that though he has had GI bleeds in the past, he has never had\n large volume hemetemesis.\n .\n In the ED: The patient had continued hemetemesis (about 200 ccs out\n total). Three PIV's placed (18g, 20g, and 22g). Given 3 more liters\n of NS (for a total of 5L); a second unit PRBCs was hung just prior to\n transfer to the floor. There are varying reports regarding stool\n output: nursing documents both brown, guaiac positive stool as well as\n maroon grossly bloody stool. Of note, he is a very difficult\n crossmatch. He was given protonix IV, zofran, compazine and morphine.\n .\n On arrival to the MICU he is in distress, complains of epigastric\n pain, + nausea, and is actively spitting up bright red blood. He had a\n brown BM that was guaic negative. Attempted an Endo but unable to\n perform to lrge amts blood and were concerned with possible\n aspration. Rec\nd a total of 7 units PC\ns since admit to AM .\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n .\n" }, { "category": "Physician ", "chartdate": "2155-09-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 341610, "text": "Chief Complaint: Hemetemesis\n 24 Hour Events:\n Admitted to MICU. On PPI drip, erythromycin. Gi and Surgery\n consulted.\n ENDOSCOPY - At 06:00 PM\n rec'd Versed 2mg and Fentanyl 50mcq, became hypotensive; unable to see\n due to large clot burden in stomach. Also with possible aspiration\n event. No interventions made. Per GI, pt will need to be intubated\n for future scopes.\n . Unable to do the scope too much.\n Transfused 3 units PRBCS: Hct fell from 20.5->15. Transfused an\n additional 3 units PRBCs (for a total of six units), Hct bumped to 29\n then 25.\n Potassium returned this AM at 7.2; ?peaked T's on EKG. Given\n insulin/D50, calcium gluc, lasix 40IV and kayexalate.\n EKG - At 06:31 AM\n Allergies:\n Nsaids\n meningitis type\n Last dose of Antibiotics:\n Erythromycin - 06:56 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Morphine Sulfate - 10:00 PM\n Dextrose 50% - 06:34 AM\n Insulin - Regular - 06:34 AM\n Furosemide (Lasix) - 06:49 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 Nutritional Support: NPO\n Gastrointestinal: Abdominal pain, Nausea, Emesis\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: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 75 (70 - 87) bpm\n BP: 116/47(64) {80/38(47) - 1,114/57(80)} mmHg\n RR: 23 (23 - 33) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.1 kg (admission): 70.8 kg\n Total In:\n 6,843 mL\n 652 mL\n PO:\n 60 mL\n TF:\n IVF:\n 1,299 mL\n 542 mL\n Blood products:\n 1,544 mL\n Total out:\n 375 mL\n 450 mL\n Urine:\n 375 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,468 mL\n 202 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ///19/\n Physical Examination\n General Appearance: Thin, pale\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Poor dentition\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, +epigastric tenderness, no guarding today\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x4,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 152 K/uL\n 9.1 g/dL\n 149 mg/dL\n 1.8 mg/dL\n 19 mEq/L\n 7.3 mEq/L\n 77 mg/dL\n 113 mEq/L\n 141 mEq/L\n 25.3 %\n 44.9 K/uL\n [image002.jpg]\n 05:23 PM\n 07:47 PM\n 12:04 AM\n 03:28 AM\n WBC\n 44.9\n Hct\n 15.8\n 21.1\n 29.2\n 25.3\n Plt\n 152\n Cr\n 1.8\n Glucose\n 149\n Other labs: PT / PTT / INR:17.7/34.7/1.6, Ca++:7.1 mg/dL, Mg++:1.5\n mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n 76M with MDS (transfusion dependent) and h/o GI bleeds due to PUD,\n dieulafoy, angioectasias XRT presents with hemetemesis.\n 1. Hemetemesis: still unclear source\nPUD vs AVMs vs all\n of which he has had previously. Epigastric pain concerning for PUD,\n abd exam improved this AM. Pain improved but still present this am.\n -PPI gtt IV\n -4 lg bore PIVs\n -active crossmatch of at least 4 units\n -NPO\n -q4 hct, transfuse to goal of 24-26\n -GI following, plan for repeat scope today -- will discuss with GI\n need for intubation with scope\n -if pain persists and nothing seen on EGD, will need CT to eval for\n etiology of this pain\n -control nausea, pain\n -appreciate surgery input\n -follow up GI recs\n .\n # Hyperkalemia- K= 7.2 this am, No EKG changes. given Calcium gluc,\n insulin/d50, kayexalate, lasix\n -improved with recheck\n -trend q4-6 hours today with Hct\n .\n #ARF: Cr 1.8 this AM from baseline of 0.9. Likely prerenal in setting\n of massive GIB.\n -volume as above\n -trend\n #HTN- hold antihypertensives, BB.\n .\n #DM: hold oral hypoglycemics as NPO, cover with HISS\n .\n #GOUT: holding allopurinol while NPO\n .\n #anemia/MDS- on aranesp and transfusion dependent. Goal Hct 24.\n -transfuse to goal of 24\n -continue B6, hydroxyurea once able to take POs again\n .\n #ACCESS: 4 PIVs\n #PPX: pneumoboots, PPI, bowel regmimen not indicated\n ICU Care\n Nutrition: NPO, D5 1/2NS, trend lytes\n Glycemic Control: Regular insulin sliding scale\n Lines: 2 18gs, a 20g and a 22g PIV\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2155-09-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 341612, "text": "Chief Complaint: hematemesis\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 76 y/o M w/MDS and hx GI bleeds, p/w hematemesis and abd pain.\n 24 Hour Events:\n ENDOSCOPY - At 06:00 PM\n rec'd Versed 2mg and Fentanyl 50mcg, became hypotensive. Unable to do\n the scope due to significant amount of blood and clot in stomach as\n well as pt was coughing/gagging.\n EKG - At 06:31 AM\n Received 3 additional units PRBCs overnight with Hct response to 29,\n now down to 25. (Total transfusion requirement 6 units PRBCs).\n This AM, K was 7.2. T waves slightly peaked. Given calcium, lasix,\n insulin/D50, and kayexalate.\n Allergies:\n Nsaids\n meningitis type\n Last dose of Antibiotics:\n Erythromycin - 06:56 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Morphine Sulfate - 10:00 PM\n Dextrose 50% - 06:34 AM\n Insulin - Regular - 06:34 AM\n Furosemide (Lasix) - 06:49 AM\n Other medications:\n insulin sliding scale, morphine prn (hasn't received since last night)\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, No(t) Nausea, No(t) Emesis, mildly\n improved from last PM\n Pain: Severe\n Pain location: abdominal pain\n Flowsheet Data as of 09:05 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: 36.2\nC (97.2\n HR: 77 (70 - 87) bpm\n BP: 128/50(70) {80/38(47) - 128/50 (70) mmHg\n RR: 24 (23 - 33) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.1 kg (admission): 70.8 kg\n Total In:\n 6,843 mL\n 708 mL\n PO:\n 60 mL\n TF:\n IVF:\n 1,299 mL\n 598 mL\n Blood products:\n 1,544 mL\n Total out:\n 375 mL\n 800 mL\n Urine:\n 375 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,468 mL\n -92 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ///19/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n JVP around 5\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: III/VI HSM at apex\n radiating to axilla)\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 at R base\n Abdominal: Soft, Bowel sounds present, mild TTP in epigastrium but\n improved from yesterday\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.1 g/dL\n 152 K/uL\n 149 mg/dL\n 1.8 mg/dL\n 19 mEq/L\n 5.9 mEq/L\n 77 mg/dL\n 113 mEq/L\n 141 mEq/L\n 24.2 %\n 44.9 K/uL\n [image002.jpg]\n 05:23 PM\n 07:47 PM\n 12:04 AM\n 03:28 AM\n 07:32 AM\n WBC\n 44.9\n Hct\n 15.8\n 21.1\n 29.2\n 25.3\n 24.2\n Plt\n 152\n Cr\n 1.8\n Glucose\n 149\n Other labs: PT / PTT / INR:17.7/34.7/1.6, Ca++:7.1 mg/dL, Mg++:1.5\n mg/dL, PO4:5.5 mg/dL\n ECG: nsr at 60, LAD, IVCD, TWI in V2 (new), PRWP, mild peaked T waves\n Assessment and Plan\n 76 y/o M w/transfusion dependent MDS and GI bleeds of multiple\n etiologies who presents with hematemesis.\n 1. Upper GI bleed: Differential is broad especially given his multiple\n GI bleeds in past, including PUD (highest on differential given his\n severe abd pain), AVMs, Dieulafoy's, gastritis. Currently\n hemodynamically stable & not having further hematemesis. Hct\n 20->15->29->24 with 6 units.\n - GI following; plan for EGD this AM\n - Surgery following; no indication for OR at this point\n - KUB negative for free air\n - Check Hct q4h. Crossmatch 4 additional units.\n - PPI infusion\n - check lactate but doubt mesenteric ischemia given how much better he\n looks today\n 2. Acute renal failure: Likely volume depletion in setting of GI\n bleed. Will volume resuscitate & continue to monitor.\n 3. Hyperkalemia: Likely due to acute renal failure. No significant\n ECG changes (perhaps mild peaked T's.) Treated with kayexalate,\n insulin/D50, calcium.\n 4. DM: Insulin sliding scale.\n 5. HTN: Holding given GI bleed.\n 6. MDS: transfusion dependent. Will follow.\n ICU Care\n Nutrition:\n Comments: NPO for EGD\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 20 Gauge - 04:04 PM\n 22 Gauge - 04:05 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: Boots\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": "2155-09-24 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 341477, "text": "Chief Complaint: hematemesis\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 76 y/o M w/transfusion-dependent MDS, hx GI bleeds PUD, AVMs, &\n Dieulafoy's lesion, who was in clinic today getting a\n transfusion when he developed nausea & vomited bright red blood. Then\n developed epigastric pain which was initially and is now . He\n finished that unit of blood, was given 2L NS, and sent to the ED.\n In the ED, he continued to have hematemesis. 3 PIVs placed, given 3L\n NS and a 2nd unit of blood. Hemodynamically stable, bp 130s drifting\n down to 100s, HR 60s-80s. ? Maroon stool vs brown guaiac positive\n stool. Given protonix, zofran, & morphine.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Nsaids\n meningitis type\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. PUD\n 2. MDS\n 3. s/p splenectomy\n 4. Transfusion-dependent anemia, baseline 20-24\n 5. Pancreatic Ca s/p subtotal pancreatectomy, xeloda, cyberknife, & XRT\n 6. CHF, EF 55%\n 7. DM\n 8. Gout\n 9. Diverticulosis\n 10. HTN\n : allopurinol, amlodipine, folate, lasix 80 , glipizide,\n hydralazine 25 tid, hydrea, lisinopril 10 mg daily, ativan 0.5 tid,\n metformin, metoprolol 125 tid, octreotide q month, omeprazole,\n sucralfate, ambien, levitra\n sister with CHF\n Occupation:\n Drugs:\n Tobacco: 30 pack years, quit\n Alcohol: occasional\n Other: Married. Retired tax attorney.\n Review of systems:\n Gastrointestinal: Abdominal pain, Nausea, Emesis\n Pain: Worst\n Pain location: abd\n Flowsheet Data as of 05:39 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.1\nC (95.1\n Tcurrent: 35.1\nC (95.1\n HR: 80 (80 - 87) bpm\n BP: 104/41(57)\n RR: 25 (25 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 157 mL\n PO:\n TF:\n IVF:\n 15 mL\n Blood products:\n 142 mL\n Total out:\n 0 mL\n 375 mL\n Urine:\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -218 mL\n Respiratory\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Thin, elderly male, lying in bed with eyes closed\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI\n SEM at apex\n Peripheral Vascular: (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, TTP in epigastrium, bilateral upper quadrants, no\n rebound or guarding, hypoactive bowel sounds\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 285\n 20.5\n 184\n 1.5\n 72\n 23\n 104\n 4.8\n 137\n 32.1 (baseline)\n [image002.jpg]\n Other labs: PT / PTT / INR:/33.4/1.4\n Imaging: CXR: low inspired lung volumes, no infiltrates/edema\n KUB: No free air\n Assessment and Plan\n 76 y/o M w/transfusion dependent MDS and GI bleeds of multiple\n etiologies who presents with hematemesis.\n 1. Upper GI bleed: Differential is broad especially given his multiple\n GI bleeds in past, including PUD (highest on differential given his\n severe abd pain), AVMs, Dieulafoy's, gastritis. Currently\n hemodynamically stable & not having further hematemesis.\n - GI has evaluated and plan for endoscopy now\n - Surgery consult given abd pain\n - KUB negative for free air\n - Transfuse 2U PRBCs, check serial Hct\n - PPI infusion\n - if pain persists and no clear etiology on EGD, will need abd CT\n 2. DM: Insulin sliding scale.\n 3. HTN: Holding given GI bleed.\n 4. Anemia: On epo. Restart B6 and folate once taking po. Current\n anemia due to GI bleed.\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 04:02 PM\n 20 Gauge - 04:04 PM\n 22 Gauge - 04:05 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:\n" }, { "category": "Nursing", "chartdate": "2155-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341667, "text": "76 year old male with MDS (transfusion dependent), h/o GIB due to\n peptic ulcer as well as multiple difficult to treat AVMs in his upper\n jejunum and duodenum ( radiation) and a Dieulafoy lesion in \n presents from heme onc clinic with hemetemesis. The patient was in\n his usual state of health thiis morning when, presented to heme\n onc clinic for a scheduled blood transfusion and then developed nausea,\n and vomited bright red blood. He then developed epigastric pain, which\n has increased in intensity since that time. He received 2L of NS and 1\n unit of PRBC's in clinic and was transferred to the ED. He has not had\n a change in diet or medications, and has not recently used alcohol. He\n reports that though he has had GI bleeds in the past, he has never had\n large volume hemetemesis.\n .\n In the ED: The patient had continued hemetemesis (about 200 ccs out\n total). Three PIV's placed (18g, 20g, and 22g). Given 3 more liters\n of NS (for a total of 5L); a second unit PRBCs was hung just prior to\n transfer to the floor. There are varying reports regarding stool\n output: nursing documents both brown, guaiac positive stool as well as\n maroon grossly bloody stool. Of note, he is a very difficult\n crossmatch. He was given protonix IV, zofran, compazine and morphine.\n .\n On arrival to the MICU he is in distress, complains of epigastric\n pain, + nausea, and is actively spitting up bright red blood. He had a\n brown BM that was guaic negative. Attempted an Endo but unable to\n perform to lrge amts blood and were concerned with possible\n aspration. Rec\nd a total of 7 units PC\ns since admit to AM of .\n Pain control (acute pain, chronic pain)\n Assessment:\n Decreased pain only requested pain med once\n Action:\n Rec\nd Morphine 1mg times one for discomfort.\n Response:\n Good response no further c/o\ns pain\n Plan:\n Continue to assess for pain administer meds as needed.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further Hematemesis, noted, no stool, HCT was stable @ 24 until 1600\n when was 23.3. Was inutubated for EGD, which showed lrge ulcer which\n was cauterized. Remains NPO. INR-1.4 Was extubated s/p EGD.\n Action:\n To rec one unit PC\n for HCT-23.3.\n Response:\n HCT decreased, but no bleeding noted.\n Plan:\n Transfuse and check HCT\ns q4hr.\n Hypotension (not Shock)\n Assessment:\n BP stable to 100-120\ns/50, HR 70-80\ns SR, K+ still elevated but down to\n 5.4, no EKG changes.\n Action:\n Rec\ning IVF and Kayexcelate\n Response:\n BP stable but K+ still elevated\n Plan:\n Check lytes s/p Kayexcleate. , monitor BP.\n .\n" }, { "category": "Physician ", "chartdate": "2155-09-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 341473, "text": "Chief Complaint: Hemetemesis\n HPI:\n 76 year old male with MDS (transfusion dependent), h/o GIB due to\n peptic ulcer as well as multiple difficult to treat AVMs in his upper\n jejunum and duodenum ( radiation) and a Dieulafoy lesion in \n presents from heme onc clinic with hemetemesis. The patient was in\n his usual state of health this morning, presented to heme onc clinic\n for a scheduled blood transfusion and then developed nausea, and\n vomited bright red blood. He then developed epigastric pain, which has\n increased in intensity since that time. He received 2L of NS and 1\n unit of PRBC's in clinic and was transferred to the ED. He has not had\n a change in diet or medications, and has not recently used alcohol. He\n reports that though he has had GI bleeds in the past, he has never had\n large volume hemetesis.\n .\n In the ED: The patient had continued hemetemesis (about 200 ccs out\n total). Three PIV's placed (18g, 20g, and 22g). Given 3 more liters\n of NS (for a total of 5L); a second unit PRBCs was hung just prior to\n transfer to the floor. There are varying reports regarding stool\n output: nursing documents both brown, guaiac positive stool as well as\n maroon grossly bloody stool. Of note, he is a very difficult\n crossmatch. He was given protonix IV, zofran, compazine and morphine.\n .\n On arrival to the MICU he is in distress, complains of epigastric\n pain, + nausea, and is actively spitting up bright red blood. He had a\n brown BM that was guaic positive.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Nsaids\n meningitis type\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Allopurinol 300 mg Tablet daily\n Amlodipine 5 mg \n Folic Acid 1 mg daily\n Furosemide 80 mg \n Glipizide 20 mg qAM and 1 tab q pm\n Hydralazine 25 mg TID\n Hydroxyurea 500 mg daily\n Lisinopril 10 mg daily\n Lorazepam 0.5 mg TID\n Metformin 1000 mg \n Metoprolol 125 mg TID\n Octreotide 200 mcg q month\n Pantoprazole 40 mg \n Sucralfate 1 gram QID\n Levitra 20 mg PRN\n Ambien 5 mg qhs prn\n Pyridoxine\n Past medical history:\n Family history:\n Social History:\n h/o PUD\n Anemia (goal Hct 24-26, transfusion and aranesp\n dependent)Myelodysplastic syndrome s/p splenectomy - diagnosed 15 years\n ago, ringed sideroblastic anemia diagnosed via BM biopsy.\n Pancreatic cancer - Adenocarcinoma, grade I, T3, LN. s/p\n subtotal pancreatectomy , Xeloda, Cyberknife, XRT in .\n Incisional Hernia\n CHF\n Multiple GI bleeds angioectasias from XRT.\n Squamous cell carcinoma in-situ\n T2DM\n BPH\n Gout\n Scarlet fever as a child\n Diverticulosis\n PSH: Lami ', TURP, knee ', Distal Panc/Splenectomy\n .\n sister w/ CHF\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient is married with three children. He quit tobacco in\n ; has a 30 pack year history. Occasional EtOH. He worked as a tax\n attorney in . He lives in .\n Review of systems:\n Ear, Nose, Throat: Dry mouth\n Gastrointestinal: Abdominal pain, Emesis, hemetemesis, epigastric pain\n Heme / Lymph: Anemia\n Neurologic: Headache\n Signs or concerns for abuse : No\n Flowsheet Data as of 05:32 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.1\nC (95.1\n Tcurrent: 35.1\nC (95.1\n HR: 80 (80 - 87) bpm\n BP: 1,114/44(80) {104/41(57) - 1,114/46(80)} mmHg\n RR: 25 (25 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 160 mL\n PO:\n TF:\n IVF:\n 18 mL\n Blood products:\n 142 mL\n Total out:\n 0 mL\n 375 mL\n Urine:\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -215 mL\n Respiratory\n SpO2: 100%\n Physical Examination\n General Appearance: distress, spitting up blood, moaning\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Poor dentition\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: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Bowel sounds present, Tender: epigstric area. + guarding\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 1.5\n 20.5\n [image002.jpg]\n Other labs: PT / PTT / INR://1.5\n Assessment and Plan\n 76M with MDS (transfusion dependent) and h/o GI bleeds due to\n angioectasias XRT presents with hemetemesis.\n 1. Hemetemesis: likely upper GIB, has a number of possible sources\n including PUD, AVMs, Dieulafoy-- all of which he has had previously.\n Epigastric tenderness concerning for PUD.\n -PPI gtt IV\n - lg bore PIVs\n -NPO\n -Transfuse 2 additional units PRBCs\n -GI to scope urgently in ICU\n -q4 hct\n -stat KUB/CXR to assess for free air\n -surgery consult\n -if pain persists and nothing seen on EGD, will need CT to eval for\n etiology of this pain\n -control nausea, pain\n -follow up GI recs\n .\n #HTN- hold antihypertensives, BB.\n .\n #DM: hold oral hypoglycemics as NPO, cover with HISS\n .\n #GOUT: holding allopurinol while NPO\n .\n #anemia/MDS- on aranesp and transfusion dependent. Goal Hct 24.\n -transfuse to goal of 24\n -continue B6, hydroxyurea once able to take POs again\n .\n #ACCESS: 3 PIVs\n #PPX: pneumoboots, PPI, bowel regmimen not indicated\n .\n .\n .\n MD \n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:02 PM\n 20 Gauge - 04:04 PM\n 22 Gauge - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\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": "2155-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341527, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Abdominal pain persists.\n Action:\n Morphine 2mg dosing.\n Response:\n States pain decreased and able to achieve short periods of sleep.\n Plan:\n Morphine IV prn.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Decreased Hct; bloody sputum production but no hematemesis.\n Action:\n Received total of 7 PRBCs since admission.\n Response:\n Hct increased initially up to 29 but now down to 25.\n Plan:\n Serial hct; endoscopy in AM.\n" }, { "category": "Physician ", "chartdate": "2155-09-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 341601, "text": "Chief Complaint: hematemesis\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 76 y/o M w/MDS and hx GI bleeds, p/w hematemesis and abd pain.\n 24 Hour Events:\n ENDOSCOPY - At 06:00 PM\n rec'd Versed 2mg and Fentanyl 50mcg, became hypotensive. Unable to do\n the scope due to significant amount of blood and clot in stomach as\n well as pt was coughing/gagging.\n EKG - At 06:31 AM\n Received 3 additional units PRBCs overnight with Hct response to 29,\n now down to 25. (Total transfusion requirement 6 units PRBCs).\n This AM, K was 7.2. T waves slightly peaked. Given calcium, lasix,\n insulin/D50, and kayexalate.\n Allergies:\n Nsaids\n meningitis type\n Last dose of Antibiotics:\n Erythromycin - 06:56 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Morphine Sulfate - 10:00 PM\n Dextrose 50% - 06:34 AM\n Insulin - Regular - 06:34 AM\n Furosemide (Lasix) - 06:49 AM\n Other medications:\n insulin sliding scale, morphine prn (hasn't received since last night)\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, No(t) Nausea, No(t) Emesis, mildly\n improved from last PM\n Pain: Severe\n Pain location: abdominal pain\n Flowsheet Data as of 09:05 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: 36.2\nC (97.2\n HR: 77 (70 - 87) bpm\n BP: 128/50(70) {80/38(47) - 128/50 (70) mmHg\n RR: 24 (23 - 33) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.1 kg (admission): 70.8 kg\n Total In:\n 6,843 mL\n 708 mL\n PO:\n 60 mL\n TF:\n IVF:\n 1,299 mL\n 598 mL\n Blood products:\n 1,544 mL\n Total out:\n 375 mL\n 800 mL\n Urine:\n 375 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,468 mL\n -92 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ///19/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.1 g/dL\n 152 K/uL\n 149 mg/dL\n 1.8 mg/dL\n 19 mEq/L\n 5.9 mEq/L\n 77 mg/dL\n 113 mEq/L\n 141 mEq/L\n 24.2 %\n 44.9 K/uL\n [image002.jpg]\n 05:23 PM\n 07:47 PM\n 12:04 AM\n 03:28 AM\n 07:32 AM\n WBC\n 44.9\n Hct\n 15.8\n 21.1\n 29.2\n 25.3\n 24.2\n Plt\n 152\n Cr\n 1.8\n Glucose\n 149\n Other labs: PT / PTT / INR:17.7/34.7/1.6, Ca++:7.1 mg/dL, Mg++:1.5\n mg/dL, PO4:5.5 mg/dL\n ECG: nsr at 60, LAD, IVCD, TWI in V2 (new), PRWP, mild peaked T waves\n Assessment and Plan\n 76 y/o M w/transfusion dependent MDS and GI bleeds of multiple\n etiologies who presents with hematemesis.\n 1. Upper GI bleed: Differential is broad especially given his multiple\n GI bleeds in past, including PUD (highest on differential given his\n severe abd pain), AVMs, Dieulafoy's, gastritis. Currently\n hemodynamically stable & not having further hematemesis. Hct\n 20->15->29->24 with 6 units.\n - GI following; plan for EGD this AM\n - Surgery following; no indication for OR at this point\n - KUB negative for free air\n - Check Hct q4h. Crossmatch 4 additional units.\n - PPI infusion\n - check lactate but doubt mesenteric ischemia given how much better he\n looks today\n 2. Acute renal failure: Likely volume depletion in setting of GI\n bleed. Will volume resuscitate & continue to monitor.\n 3. Hyperkalemia: Likely due to acute renal failure. No significant\n ECG changes (perhaps mild peaked T's.) Treated with kayexalate,\n insulin/D50, calcium.\n 4. DM: Insulin sliding scale.\n 5. HTN: Holding given GI bleed.\n 6. MDS: transfusion dependent. Will follow.\n ICU Care\n Nutrition:\n Comments: NPO for EGD\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 20 Gauge - 04:04 PM\n 22 Gauge - 04:05 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: Boots\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": "2155-09-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 341584, "text": "Chief Complaint: Hemetemesis\n 24 Hour Events:\n Admitted to MICU. On PPI drip, erythromycin. Gi and Surgery\n consulted.\n ENDOSCOPY - At 06:00 PM\n rec'd Versed 2mg and Fentanyl 50mcq, became hypotensive; unable to see\n due to large clot burden in stomach. Also with possible aspiration\n event. No interventions made. Per GI, pt will need to be intubated\n for future scopes.\n . Unable to do the scope too much.\n Transfused 3 units PRBCS: Hct fell from 20.5->15. Transfused an\n additional 3 units PRBCs (for a total of six units), Hct bumped to 29\n then 25.\n Potassium returned this AM at 7.2; ?peaked T's on EKG. Given\n insulin/D50, calcium gluc, lasix 40IV and kayexalate.\n EKG - At 06:31 AM\n Allergies:\n Nsaids\n meningitis type\n Last dose of Antibiotics:\n Erythromycin - 06:56 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Morphine Sulfate - 10:00 PM\n Dextrose 50% - 06:34 AM\n Insulin - Regular - 06:34 AM\n Furosemide (Lasix) - 06:49 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 Nutritional Support: NPO\n Gastrointestinal: Abdominal pain, Nausea, Emesis\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: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 75 (70 - 87) bpm\n BP: 116/47(64) {80/38(47) - 1,114/57(80)} mmHg\n RR: 23 (23 - 33) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.1 kg (admission): 70.8 kg\n Total In:\n 6,843 mL\n 652 mL\n PO:\n 60 mL\n TF:\n IVF:\n 1,299 mL\n 542 mL\n Blood products:\n 1,544 mL\n Total out:\n 375 mL\n 450 mL\n Urine:\n 375 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,468 mL\n 202 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ///19/\n Physical Examination\n General Appearance: Thin, pale\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Poor dentition\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, +epigastric tenderness, no guarding today\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x4,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 152 K/uL\n 9.1 g/dL\n 149 mg/dL\n 1.8 mg/dL\n 19 mEq/L\n 7.3 mEq/L\n 77 mg/dL\n 113 mEq/L\n 141 mEq/L\n 25.3 %\n 44.9 K/uL\n [image002.jpg]\n 05:23 PM\n 07:47 PM\n 12:04 AM\n 03:28 AM\n WBC\n 44.9\n Hct\n 15.8\n 21.1\n 29.2\n 25.3\n Plt\n 152\n Cr\n 1.8\n Glucose\n 149\n Other labs: PT / PTT / INR:17.7/34.7/1.6, Ca++:7.1 mg/dL, Mg++:1.5\n mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n 76M with MDS (transfusion dependent) and h/o GI bleeds due to\n angioectasias XRT presents with hemetemesis.\n 1. Hemetemesis: likely upper GIB, has a number of possible sources\n including PUD, AVMs, Dieulafoy-- all of which he has had previously.\n Epigastric tenderness concerning for PUD.\n -PPI gtt IV\n - lg bore PIVs\n -NPO\n -Transfuse 2 additional units PRBCs\n -GI to scope urgently in ICU\n -q4 hct\n -stat KUB/CXR to assess for free air\n -surgery consult\n -if pain persists and nothing seen on EGD, will need CT to eval for\n etiology of this pain\n -control nausea, pain\n -follow up GI recs\n .\n Hyperkalemia- given Calcium gluc, insulin/d50, kayexalate, lasix\n -recheck in 2 hrs\n -trend\n .\n #HTN- hold antihypertensives, BB.\n .\n #DM: hold oral hypoglycemics as NPO, cover with HISS\n .\n #GOUT: holding allopurinol while NPO\n .\n #anemia/MDS- on aranesp and transfusion dependent. Goal Hct 24.\n -transfuse to goal of 24\n -continue B6, hydroxyurea once able to take POs again\n .\n #ACCESS: 3 PIVs\n #PPX: pneumoboots, PPI, bowel regmimen not indicated\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:04 PM\n 22 Gauge - 04:05 PM\n 18 Gauge - 07:00 PM\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" }, { "category": "General", "chartdate": "2155-09-26 00:00:00.000", "description": "ICU Event Note", "row_id": 341767, "text": "Clinician: Resident\n Patient found to have hemoptysis and marroon stools at 9:30 PM.\n Mentating well initially but became hypotensive to 50s systolic.\n Patient had three 18 guage peripherals and one 20 guage. He was given\n IVFs and started on peripheral dopamine. MICU attending, Dr.\n , was informed and came to MICU. Family (daughter, ,\n and wife, notified of patient\ns critical condition. After\n discussion with GI, they felt he had already been scoped twice in 24\n hours and so recommended IR and surgery evaluations. He remained\n hypotensive, so a triple lumen in right groin was placed. He remained\n hypotensive, so levo, neo and dopa was used to maintain BP. Surgery\n evaluated patient and recommended IR. Due to ongoing hematemasis, he\n was intubated for airway protection. Patient was type and crossed for\n numerous bags of PRBCs and was tranfused over 12 units of PRBCs, 4\n units FFP, and 2 bags of Cryoprecipitate during the night. Attempt at\n right groin cordis was unsuccessful and further efforts were aborted as\n they were calling for patient in IR. He was taken to IR, but was\n hypotensive to 70s systolic on triple pressors and was inadequately\n sedated, so decision was made to stop procedure. Surgery attending was\n notified and he agreed to take patient to the OR. Patient returned to\n MICU. He was given D5W with 150 meq of bicarb due to acidosis (pH of\n 6.9). He was given 2 grams of calcium gluconate due to low free\n ionized calcium (0.95) in setting of large amount of blood products.\n He was given 4 units of FFP for INR of 2.1. He was given 2 units of\n Cryoprecipitate for presumed DIC. He was taken to the OR at\n approximately 2:30 AM.\n Total time spent: 3600 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2155-09-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341502, "text": "76 year old male with MDS (transfusion dependent), h/o GIB due to\n peptic ulcer as well as multiple difficult to treat AVMs in his upper\n jejunum and duodenum ( radiation) and a Dieulafoy lesion in \n presents from heme onc clinic with hemetemesis. The patient was in\n his usual state of health this morning, presented to heme onc clinic\n for a scheduled blood transfusion and then developed nausea, and\n vomited bright red blood. He then developed epigastric pain, which has\n increased in intensity since that time. He received 2L of NS and 1\n unit of PRBC's in clinic and was transferred to the ED. He has not had\n a change in diet or medications, and has not recently used alcohol. He\n reports that though he has had GI bleeds in the past, he has never had\n large volume hemetesis.\n .\n In the ED: The patient had continued hemetemesis (about 200 ccs out\n total). Three PIV's placed (18g, 20g, and 22g). Given 3 more liters\n of NS (for a total of 5L); a second unit PRBCs was hung just prior to\n transfer to the floor. There are varying reports regarding stool\n output: nursing documents both brown, guaiac positive stool as well as\n maroon grossly bloody stool. Of note, he is a very difficult\n crossmatch. He was given protonix IV, zofran, compazine and morphine.\n .\n On arrival to the MICU he is in distress, complains of epigastric\n pain, + nausea, and is actively spitting up bright red blood. He had a\n brown BM that was guaic positive.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Spitting up bloody secretions, in small amts, had small OB neg brown\n stool times 2, c/ pain, with nausea. HCT dropped to 15 form\n 20.5 On Protonix Gtt.\n Action:\n Rec\nd 3units total of PC\ns between EU and MICU. Attempted Endo, but\n unable to do procedure due to too much blood, and possibilbity of\n aspiration. 3 additional PC\ns ordered.\n Response:\n Still bleeding ?\ning source.\n Plan:\n Administer additional PC\ns as ordered, monitor HCT q4hrs, assess for\n s/s bleeding.\n Hypotension (not Shock)\n Assessment:\n BP down to 80/30 during Endo, s/p Versed and Fentanyl for procedure.\n Action:\n Rec\nd 1L NS and one unit PC\n Response:\n BP back to 100-110\ns/50.\n Plan:\n Monitor BP.\n Pain control (acute pain, chronic pain)\n Assessment:\n C/O acute pain,\n Action:\n Rec\nd Morphine 4mg with no response, required Dilaudid .5mg IVP. Rec\n Response:\n Had slight relief with Dilaudid but had complete relief with sedation\n with Endo.\n Plan:\n Monitor pain and administer pain med as needed.\n" }, { "category": "Nursing", "chartdate": "2155-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341711, "text": "Significant events:\n Hemodynamically stable start of shift with BPs 130s. Episode of melana\n initially thought to be old blood from previous bleed. Quickly\n progressed to BRBPR in addition to hematemasis. Hct at that time found\n to be 16 with INR 2.2. Became hypotensive down to 60s. Started on\n Dopamine and additional PRBCs ordered. Groin line placed and LEVO and\n NEO added as fluid boluses unsuccessful. Acute drop in O2 sat down to\n 80s and was intubated emergently. Brought to IR to assess bleed but\n became too unstable with BP down to 60s despite maximum dosing on\n pressors. Brought back to MICU to stabilize before sending to OR.\n Received several units of PRBCs, FFP, and cryoprecipitate.\n" }, { "category": "Nursing", "chartdate": "2155-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341656, "text": "76 year old male with MDS (transfusion dependent), h/o GIB due to\n peptic ulcer as well as multiple difficult to treat AVMs in his upper\n jejunum and duodenum ( radiation) and a Dieulafoy lesion in \n presents from heme onc clinic with hemetemesis. The patient was in\n his usual state of health thiis morning when, presented to heme\n onc clinic for a scheduled blood transfusion and then developed nausea,\n and vomited bright red blood. He then developed epigastric pain, which\n has increased in intensity since that time. He received 2L of NS and 1\n unit of PRBC's in clinic and was transferred to the ED. He has not had\n a change in diet or medications, and has not recently used alcohol. He\n reports that though he has had GI bleeds in the past, he has never had\n large volume hemetemesis.\n .\n In the ED: The patient had continued hemetemesis (about 200 ccs out\n total). Three PIV's placed (18g, 20g, and 22g). Given 3 more liters\n of NS (for a total of 5L); a second unit PRBCs was hung just prior to\n transfer to the floor. There are varying reports regarding stool\n output: nursing documents both brown, guaiac positive stool as well as\n maroon grossly bloody stool. Of note, he is a very difficult\n crossmatch. He was given protonix IV, zofran, compazine and morphine.\n .\n On arrival to the MICU he is in distress, complains of epigastric\n pain, + nausea, and is actively spitting up bright red blood. He had a\n brown BM that was guaic negative. Attempted an Endo but unable to\n perform to lrge amts blood and were concerned with possible\n aspration. Rec\nd a total of 7 units PC\ns since admit to AM of .\n Pain control (acute pain, chronic pain)\n Assessment:\n Decreased pain only requested pain med once\n Action:\n Rec\nd Morphine 1mg times one for discomfort.\n Response:\n Good response no further c/o\ns pain\n Plan:\n Continue to assess for pain administer meds as needed.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further Hematemesis, noted, no stool, HCT was stable @ 24 until 1600\n when was 23.3. Was inutubated for EGD, which showed lrge ulcer which\n was cauterized. Remains NPO. INR-1.4 Was extubated s/p EGD.\n Action:\n To rec one unit PC\n for HCT-23.3.\n Response:\n HCT decreased, but no bleeding noted.\n Plan:\n Transfuse and check HCT\ns q4hr.\n Hypotension (not Shock)\n Assessment:\n BP stable to 100-120\ns/50, HR 70-80\ns SR, K+ still elevated but down to\n 5.4, no EKG changes.\n Action:\n Rec\ning IVF and Kayexcelate\n Response:\n BP stable but K+ still elevated\n Plan:\n Check lytes s/p Kayexcleate. , monitor BP.\n .\n" }, { "category": "Nursing", "chartdate": "2155-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341713, "text": "76 year old male with MDS (transfusion dependent), h/o GIB due to\n peptic ulcer as well as multiple difficult to treat AVMs in his upper\n jejunum and duodenum ( radiation) and a Dieulafoy lesion in \n presents from heme onc clinic with hemetemesis. The patient was in\n his usual state of health this morning, presented to heme onc clinic\n for a scheduled blood transfusion and then developed nausea, and\n vomited bright red blood. He then developed epigastric pain, which has\n increased in intensity since that time. He received 2L of NS and 1\n unit of PRBC's in clinic and was transferred to the ED. He has not had\n a change in diet or medications, and has not recently used alcohol. He\n reports that though he has had GI bleeds in the past, he has never had\n large volume hemetemesis.\n .\n In the ED: The patient had continued hemetemesis (about 200 ccs out\n total). Three PIV's placed (18g, 20g, and 22g). Given 3 more liters\n of NS (for a total of 5L); a second unit PRBCs was hung just prior to\n transfer to the floor. There are varying reports regarding stool\n output: nursing documents both brown, guaiac positive stool as well as\n maroon grossly bloody stool. Of note, he is a very difficult\n crossmatch. He was given protonix IV, zofran, compazine and morphine.\n Endoscopy on showing ulcer which was cauterized.\n Significant events this shift:\n Hemodynamically stable start of shift with BPs 130s. Episode of melana\n initially thought to be old blood from previous bleed. Quickly\n progressed to BRBPR in addition to hematemasis. Hct at that time found\n to be 16 with INR 2.2. Became hypotensive down to 60s. Started on\n Dopamine and additional PRBCs ordered. Groin line placed and LEVO and\n NEO added as fluid boluses unsuccessful. Acute drop in O2 sat down to\n 80s and was intubated emergently. Brought to IR to assess bleed but\n became too unstable with BP down to 60s despite maximum dosing on\n pressors. Brought back to MICU to stabilize before sending to OR.\n Received several units of PRBCs, FFP, and cryoprecipitate.\n" }, { "category": "Nursing", "chartdate": "2155-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341763, "text": "76 year old male with MDS (transfusion dependent), h/o GIB due to\n peptic ulcer as well as multiple difficult to treat AVMs in his upper\n jejunum and duodenum ( radiation) and a Dieulafoy lesion in \n presents from heme onc clinic with hemetemesis. The patient was in\n his usual state of health this morning, presented to heme onc clinic\n for a scheduled blood transfusion and then developed nausea, and\n vomited bright red blood. He then developed epigastric pain, which has\n increased in intensity since that time. He received 2L of NS and 1\n unit of PRBC's in clinic and was transferred to the ED. He has not had\n a change in diet or medications, and has not recently used alcohol. He\n reports that though he has had GI bleeds in the past, he has never had\n large volume hemetemesis.\n .\n In the ED: The patient had continued hemetemesis (about 200 ccs out\n total). Three PIV's placed (18g, 20g, and 22g). Given 3 more liters\n of NS (for a total of 5L); a second unit PRBCs was hung just prior to\n transfer to the floor. There are varying reports regarding stool\n output: nursing documents both brown, guaiac positive stool as well as\n maroon grossly bloody stool. Of note, he is a very difficult\n crossmatch. He was given protonix IV, zofran, compazine and morphine.\n Endoscopy on showing ulcer which was cauterized. (Please see\n nursing note 9/11 days for details).\n SIGNIFICANT EVENTS THIS SHIFT:\n Hemodynamically stable start of shift with BPs 130s. Episode of melena\n initially thought to be old blood from previous bleed. Quickly\n progressed to BRBPR in addition to hematemasis accompanied by\n tachycardia to 120s and diaphoresis. Hct at that time found to be 16\n with INR 2.1. Became hypotensive down to 60s. Started on Dopamine and\n additional PRBCs ordered. Groin line placed and LEVO and NEO added as\n Dopamine and fluid boluses unsuccessful. Acute drop in O2 sat down to\n 80s and was intubated emergently. Brought to IR to assess bleed but\n became too unstable with BP down to 60s despite maximum dosing on\n pressors. Brought back to MICU to stabilize before sending to OR.\n Received 12 units of PRBCs, 4 FFP, and 1 cryoprecipitate here in\n MICU. Sent to OR at 0200 and awaiting update. Family in ICU waiting\n area.\n" }, { "category": "Nursing", "chartdate": "2155-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341765, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Abdominal pain persists.\n Action:\n Morphine 2mg dosing.\n Response:\n States pain decreased and able to achieve periods of sleep.\n Plan:\n Morphine IV prn.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Decreased Hct; bloody sputum production but no hematemesis.\n Action:\n Received total of 7 PRBCs since admission.\n Response:\n Hct increased.\n Plan:\n Protonix gtt; serial hct; endoscopy in AM.\n ------ Protected Section------\n Duplicate note.\n ------ Protected Section Error Entered By: , RN\n on: 05:49 ------\n" }, { "category": "Nursing", "chartdate": "2155-09-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341499, "text": "76 year old male with MDS (transfusion dependent), h/o GIB due to\n peptic ulcer as well as multiple difficult to treat AVMs in his upper\n jejunum and duodenum ( radiation) and a Dieulafoy lesion in \n presents from heme onc clinic with hemetemesis. The patient was in\n his usual state of health this morning, presented to heme onc clinic\n for a scheduled blood transfusion and then developed nausea, and\n vomited bright red blood. He then developed epigastric pain, which has\n increased in intensity since that time. He received 2L of NS and 1\n unit of PRBC's in clinic and was transferred to the ED. He has not had\n a change in diet or medications, and has not recently used alcohol. He\n reports that though he has had GI bleeds in the past, he has never had\n large volume hemetesis.\n .\n In the ED: The patient had continued hemetemesis (about 200 ccs out\n total). Three PIV's placed (18g, 20g, and 22g). Given 3 more liters\n of NS (for a total of 5L); a second unit PRBCs was hung just prior to\n transfer to the floor. There are varying reports regarding stool\n output: nursing documents both brown, guaiac positive stool as well as\n maroon grossly bloody stool. Of note, he is a very difficult\n crossmatch. He was given protonix IV, zofran, compazine and morphine.\n .\n On arrival to the MICU he is in distress, complains of epigastric\n pain, + nausea, and is actively spitting up bright red blood. He had a\n brown BM that was guaic positive.\n" }, { "category": "Nursing", "chartdate": "2155-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341708, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Abdominal pain persists.\n Action:\n Morphine 2mg dosing.\n Response:\n States pain decreased and able to achieve periods of sleep.\n Plan:\n Morphine IV prn.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Decreased Hct; bloody sputum production but no hematemesis.\n Action:\n Received total of 7 PRBCs since admission.\n Response:\n Hct increased.\n Plan:\n Protonix gtt; serial hct; endoscopy in AM.\n" }, { "category": "Respiratory ", "chartdate": "2155-09-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 341861, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 71.2 None\n Ideal tidal volume: 284.8 / 427.2 / 569.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\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: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Pending procedure / OR, Underlying illness 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": "Nursing", "chartdate": "2155-09-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341501, "text": "76 year old male with MDS (transfusion dependent), h/o GIB due to\n peptic ulcer as well as multiple difficult to treat AVMs in his upper\n jejunum and duodenum ( radiation) and a Dieulafoy lesion in \n presents from heme onc clinic with hemetemesis. The patient was in\n his usual state of health this morning, presented to heme onc clinic\n for a scheduled blood transfusion and then developed nausea, and\n vomited bright red blood. He then developed epigastric pain, which has\n increased in intensity since that time. He received 2L of NS and 1\n unit of PRBC's in clinic and was transferred to the ED. He has not had\n a change in diet or medications, and has not recently used alcohol. He\n reports that though he has had GI bleeds in the past, he has never had\n large volume hemetesis.\n .\n In the ED: The patient had continued hemetemesis (about 200 ccs out\n total). Three PIV's placed (18g, 20g, and 22g). Given 3 more liters\n of NS (for a total of 5L); a second unit PRBCs was hung just prior to\n transfer to the floor. There are varying reports regarding stool\n output: nursing documents both brown, guaiac positive stool as well as\n maroon grossly bloody stool. Of note, he is a very difficult\n crossmatch. He was given protonix IV, zofran, compazine and morphine.\n .\n On arrival to the MICU he is in distress, complains of epigastric\n pain, + nausea, and is actively spitting up bright red blood. He had a\n brown BM that was guaic positive.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Spitting up bloody secretions, in small amts, had small OB neg brown\n stool times 2,\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2155-09-25 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 341643, "text": "Chief Complaint: hematemesis\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 76 y/o M w/transfusion-dependent MDS, hx GI bleeds PUD, AVMs, &\n Dieulafoy's lesion, who was in clinic today getting a\n transfusion when he developed nausea & vomited bright red blood. Then\n developed epigastric pain which was initially and is now . He\n finished that unit of blood, was given 2L NS, and sent to the ED.\n In the ED, he continued to have hematemesis. 3 PIVs placed, given 3L\n NS and a 2nd unit of blood. Hemodynamically stable, bp 130s drifting\n down to 100s, HR 60s-80s. ? Maroon stool vs brown guaiac positive\n stool. Given protonix, zofran, & morphine.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Nsaids\n meningitis type\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. PUD\n 2. MDS\n 3. s/p splenectomy\n 4. Transfusion-dependent anemia, baseline 20-24\n 5. Pancreatic Ca s/p subtotal pancreatectomy, xeloda, cyberknife, & XRT\n 6. CHF, EF 55%\n 7. DM\n 8. Gout\n 9. Diverticulosis\n 10. HTN\n : allopurinol, amlodipine, folate, lasix 80 , glipizide,\n hydralazine 25 tid, hydrea, lisinopril 10 mg daily, ativan 0.5 tid,\n metformin, metoprolol 125 tid, octreotide q month, omeprazole,\n sucralfate, ambien, levitra\n sister with CHF\n Occupation:\n Drugs:\n Tobacco: 30 pack years, quit\n Alcohol: occasional\n Other: Married. Retired tax attorney.\n Review of systems:\n Gastrointestinal: Abdominal pain, Nausea, Emesis\n Pain: Worst\n Pain location: abd\n Flowsheet Data as of 05:39 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.1\nC (95.1\n Tcurrent: 35.1\nC (95.1\n HR: 80 (80 - 87) bpm\n BP: 104/41(57)\n RR: 25 (25 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 157 mL\n PO:\n TF:\n IVF:\n 15 mL\n Blood products:\n 142 mL\n Total out:\n 0 mL\n 375 mL\n Urine:\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -218 mL\n Respiratory\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Thin, elderly male, lying in bed with eyes closed\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI\n SEM at apex\n Peripheral Vascular: (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, TTP in epigastrium, bilateral upper quadrants, no\n rebound or guarding, hypoactive bowel sounds\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 285\n 20.5\n 184\n 1.5\n 72\n 23\n 104\n 4.8\n 137\n 32.1 (baseline)\n [image002.jpg]\n Other labs: PT / PTT / INR:/33.4/1.4\n Imaging: CXR: low inspired lung volumes, no infiltrates/edema\n KUB: No free air\n Assessment and Plan\n 76 y/o M w/transfusion dependent MDS and GI bleeds of multiple\n etiologies who presents with hematemesis.\n 1. Upper GI bleed: Differential is broad especially given his multiple\n GI bleeds in past, including PUD (highest on differential given his\n severe abd pain), AVMs, Dieulafoy's, gastritis. Currently\n hemodynamically stable & not having further hematemesis.\n - GI has evaluated and plan for endoscopy now\n - Surgery consult given abd pain\n - KUB negative for free air\n - Transfuse 2U PRBCs, check serial Hct\n - PPI infusion\n - if pain persists and no clear etiology on EGD, will need abd CT\n 2. DM: Insulin sliding scale.\n 3. HTN: Holding given GI bleed.\n 4. Anemia: On epo. Restart B6 and folate once taking po. Current\n anemia due to GI bleed.\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 04:02 PM\n 20 Gauge - 04:04 PM\n 22 Gauge - 04:05 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: 60 min\n" }, { "category": "Physician ", "chartdate": "2155-09-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 341644, "text": "Chief Complaint: hematemesis\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 76 y/o M w/MDS and hx GI bleeds, p/w hematemesis and abd pain.\n 24 Hour Events:\n ENDOSCOPY - At 06:00 PM\n rec'd Versed 2mg and Fentanyl 50mcg, became hypotensive. Unable to do\n the scope due to significant amount of blood and clot in stomach as\n well as pt was coughing/gagging.\n EKG - At 06:31 AM\n Received 3 additional units PRBCs overnight with Hct response to 29,\n now down to 25. (Total transfusion requirement 6 units PRBCs).\n This AM, K was 7.2. T waves slightly peaked. Given calcium, lasix,\n insulin/D50, and kayexalate.\n Allergies:\n Nsaids\n meningitis type\n Last dose of Antibiotics:\n Erythromycin - 06:56 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Morphine Sulfate - 10:00 PM\n Dextrose 50% - 06:34 AM\n Insulin - Regular - 06:34 AM\n Furosemide (Lasix) - 06:49 AM\n Other medications:\n insulin sliding scale, morphine prn (hasn't received since last night)\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, No(t) Nausea, No(t) Emesis, mildly\n improved from last PM\n Pain: Severe\n Pain location: abdominal pain\n Flowsheet Data as of 09:05 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: 36.2\nC (97.2\n HR: 77 (70 - 87) bpm\n BP: 128/50(70) {80/38(47) - 128/50 (70) mmHg\n RR: 24 (23 - 33) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.1 kg (admission): 70.8 kg\n Total In:\n 6,843 mL\n 708 mL\n PO:\n 60 mL\n TF:\n IVF:\n 1,299 mL\n 598 mL\n Blood products:\n 1,544 mL\n Total out:\n 375 mL\n 800 mL\n Urine:\n 375 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,468 mL\n -92 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ///19/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n JVP around 5\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: III/VI HSM at apex\n radiating to axilla)\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 at R base\n Abdominal: Soft, Bowel sounds present, mild TTP in epigastrium but\n improved from yesterday\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.1 g/dL\n 152 K/uL\n 149 mg/dL\n 1.8 mg/dL\n 19 mEq/L\n 5.9 mEq/L\n 77 mg/dL\n 113 mEq/L\n 141 mEq/L\n 24.2 %\n 44.9 K/uL\n [image002.jpg]\n 05:23 PM\n 07:47 PM\n 12:04 AM\n 03:28 AM\n 07:32 AM\n WBC\n 44.9\n Hct\n 15.8\n 21.1\n 29.2\n 25.3\n 24.2\n Plt\n 152\n Cr\n 1.8\n Glucose\n 149\n Other labs: PT / PTT / INR:17.7/34.7/1.6, Ca++:7.1 mg/dL, Mg++:1.5\n mg/dL, PO4:5.5 mg/dL\n ECG: nsr at 60, LAD, IVCD, TWI in V2 (new), PRWP, mild peaked T waves\n Assessment and Plan\n 76 y/o M w/transfusion dependent MDS and GI bleeds of multiple\n etiologies who presents with hematemesis.\n 1. Upper GI bleed: Differential is broad especially given his multiple\n GI bleeds in past, including PUD (highest on differential given his\n severe abd pain), AVMs, Dieulafoy's, gastritis. Currently\n hemodynamically stable & not having further hematemesis. Hct\n 20->15->29->24 with 6 units.\n - GI following; plan for EGD this AM\n - Surgery following; no indication for OR at this point\n - KUB negative for free air\n - Check Hct q4h. Crossmatch 4 additional units.\n - PPI infusion\n - check lactate but doubt mesenteric ischemia given how much better he\n looks today\n 2. Acute renal failure: Likely volume depletion in setting of GI\n bleed. Will volume resuscitate & continue to monitor.\n 3. Hyperkalemia: Likely due to acute renal failure. No significant\n ECG changes (perhaps mild peaked T's.) Treated with kayexalate,\n insulin/D50, calcium.\n 4. DM: Insulin sliding scale.\n 5. HTN: Holding given GI bleed.\n 6. MDS: transfusion dependent. Will follow.\n ICU Care\n Nutrition:\n Comments: NPO for EGD\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 20 Gauge - 04:04 PM\n 22 Gauge - 04:05 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent: 45 min\n" }, { "category": "Nursing", "chartdate": "2155-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341548, "text": "76 year old male with MDS (transfusion dependent), h/o GIB due to\n peptic ulcer as well as multiple difficult to treat AVMs in his upper\n jejunum and duodenum ( radiation) and a Dieulafoy lesion in \n presents from heme onc clinic with hemetemesis. The patient was in\n his usual state of health this morning, presented to heme onc clinic\n for a scheduled blood transfusion and then developed nausea, and\n vomited bright red blood. He then developed epigastric pain, which has\n increased in intensity since that time. He received 2L of NS and 1\n unit of PRBC's in clinic and was transferred to the ED. He has not had\n a change in diet or medications, and has not recently used alcohol. He\n reports that though he has had GI bleeds in the past, he has never had\n large volume hemetemesis.\n .\n In the ED: The patient had continued hemetemesis (about 200 ccs out\n total). Three PIV's placed (18g, 20g, and 22g). Given 3 more liters\n of NS (for a total of 5L); a second unit PRBCs was hung just prior to\n transfer to the floor. There are varying reports regarding stool\n output: nursing documents both brown, guaiac positive stool as well as\n maroon grossly bloody stool. Of note, he is a very difficult\n crossmatch. He was given protonix IV, zofran, compazine and morphine.\n .\n On arrival to the MICU he is in distress, complains of epigastric\n pain, + nausea, and is actively spitting up bright red blood. He had a\n brown BM that was guaic positive\n Pain control (acute pain, chronic pain)\n Assessment:\n Abdominal pain persists.\n Action:\n Morphine 2mg dosing.\n Response:\n States pain decreased and able to achieve short periods of sleep.\n Plan:\n Morphine IV prn.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Decreased Hct; bloody sputum production but no hematemesis.\n Action:\n Received total of 7 PRBCs since admission.\n Response:\n Hct increased initially up to 29 but now down to 25.\n Plan:\n Protonix gtt; serial hct; endoscopy today.\n Other data and overall plan:\n Increased potassium of 7.4 with a repeat value of 7.3.\n" }, { "category": "Respiratory ", "chartdate": "2155-09-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 341640, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: Diagnostic lab\n Reason: Elective\n Tube Type\n ETT:\n Position: 21 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: 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: Unassisted spontaneous breathing\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 was intubated for upper GI scope tol well. Pt was extubated after\n scope doing well. See respiratory page of medivision for more\n information.\n" }, { "category": "Nursing", "chartdate": "2155-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341841, "text": "Liver function abnormalities\n Assessment:\n Increasing liver enzymes & lactic acid. Blood sugars trending down.\n Action:\n 1amp 50% Dextrose given\n D10 infusion ordered\n Response:\n Blood sugars stabilized\n Plan:\n Cont to assess LFTs Q6hrs\n Plan for OR tmrw to ?close abdomen\n Monitor FBS\n Shock, hypovolemic or hemorrhagic\n Assessment:\n BP unstable, tachycardic. Urine output low. Dark Red blood suctioned\n from NGT & oral cavity\n Action:\n LSC TLC placed\n L Femoral Arterial Line placed\n Conts on Neo & Levo gtts\n 1unit PRBCs & 2units FFP given\n 1500cc total of Plasmalyte boluses\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2155-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341845, "text": "Liver function abnormalities\n Assessment:\n Increasing liver enzymes & lactic acid, acidotic. Blood sugars\n trending down.\n Action:\n 1amp 50% Dextrose given\n D10 infusion ordered\n Pt hyperventilated\n Response:\n Blood sugars stabilized\n ABGs slightly improved\n Plan:\n Cont to assess LFTs Q6hrs\n Plan for OR tmrw to ?close abdomen\n Monitor FBS\n Shock, hypovolemic or hemorrhagic\n Assessment:\n BP unstable, tachycardic. Urine output low. Dark Red blood , clots\n suctioned from NGT & oral cavity\n Action:\n LSC TLC placed\n L Femoral Arterial Line placed\n Conts on Neo & Levo gtts\n 1unit PRBCs & 2units FFP given\n 1500cc total of Plasmalyte boluses\n Response:\n BP stabilized\n Pt remains anuric\n Plan:\n Maintain hemodynamic stability\n Titrate gtts as needed\n Cont to assess cardiac function w/ \n Cont to assess urine output\n" }, { "category": "Nursing", "chartdate": "2155-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341846, "text": "Liver function abnormalities\n Assessment:\n Increasing liver enzymes & lactic acid, acidotic. Blood sugars\n trending down.\n Action:\n 1amp 50% Dextrose given\n D10 infusion ordered\n Pt hyperventilated\n Response:\n Blood sugars stabilized\n ABGs slightly improved\n Plan:\n Cont to assess LFTs Q6hrs\n Plan for OR tmrw to ?close abdomen\n Monitor FBS\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt received from OR s/p ex lap, antrectomy, repair of arteriotomy w/\n pericardial patch. BP unstable, tachycardic. Urine output low. Dark\n Red blood , clots suctioned from NGT & oral cavity\n Action:\n LSC TLC placed\n L Femoral Arterial Line placed\n Conts on Neo & Levo gtts\n 1unit PRBCs & 2units FFP given\n 1500cc total of Plasmalyte boluses\n Response:\n BP stabilized\n Pt remains anuric\n Plan:\n Maintain hemodynamic stability\n Titrate gtts as needed\n Cont to assess cardiac function w/ \n Cont to assess urine output\n" }, { "category": "Nursing", "chartdate": "2155-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341538, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Abdominal pain persists.\n Action:\n Morphine 2mg dosing.\n Response:\n States pain decreased and able to achieve short periods of sleep.\n Plan:\n Morphine IV prn.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Decreased Hct; bloody sputum production but no hematemesis.\n Action:\n Received total of 7 PRBCs since admission.\n Response:\n Hct increased initially up to 29 but now down to 25.\n Plan:\n Serial hct; endoscopy in AM.\n" }, { "category": "Nursing", "chartdate": "2155-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341540, "text": "76 year old male with MDS (transfusion dependent), h/o GIB due to\n peptic ulcer as well as multiple difficult to treat AVMs in his upper\n jejunum and duodenum ( radiation) and a Dieulafoy lesion in \n presents from heme onc clinic with hemetemesis. The patient was in\n his usual state of health this morning, presented to heme onc clinic\n for a scheduled blood transfusion and then developed nausea, and\n vomited bright red blood. He then developed epigastric pain, which has\n increased in intensity since that time. He received 2L of NS and 1\n unit of PRBC's in clinic and was transferred to the ED. He has not had\n a change in diet or medications, and has not recently used alcohol. He\n reports that though he has had GI bleeds in the past, he has never had\n large volume hemetesis.\n .\n In the ED: The patient had continued hemetemesis (about 200 ccs out\n total). Three PIV's placed (18g, 20g, and 22g). Given 3 more liters\n of NS (for a total of 5L); a second unit PRBCs was hung just prior to\n transfer to the floor. There are varying reports regarding stool\n output: nursing documents both brown, guaiac positive stool as well as\n maroon grossly bloody stool. Of note, he is a very difficult\n crossmatch. He was given protonix IV, zofran, compazine and morphine.\n .\n On arrival to the MICU he is in distress, complains of epigastric\n pain, + nausea, and is actively spitting up bright red blood. He had a\n brown BM that was guaic positive\n Pain control (acute pain, chronic pain)\n Assessment:\n Abdominal pain persists.\n Action:\n Morphine 2mg dosing.\n Response:\n States pain decreased and able to achieve short periods of sleep.\n Plan:\n Morphine IV prn.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Decreased Hct; bloody sputum production but no hematemesis.\n Action:\n Received total of 7 PRBCs since admission.\n Response:\n Hct increased initially up to 29 but now down to 25.\n Plan:\n Serial hct; endoscopy in AM.\n" }, { "category": "Nursing", "chartdate": "2155-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341919, "text": "76 y.o.m. with significant PMH. Admitted to MICU for hematemesis\n and hct of 17. To OR for ex lap, antrectomy and repair of\n arteriotomy. In OR, pt found to have posterior gastric ulcer eroded\n through to celiac trunk with hepatic artery sacrifice. Transferred to\n TSICU for fluid resuscitation and monitoring.\n Patient in multisystem organ failure. On full ventilatory support and\n vasopressors, requiring fluid resuscitation and sodium bicarbonate gtt\n for worsening metabolic acidosis. Dr. spoke with patient\n family in regard to patient\ns poor prognosis, family decided to make\n patient CMO. Morphine gtt initiated for patient comfort, vasopressors\n discontinued, patient extubated at 0145. TOD 0208.\n Will request social work to f/u with family in a.m.\n" }, { "category": "Radiology", "chartdate": "2155-09-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033703, "text": " 12:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval position of esophageal balloon catheter\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with sepsis\n REASON FOR THIS EXAMINATION:\n eval position of esophageal balloon catheter\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf FRI 3:12 PM\n Esophageal catheter ends at the GE junction. Endotracheal tube placed too\n high, distances between end of endotracheal tube and carina measures 10 cm.\n End of endotracheal tube appears above carina. Results discussed with Dr.\n at 2 p.m.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old man with sepsis. Please evaluate position of esophageal\n balloon catheter.\n\n TECHNIQUE: Portable AP chest radiograph:\n\n COMPARISON: Compared to chest radiograph from , done at\n 9:07 a.m.\n\n FINDINGS: Stable bilateral effusion, associated with stable bilateral\n atelectasis. The esophageal catheter is ending at the GE junction. Lungs are\n clear. The ET tube is placed too high. The distance between the end of the\n ET tube and carina measures 10 cm. Recommendation is made to push down the\n tube for 3 cm. The left subclavian line ends in superior vena cava, unchanged\n from the previous scan. The right internal jugular sheath at the thoracic\n inlet is unchanged. The nasogastric tube ends in the stomach, unchanged.\n\n IMPRESSION:\n 1. Esophageal catheter ends at the GE junction.\n 2. ET tube placed too high, distance between end of ET tube and carina\n measures 10 cm. Recommendation to advance the ET tube for 3 cm is made.\n 3. Stable bilateral pleural effusion and bilateral basilar atelectasis.\n\n Findings discussed with Dr. at 2 p.m.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-09-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033704, "text": ", M. TSICU 12:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval position of esophageal balloon catheter\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with sepsis\n REASON FOR THIS EXAMINATION:\n eval position of esophageal balloon catheter\n ______________________________________________________________________________\n PFI REPORT\n Esophageal catheter ends at the GE junction. Endotracheal tube placed too\n high, distances between end of endotracheal tube and carina measures 10 cm.\n End of endotracheal tube appears above carina. Results discussed with Dr.\n at 2 p.m.\n\n" }, { "category": "Radiology", "chartdate": "2155-09-24 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1033280, "text": ", F. MED MICU-7 4:47 PM\n PORTABLE ABDOMEN Clip # \n Reason: ? free air\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with hemetemesis, epigastric pain\n REASON FOR THIS EXAMINATION:\n ? free air\n ______________________________________________________________________________\n PFI REPORT\n No free air, ileus or obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2155-09-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033281, "text": " 4:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? free air\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with hemetemesis, epigastric pain\n REASON FOR THIS EXAMINATION:\n ? free air\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: .\n\n INDICATION: Epigastric pain. Question free intraperitoneal air.\n\n Allowing for diaphragmatic motion, no definite free intraperitoneal air is\n identified, but a small amount of air could be obscured in the setting of\n motion artifact. If clinical suspicion persists, repeat upright radiograph or\n left lateral decubitus abdomen radiograph would be suggested. Patchy\n bibasilar atelectasis is demonstrated. Cardiomediastinal contours are\n unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-09-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033575, "text": " 11:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placements\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with with hematemasis intubated for airway protection\n REASON FOR THIS EXAMINATION:\n ET tube placements\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS FRI 12:00 PM\n ET tube OK. Mild edema is new.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:37 P.M., :\n\n HISTORY: Hematemesis. Intubated for airway protection.\n\n IMPRESSION: AP chest compared to :\n\n Mild perihilar infiltration suggests early edema. No focal consolidation.\n Heart size normal. No pleural effusion or pneumothorax. ET tube tip at the\n thoracic inlet, nasogastric tube passes below the diaphragm and out of view.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-09-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033576, "text": ", D. MED MICU-7 11:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placements\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with with hematemasis intubated for airway protection\n REASON FOR THIS EXAMINATION:\n ET tube placements\n ______________________________________________________________________________\n PFI REPORT\n ET tube OK. Mild edema is new.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-09-24 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1033279, "text": " 4:47 PM\n PORTABLE ABDOMEN Clip # \n Reason: ? free air\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with hemetemesis, epigastric pain\n REASON FOR THIS EXAMINATION:\n ? free air\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CHgc WED 5:41 PM\n No free air, ileus or obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN\n\n INDICATION: 76-year-old man with hematemesis and epigastric pain, ? free air.\n\n COMPARISON: CTA chest from and CT abdomen from .\n\n FINDINGS: There is no evidence of ileus, obstruction, or massive free air on\n this supine radiograph. There are no radiopaque densities to suggest renal\n stones. There are surgical clips in the left upper quadrant. The lumbar spine\n appears somewhat sclerotic, of uncertain significance. The lung bases are\n clear.\n\n IMPRESSION: No acute intra-abdominal process.\n\n" }, { "category": "Radiology", "chartdate": "2155-09-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033641, "text": " 8:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: COnsolidations? PTX?\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with GI Bleed, post op\n REASON FOR THIS EXAMINATION:\n COnsolidations? PTX?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS FRI 10:58 AM\n Right IJ sheath ends at the thoracic inlet, left subclavian line in SVC, ET\n tube okay, NG tube into the stomach. New small bilateral pleural effusions.\n Heart size normal. Lungs clear. No pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:07 A.M., \n\n HISTORY: GI bleed postop. Question consolidation or pneumothorax.\n\n IMPRESSION: AP chest compared to :\n\n Small bilateral pleural effusions are new. Lungs clear. Heart size normal.\n ET tube in standard placement. New left subclavian line ends in the SVC,\n right internal jugular sheath at the thoracic inlet. No pneumothorax.\n Nasogastric tube passes below the diaphragm and out of view.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-09-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033642, "text": ", M. TSICU 8:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: COnsolidations? PTX?\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with GI Bleed, post op\n REASON FOR THIS EXAMINATION:\n COnsolidations? PTX?\n ______________________________________________________________________________\n PFI REPORT\n Right IJ sheath ends at the thoracic inlet, left subclavian line in SVC, ET\n tube okay, NG tube into the stomach. New small bilateral pleural effusions.\n Heart size normal. Lungs clear. No pneumothorax.\n\n\n" }, { "category": "ECG", "chartdate": "2155-09-25 00:00:00.000", "description": "Report", "row_id": 303472, "text": "Sinus rhythm. Borderline left anterior fascicular block. Mild\nintraventricular conduction delay. First degree A-V delay. Compared to the\nprevious tracing of upright T waves are now present in lead V2.\n\n" }, { "category": "ECG", "chartdate": "2155-09-25 00:00:00.000", "description": "Report", "row_id": 303473, "text": "Normal sinus rhythm, rate 80. Borderline first degree A-V block. Left\nanterior hemiblock. Intraventricular conduction delay. Non-specific\nseptal and lateral repolarization changes. Compared to the previous tracing\nof T wave changes in leads aVL and V2 are new.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2118-03-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 786687, "text": " 2:36 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with CAD, preop CABG\n\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG. Evaluate for effusion.\n\n Frontal and lateral radiogaphs of the chest are compared with the previous\n exam dated . Since that examination, the patient has undergone\n median sternotomy and CABG. There are expected postoperative changes,\n including mild widening of the mediastinum, bibasilar atelectasis and a small\n left pleural effusion. The pulmonary vessels are normal with no evidence of\n CHF. No focal consolidation is identified, though an underlying infectious\n process at the bases is difficult to exclude with certainty.\n\n IMPRESSION: Expected postoperative changes status post CABG.\n\n" }, { "category": "ECG", "chartdate": "2118-03-18 00:00:00.000", "description": "Report", "row_id": 169146, "text": "Sinus rhythm\nLeft axis deviation\n\n" }, { "category": "ECG", "chartdate": "2118-03-19 00:00:00.000", "description": "Report", "row_id": 169147, "text": "Sinus tachycardia\n - supraventricular extrasystoles\nrSr'(V1) - probable normal variant\n Extensive ST elevation, consider pericarditis\n\n" }, { "category": "Nursing/other", "chartdate": "2118-03-18 00:00:00.000", "description": "Report", "row_id": 1479423, "text": "S/P CABG X4\nS: \"IT'S ABOUT A THREE\"\nO: CARDIAC: SR-ST 80'S-110'S,RECIEVED 2 LITERS OF LR. SBP INITIALLY TRANSIENT NTG AND NEO,PRESENTLY NEO @ .4MCQ TO KEEP SBP 100.CVP 13-7 , TO RECIEVE 500 ML HESPAN. CT 325 ML TOTAL DRAINAGE. IN OR COAGS ELEVATED, REPEAT INR 1.5. ACT 121. DSGS D+I. FEET SLIGHTLY COOL,+PP PALP. HCT 31.3. K 3.4 GIVEN 40 MEQ KCL AND REPEAT 4.4. MAG BEING REPLACED.\n RESP: EXTUBATED @ 1800 WITHOUT INCIDENT. BS CLEAR. RR TEENS. NO CT LEAK. WEAK COUGH PRESENTLY. O2 SAT ON 40 % >97%.\n NEURO: REVERSED AND MAE, FOLLOWING COMMANDS, PERL, PLEASANT.\n GI: NPO , CARAFATE X 1. ABD SOFT . ABSENT BOWEL SOUNDS.\n GU: DIURESED 1800 ML SINCE OR.\n ENDO: INSULIN GTT STARTED @ 1 UNIT WITH 1 UNIT IV BOLUS FOR GLUCOSE OF 137.\n PAIN: 2 MG MSO4 X1. HAD DENIED PAIN - SPOKE TO HIM REGARDING THE NEED TO TAKE PAIN MED AND PT STATED HE HAD INCISIONAL PAIN.\n SOCIAL: WIFE AND CHILDREN INTO VISIT.\nA: ST RESPONDING TO HESPAN, STABLE OTHERWISE.\nP: MONITOR COMFORT, HR AND RYHTYM, SBP -WEAN NEO AS TOLERATED, CT DRAINAGE, DSGS, RESP STATUS- PULM TOILET, NEURO STATUS, I+O, LABS- GLUCOSE @ - LABS Q 6. AS PER ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2118-03-19 00:00:00.000", "description": "Report", "row_id": 1479424, "text": "NEURO: A+OX3, Mae, Following commands. Medicated @ ,2200,03,04 with 2mg mso4 iv for c/o incisional pain.\n\nCV: Hr 90-110's ST. Stable Bp off neo. Palpable distal pulses. Moderate ct serosang drainage. Hct 29.\n\nRESP: No c/o sob. Lungs are clear bilat. Desat's off o2. Spo2 93-98% 40% aeresol mask. Encouraged to CDB. not raising any secretions. 750cc achieved on IS.\n\nRENAL: Adequate hourly uop via foley.\n\nGI: Tolerating clear liquids.\n\nENDO: Insulin gtt infusing and titrated for bs control.\n\nSKIN: Noted large reddened areas on anterior upper torso; No breakdown of lesions. Pt denied that it itched. Ct notified.\n\nASSESS: Stable.\n\nPLAN: Pulm hygiene. Enforce IS, CDB. Wean insulin gtt as tol. Increase activity as tol.\n" }, { "category": "Nursing/other", "chartdate": "2118-03-19 00:00:00.000", "description": "Report", "row_id": 1479425, "text": "PROB: S/P CABG\n\nCV: SR OCC PAC NOTED, VSS. CT DRAINING S/S DRAINAGE. PACER ON A DEMAND. MED FOR PAIN WITH PERCOCET WITH GOOD EFFECT. OOB TO CHAIR.\n\nRESP: LUNGS CLEAR.\n\nGU: LASIX PO WITH POOR RESPONSE, LASIX 20 IV WITH FAIR RESPONSE.\n\nGI: APPETITE POOR, BOWEL SOUNDS PRESENT.\n\nENDO: BS AND INSULIN DRIP PER FLOW SHEET.\n\nASSESSMENT: DOING WELL\n\nPLAN: CONT\nMONITOR BS\n\n\n" }, { "category": "Nursing/other", "chartdate": "2118-03-20 00:00:00.000", "description": "Report", "row_id": 1479426, "text": "PATIENT WITH PEACEFUL NIGHT SLEEP, AFTER PERCOCET GIVEN. SR INTHE 70'S WITH SBP 90-100, FAIR DIURESIS AFTER PO LASIX GIVEN. BS 100-129 WITHDRIP AT 2U/HR. MINIMALCT DRAINAGE ??? D/C CTS THIS AM.\n" } ]

[ { "category": "Echo", "chartdate": "2167-08-10 00:00:00.000", "description": "Report", "row_id": 104508, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease.\nHeight: (in) 66\nWeight (lb): 162\nBSA (m2): 1.83 m2\nBP (mm Hg): 136/65\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 10:15\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\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 chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Aortic CoreValve. AVR well seated, normal leaflet/disc motion\nand transvalvular gradients. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. No MS. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild [1+]\nTR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. The diameters of aorta at the sinus, ascending and arch levels are\nnormal. An aortic CoreValve prosthesis is present. The aortic valve prosthesis\nappears well seated, with normal leaflet/disc motion and transvalvular\ngradients. Trace paravalvar aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Trivial\nmitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is mild pulmonary artery systolic hypertension. There is a\ntrivial/physiologic pericardial effusion. There are no echocardiographic signs\nof tamponade.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n" }, { "category": "Echo", "chartdate": "2167-08-05 00:00:00.000", "description": "Report", "row_id": 104509, "text": "PATIENT/TEST INFORMATION:\nIndication: CoreValve evaluation.\nHeight: (in) 68\nWeight (lb): 160\nBSA (m2): 1.86 m2\nBP (mm Hg): 143/57\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 16:02\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Dilated RV cavity. Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Aortic CoreValve. Normal AVR gradient. Paravalvular leak. Mild\n(1+) 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 MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] TR. Moderate\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. Due to suboptimal technical quality, a\nfocal wall motion abnormality cannot be fully excluded. Overall left\nventricular systolic function is normal (LVEF >55%). The right ventricular\ncavity is dilated with mild global free wall hypokinesis. An aortic CoreValve\nprosthesis is present. The transaortic gradient is normal for this prosthesis.\nA paravalvular aortic valve leak is probably present. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral regurgitation. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with low-normal global\nsystolic function. Dilated right ventricle with mild global hypokinesis.\nCorevalve aortic prosthesis with normal transvalvular gradient and a very\nsmall perivalvular leak. Moderate pulmonary artery systolic hypertension.\n\nCompared with the prior study (images reviewed) of , estimated\npulmonary artery pressures are higher. A Corevalve prosthesis is now present.\n\n\n" }, { "category": "Echo", "chartdate": "2167-08-04 00:00:00.000", "description": "Report", "row_id": 104510, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for TAVI. Aortic valve disease. Chest pain. Left ventricular function. Mitral valve disease. Preoperative assessment. Prosthetic valve function. Right ventricular function. Valvular heart disease.\nHeight: (in) 68\nWeight (lb): 160\nBSA (m2): 1.86 m2\nBP (mm Hg): 154/78\nHR (bpm): 45\nStatus: Inpatient\nDate/Time: at 13:33\nTest: TEE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild spontaneous echo contrast in the body of the LA. No\nmass/thrombus in the LAA. Mild spontaneous echo contrast in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mildly depressed LVEF.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Simple atheroma in ascending\naorta. Simple atheroma in aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS\n(area <0.8cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mild mitral annular calcification. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Physiologic TR.\n\nGENERAL COMMENTS: Written informed consent was obtained from the patient. The\npatient was under general anesthesia throughout the procedure. No TEE related\ncomplications. The patient appears to be in sinus rhythm. Results were\npersonally reviewed with the MD caring for the patient.\n\nConclusions:\nPreimplant\n\nMild spontaneous echo contrast is seen in the body of the left atrium. No\nmass/thrombus is seen in the left atrium or left atrial appendage. Mild\nspontaneous echo contrast is present in the left atrial appendage. No atrial\nseptal defect is seen by 2D or color Doppler. Overall left ventricular\nsystolic function is mildly depressed (LVEF= 45 %). The right ventricular\ncavity is mildly dilated with mild global free wall hypokinesis. There are\nsimple atheroma in the ascending aorta. There are simple atheroma in the\naortic arch. There are simple atheroma in the descending thoracic aorta. The\naortic valve leaflets are severely thickened/deformed. There is critical\naortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is\nseen. Mild to moderate (+) mitral regurgitation is seen. Drs and\n was notified in person of the results on \n\n\nPost implant\n\nCorevalve seen in the aortic position. It appears well seated . There is 1- 2\n+ perivalvular regurgitation seen. Mild mitral regurgitation persists. Rest of\nexamination is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2167-08-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1253965, "text": " 9:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement, r/o effusion, ptx\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\TRANSCATHETER AORTIC VALVE IMPLANT (TAVI) PERCUTANEOUS APPROACH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with CoreValve\n REASON FOR THIS EXAMINATION:\n line placement, r/o effusion, ptx\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:06 P.M. ON \n\n HISTORY: 86-year-old man with core valve. Check line placement and possible\n complications.\n\n IMPRESSION:\n AP chest compared to :\n\n The right transjugular device is temporary pacer lead, and not a vascular\n line, and passes into the distal right ventricle and out of view. Supine\n positioning explains slight increase in pulmonary vascular caliber. Heart\n size is normal.\n\n Hyperlucency projecting over the right upper abdominal quadrant could be\n pneumoperitoneum on the supine positioning.\n\n Findings were discussed by telephone with Dr. at 9:30 a.m., 2 minutes\n following recognition of the findings. Atherosclerotic calcification in both\n carotid systems is heavy.\n\n\n" }, { "category": "Radiology", "chartdate": "2167-08-03 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1253789, "text": " 1:50 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CONGESTIVE HEART FAILURE\\TRANSCATHETER AORTIC VALVE IMPLANT (TAVI) PERCUTANEOUS APPROACH\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\TRANSCATHETER AORTIC VALVE IMPLANT (TAVI) PERCUTANEOUS APPROACH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with severe aortic stenosis\n REASON FOR THIS EXAMINATION:\n preop\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n COMPARISON: CT of the chest from .\n\n FINDINGS: Heart size is normal. Aorta is tortuous and calcified.\n Saber-sheath type configuration of the trachea suggests the possibility of\n COPD, and note is made of documented pulmonary emphysema on prior CT scan.\n Minimal linear areas of scar or atelectasis are present within the lower\n lungs, but there are no focal areas of consolidation or pleural effusion.\n Compression deformity in the lower thoracic spine is without change since the\n prior CT.\n\n IMPRESSION: No acute cardiopulmonary abnormality. Findings suggestive of\n COPD.\n\n" }, { "category": "ECG", "chartdate": "2167-08-10 00:00:00.000", "description": "Report", "row_id": 304480, "text": "Probable atrial fibrillation with a controlled ventricular response. One\nventricular premature contraction versus aberrantly conducted ventricular\ncomplex. Possible inferior wall myocardial infarction of indeterminate age.\nPoor R wave progression. Diffuse and non-specific ST-T wave changes. Compared\nto the previous tracing of the findings are similar.\n\n" }, { "category": "ECG", "chartdate": "2167-08-06 00:00:00.000", "description": "Report", "row_id": 304481, "text": "Atrial fibrillation with borderline controlled ventricular response rate and\nventricular premature complex. Probable prior inferior wall myocardial\ninfarction. Delayed R wave transition. Non-specific ST segment changes in the\ninferolateral leads. Compared to the previous tracing of the findings\nare similar.\n\n\n" }, { "category": "ECG", "chartdate": "2167-08-05 00:00:00.000", "description": "Report", "row_id": 304482, "text": "Atrial fibrillation with moderate ventricular response. Single ventricular\npremature contraction. Low voltage in the limb leads of unclear etiology.\nDiffuse non-specific ST-T wave abnormalities. Compared to the previous tracing\nof criteria for inferior wall myocardial infarction are not seen now.\nDiffuse non-specific ST-T wave abnormalities persist.\n\n" }, { "category": "ECG", "chartdate": "2167-08-03 00:00:00.000", "description": "Report", "row_id": 304646, "text": "Atrial fibrillation with a controlled ventricular response. Poor R wave\nprogression. Prior inferior wall myocardial infarction of indeterminate age.\nDiffuse non-specific ST-T wave changes. Compared to the previous tracing\nof the findings are similar.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2101-04-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1010416, "text": " 7:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess position of trach, assess PTX?\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p open trach\n REASON FOR THIS EXAMINATION:\n assess position of trach, assess PTX?\n ______________________________________________________________________________\n WET READ: JRCi WED 8:44 PM\n Trach midline without pneumothorax identified. RIJ in stable position. NGT\n below diaphragm with tip out of view. Increased vascular congestion and mild\n edema. Bilateral effusions.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the tracheal placement.\n\n Portable AP chest radiograph compared to obtained at 12:12 p.m.\n\n The tracheostomy was inserted in the meantime interval, demonstrated to be at\n the midline. The right internal jugular line tip is in superior SVC. The NG\n tube tip passes below the diaphragm, most likely terminating in the stomach\n although its tip is below the field of view. There is no appreciable change\n in the moderate cardiomegaly, prominent aorta especially at the level of the\n arch, bilateral perihilar opacities consistent with pulmonary edema have\n progressed in the meantime interval consistent with worsening of the volume\n overload/pulmonary edema. Bilateral pleural effusion is at least moderate.\n\n IMPRESSION:\n\n Tubes and lines as described.\n\n Interval worsening of pulmonary edema.\n\n Bilateral pleural effusions, at least moderate.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-04-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1010151, "text": " 11:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP ON \n\n COMPARISON: .\n\n HISTORY: 70-year-old man with endotracheal tube placement.\n\n FINDINGS:\n\n The endotracheal tube tip is approximately 5 cm from the carina. The right\n internal jugular line terminates in the proximal SVC. The heart is\n persistently mildly enlarged. There is slight decrease in the pulmonary edema\n seen in both lungs. Minimal left bilateral pleural effusion is again noted\n with no change.\n\n IMPRESSION:\n 1. ET tube placement in satisfactory location with less pulmonary edema.\n 2. Persistent cardiomegaly and effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-04-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009496, "text": " 8:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary edema. assess for underlying infiltrate\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with\n REASON FOR THIS EXAMINATION:\n pulmonary edema. assess for underlying infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY .\n\n COMPARISON: .\n\n INDICATION: Pulmonary edema.\n\n Indwelling devices are unchanged in position. Heart remains enlarged.\n Pulmonary edema has substantially improved. Pleural effusions are not\n considerably changed.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-04-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1011289, "text": " 3:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p dht placement\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with\n REASON FOR THIS EXAMINATION:\n s/p dht placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate Dobbhoff tube placement.\n\n COMPARISON: .\n\n PORTABLE CHEST RADIOGRAPH: Dobbhoff tube is seen coiled within the esophagus.\n The distal tip is superior to the visualized neck. Right-sided central venous\n line is seen with tip projecting over the SVC. Otherwise, no significant\n change is seen compared to prior study, with pulmonary edema, bilateral\n pleural effusions and basilar atelectasis again noted.\n\n IMPRESSION: Dobbhoff tube malpositioned, coiled within the esophagus.\n Discussed with immediately following completion of the study.\n\n" }, { "category": "Radiology", "chartdate": "2101-04-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1011368, "text": " 9:06 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval picc placement\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with\n REASON FOR THIS EXAMINATION:\n eval picc placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old male with PICC placement.\n\n COMPARISON: .\n\n SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH: A left PICC line has been placed\n with tip terminating over the junction of the left brachiocephalic vein and\n SVC. A right internal jugular catheter tip terminates within the upper SVC.\n Tracheostomy tube is unchanged. The cardiomediastinal silhouette is stable.\n There is stable retrocardiac and left upper lung opacity. The apparent mild\n increase in density within the right mid lung opacity could be related to\n positional change.\n\n IMPRESSION: Left PICC tip terminating at junction of brachiocephalic vein and\n SVC. The catheter can be advanced 3-5 cm.\n\n" }, { "category": "Radiology", "chartdate": "2101-04-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1011307, "text": " 5:35 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: check DHT placement\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with\n REASON FOR THIS EXAMINATION:\n check DHT placement\n ______________________________________________________________________________\n WET READ: KYg WED 6:14 PM\n Right IJ CVL terminates in the svc. trach in stable position. NG tube is\n curled on itself and terminates in the mid esophagus. left retrocardiac\n opacity, bilateral effusions and pulmonary edema persists not significantly\n changed. \n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY AT 1756\n\n COMPARISON: Previous study of same day at 1601.\n\n INDICATION: Dobbhoff tube placement.\n\n Feeding tube is coiled within the esophagus with the distal tip projected\n cephalad several centimeters below the carina. Other indwelling devices are\n unchanged in position, and the remaining portion of the chest appears\n unchanged since the recent examination of less than two hours earlier.\n was contact to discuss these findings on .\n\n\n" }, { "category": "Radiology", "chartdate": "2101-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1010835, "text": " 10:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess lung fields\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p trach, with hypoxia\n REASON FOR THIS EXAMINATION:\n assess lung fields\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Hypoxia.\n\n CHEST:\n\n The current films are compared with those of . The bases are not\n included on this chest x-ray. There is increased opacification in both right\n and left bases and some perihilar edema is again seen indicating a worsening\n of the failure since the prior chest x-ray.\n\n IMPRESSION: Worsening failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-04-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009663, "text": " 9:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess chf/effusions\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p endovascular ao stent post-op pulm edema\n REASON FOR THIS EXAMINATION:\n assess chf/effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old man, postoperative evaluation following endovascular\n stent.\n\n COMPARISON: .\n\n SINGLE SEMI-UPRIGHT VIEW OF THE CHEST AT 10:10 A.M.: An endotracheal tube\n terminates approximately 9 cm from the carina, and advancement of\n approximately 4 cm is recommended for standard positioning. The right\n internal jugular catheter terminates in the proximal SVC, and a nasogastric\n tube extends below the diaphragm.\n\n There has been a substantial interval improvement in pulmonary edema, with\n minimal remaining pulmonary vascular congestion. There is no pleural\n effusion, and no new foci of air space consolidation. Bibasilar atelectasis\n has also undergone interval improvement. Mild cardiomegaly is unchanged, and\n there is no hilar or mediastinal enlargement.\n\n IMPRESSION: Improved pulmonary edema and bibasilar atelectasis. Persistent\n cardiomegaly with vascular congestion.\n\n" }, { "category": "Radiology", "chartdate": "2101-04-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1009037, "text": " 11:25 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: asess line placement r/o PTX\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p EVAR s/p new central line\n REASON FOR THIS EXAMINATION:\n asess line placement r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:25 A.M., \n\n HISTORY: New central venous line. Rule out pneumothorax.\n\n IMPRESSION: AP chest compared to :\n\n Right internal jugular line tip projects over the mid SVC. Mediastinal\n widening is unchanged. There is no pneumothorax or pleural effusion. ET tube\n in standard placement, traversing what may be an area of mild mid tracheal\n narrowing. New geographic opacity in the left mid lung could be fluid trapped\n in the fissure or pleural thickening. Pneumonia is less likely. Moderate\n cardiomegaly is longstanding. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-04-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009778, "text": " 7:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for pulmonary edema, pneumothorax\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with respiratory distress on the vent\n REASON FOR THIS EXAMINATION:\n Evaluate for pulmonary edema, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE\n\n HISTORY: Respiratory distress, evaluate for edema and pneumothorax.\n\n FINDINGS: Two Frontal views of the chest are compared to prior study .\n Current exam is significantly limited and that the lower chest is excluded on\n both radiographs. Right internal jugular central venous catheter is\n unchanged. Endotracheal tube terminates at the level of the clavicular heads.\n Cardiomediastinal silhouette is stable. There has been interval increase in\n interstitial markings bilaterally, consistent with worsening CHF. Bony\n structures unchanged.\n\n IMPRESSION: Worsening CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-04-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1010520, "text": " 1:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess dophoff placement\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p Ao evs/trach and now dophoff placement\n REASON FOR THIS EXAMINATION:\n assess dophoff placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Feeding tube placement.\n\n Feeding tube courses below the diaphragm, but the tip is not included on this\n radiograph. Tracheostomy tube and central venous catheter are unchanged in\n position. Pulmonary edema has markedly improved, and pleural effusions appear\n slightly smaller.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-04-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009942, "text": " 6:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n WET READ: KYg SUN 7:43 PM\n ETT TERMINATES 4.4CM ABOVE THE CARINA. NO PTX. DIFFUSE BILATERAL AIRSPACE\n OPACITY IS CONSISTENT WITH PULMONARY EDEMA NOT SIGNIFICATNLY CHANGED FROM\n PRIOR RADIOGRAPH. LEFT RETROCARDIAC OPACITY PERSISTS. RIGHT IJ TERMINATES IN\n THE SVC. NG TUBE PRESENT. \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Endotracheal tube placement.\n\n A single portable radiograph of the chest excludes the bilateral costophrenic\n angles. Support lines are unchanged from . Increased opacity\n involving both lungs is similar to that seen on . There are probably\n small bilateral pleural effusions. No pneumothorax is evident. Trachea is\n midline. There is a nasogastric tube present with its tip in the stomach.\n\n IMPRESSION:\n\n Persistent CHF.\n\n Support lines in place.\n\n" }, { "category": "Radiology", "chartdate": "2101-04-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009149, "text": " 6:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tube position, ? pulmonary process, pulm edema?\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with COPD, s/p EVAR. Now intubated due to acute resp failure\n REASON FOR THIS EXAMINATION:\n tube position, ? pulmonary process, pulm edema?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: COPD status post EVAR, now intubated due to respiratory failure.\n\n FINDINGS: In comparison with study of , there is diffuse increase in\n ill-defined pulmonary vessels, consistent with overhydration or congestive\n failure. Enlargement of the cardiac silhouette persists. The hemidiaphragms\n are not sharply seen and the possibility of bilateral pleural effusion should\n be considered.\n\n Endotracheal and right IJ catheter remain in place.\n\n IMPRESSION: Increasing volume overload or congestive failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-04-05 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1009154, "text": " 7:38 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with acute hypoxia, hypercarbia\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old male with acute hypoxia and hypercarbia, to rule out\n pulmonary embolism.\n\n TECHNIQUE: CT of the chest was performed without intravenous contrast\n followed by CT of the chest post administration of intravenous contrast, and\n reconstructions were performed in the axial, sagittal and coronal planes.\n\n COMPARISON: With chest radiograph of .\n\n FINDINGS:\n\n CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST:\n\n There are bibasilar effusions present with passive atelectasis at the lung\n bases. There is multifocal consolidation present scattered throughout both\n lungs. There are scattered pulmonary nodules with the largest measuring 11 x\n 9 mm in the right middle lobe. There is emphysematous change present in the\n upper lobes. There is a nasogastric tube with the tip in the stomach. There\n is an ET tube with its tip in the upper intrathoracic trachea.\n\n There is no central or segmental pulmonary embolism. There is no aortic\n dissection. Atherosclerotic changes are present in the aortic arch.\n Atherosclerotic changes are also present in the coronary arteries.\n\n The visualized liver and spleen appear unremarkable.\n\n MUSCULOSKELETAL:\n\n Multilevel degenerative changes are present in the spine. There are no\n worrisome bone lesions.\n\n CONCLUSION:\n\n 1. No pulmonary embolism or aortic dissection. Atherosclerotic changes are\n present in the aortic arch as well as the coronary vasculature.\n\n 2. Multifocal consolidation, bibasal effusions and scattered subcentimeter\n pulmonary nodules as described above. A chest CT in three months is\n recommended to ensure stability/resolution of the pulmonary nodules.\n\n The findings were added to the critical results communication dashboard.\n (Over)\n\n 7:38 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2101-04-12 00:00:00.000", "description": "Report", "row_id": 1620692, "text": "N: ALERTED, ANXIOUS/FRUSTRATED. FOLLOWS COMMANDS AND ATTEMPTS TO COMMUNICATE. MAKES NEEDS KNOWN. REQ. VERSED/FENTANYL FOR ANXIETY AS SBP INCREASES DRAMATICALLY.\n\nR: COPIOUS SECRETIONS-THICK/YELLOW. SPUTUM SENT AT 0300. RHONCHI TO CLEAR WITH SATS 100%. PS 40% TUBE RETAPED\n\nCV: NSR W/PAC'S PVC RARE TO OCCAS. HR 70-80 PULSES BY DOPPLER..VERY LARGE LEGS DIFFICULT TO LOCATE DP KEEP SBP <140 HYDRALAZINE Q6H PRN\nLAST GIVEN AT 0400 AFEBRILE\n\nGI/U OGT W/NUTREN PULMONARY 50HR (GOAL) LASIX WITH EXCELLENT RESULTS. ABD SOFT NTND\n\nIV: TLC, RIGHT RADIAL ALINE\nINSULIN 4U HR, KVO\nREC'D K+ WITH LASIX DOSE\n\nENDO: INSULIN GTT WITH SSI...SUGARS 91-117\n\nPLAN: TRACH/PEG SHORTLY/ MONITOR BP AND ANXIETY\nSKIN NURSE TO SEE TODAY. PT NEEDS BUTTOCKS ASSESSED FOR APPROPRIATE TREATMENT\n" }, { "category": "Nursing/other", "chartdate": "2101-04-12 00:00:00.000", "description": "Report", "row_id": 1620693, "text": "resp care\nPt initially on psv8/peep8 and 40%. Volumes to 400cc and pt c/o sob. Suct/mdi with no improvement in volumes. Psv inc to 12 with better volumes 500-800cc. RR 20's.BS coarse bil. Suct frequently thick pale yellow sput.Alb/atro/ qvar given as needed. RSBI done=56.Will cont to follow with freq mdi/suct.Will cont with psv wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-12 00:00:00.000", "description": "Report", "row_id": 1620694, "text": "Pt has been agitated all AM, cannot get comfortable, wiggling in bed every time after get pull up in bed, MAE's, following commands consistently; SR 70's-80's with BBB, SBP 140's-150's, 10 mg IV hrdralazine given with minimal effect, pt getting more agitated & restless, 2mg versed & 100mg fentanyl given with good effect, pt calmed down, HR 70's, SBP 100's-110's, lung sound clear, dim @ bases, suctioned with copious amount thick tan secretion, extubated & put on BiPAP per vascular team, awared of CPAP 5/0 ABG, after extubation, pt went into rapid afib 130's, hypertensive 170's, acute resp distress, NP & MD @ bedside, 10 mg IV hydralazine given x2, 5 mg IV lopressor x1, 40 mg IV lasix x1, 1 mg IV morphine x1, NTG gtt started for BP control, cont on BiPAP for now\n" }, { "category": "Nursing/other", "chartdate": "2101-04-12 00:00:00.000", "description": "Report", "row_id": 1620695, "text": "Neuro: MAE; FC; afebrile; 100mcg Fentanyl & 2mg Versed PRN pain/agitation w/ good effect;\n\nCV: SR 60's-70's; sb/p 120/2-140's; CVP 14-17; 3+ edema; doppler pulses;\n\nResp: ext. @ 1045 & re-int. 1145 d/t resp dx; #8 taped @ 22; AC 16, Fi02 40%, PEEP 8, TV 650; Sat 91-94%; lungs clear bil, dim. bases; sx thick, tan, small amt. secretions via in-line sx cath; trach scheduled TF tomorrow;\n\nGI: OGT w/ Nutren Pulm w/ Beneprotein @ goal rate 60ml/hr, min. residuals; + bowel sounds; 0 BM; after midnight;\n\nGU: foley to gravity w/ clear, yellow drainage; 40mg Lasix Q8hr.;\n\nIV: Rt IJ TLC; Rt radial a-line; Heparin @ 1000units/hr (turn off @ 4am tomorrow); Insulin gtt per protocol; D5W @ KVO;\n\nSkin: Rt LE injury w/ dsg - D&I; coccyx red/purple, deep tissue injury - skin care RN consulted;\n\nLab/Endo: repleted K+; finger sticks per protocol;\n\nPlan: Trach tomorrow; keep sb/p <140; cont. pulm. toilet; tx labs as needed; meds per pain/agitation; after midnight; Heparin gtt off @ 4am tomorrow;\n" }, { "category": "Nursing/other", "chartdate": "2101-04-11 00:00:00.000", "description": "Report", "row_id": 1620690, "text": "Respiratory Care: Pt. currently on AC/20/650/40%/+10. ABG 7.42/44/121/30/4, FiO2 decreased to 40%, tolerating well. Lung sounds decreased with scattered rhonchi. Suctioned for moderate amounts of thick yellow to green colored secretions. MDI's given as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-11 00:00:00.000", "description": "Report", "row_id": 1620691, "text": "Neuro: Propofol off. Pt intitially calm and following commands. As day increased pt more agitated and frustrated with staff inability to read lops. ALso very fidgety in bed. Requiring prn fentanyl and versed boluses. , \nCv: Pt in SB this am with runs frequent pac's and pvc's noted. As sedation wore off rate increased. Pt given lorpessor 15mg po. This afternoon pt had hypertensive epidose and rate increased to low 100's. then switched into afib. Pt given sedation, hydralazine, and lopressor. Improved hemodyanamics. Cont to have frequent pac's and rare pvc's. dopplerable pulses.\nResp: Lungs dim at bases, pt orally intubated. Pt vent weaned to cpap 5/5 fio2 40%. Pt tolerated well initially with compensated resp acidosis. With above mentioned episode pt desated and became acidodic rested x1 hr on AC now back on cpap. Sx for thick yellow with plugs to send cx with next sx. Pt has strong cough\nGi: OGt with TF at goal, nutren pulm at 50cc/hr. Minimal residuals. Abd obese but soft. NO BM. hypoactive bs\nGU: UOP with good response to lasix. foley patent\nSkin: Coccyx with lg purplish/black decub. Pt already followed by skin nurse on per staff not new. criticare applied. SKin nurse to be called to follow in am. Pt turned frequently but in constant motion on bed. ALoe vesta to b/l legs. DSD intact\nSocial: wife and daughter into visit. Spoke with vascular team about ? trach/peg\nEndo: cont on insulin gtt per protocol\nPlan: cont assess hemodynamics/resp status. send sputum cx. call skin nurse for follow up. ? trach peg vs extubation. follow q1hr bs\n" }, { "category": "Nursing/other", "chartdate": "2101-04-12 00:00:00.000", "description": "Report", "row_id": 1620696, "text": "Respiratory Care Note\nPt received on PSV 8/8 as noted. BS diminished throughout. Pt suctioned for moderate amts thick, yellow secretions. Pt placed on SBT 5/0 from 8:50am to 10:25am - pt tolerated well with VT ranges 600-700 and RR 20-25. Subglottic suctioning done prior to extubation. Pt has a positive cuff leak test. Pt extubated to NIV as noted at 10:45am. Pt became diaphoretic and went into A-fib from increased WOB. PaCO2 after 30min was 74 and 45min after extubation 87. Pt re-intubated over a bougie with a #8.0ETT taped at 22cm at lip. ETCO2 had a positive color change and BS were equal. Pt placed on AC as noted - ABG reveals compensated respiratory acidosis with a PaO2 of 68. Plan to continue on current settings at this time and possibly trach tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-13 00:00:00.000", "description": "Report", "row_id": 1620697, "text": "CVICU NPN 1900-0700\nNeuro: , , afebrile, fentanyl and versed prn for pain and agitation with good effect. Able to communicate needs.\n\nResp: Pt remains vented, lungs clear and diminished, suctioning moderate amounts of thick tan/yellow sputum.\n\nCV: SP 60's-100, rare ectopy, one episode of ST 120's, self limiting. Peripheral pulses via dopplar. Heparin gtt off at 0000 for trach today. Potassium repleted.\n\nGI: OGT clamped, TF off at 0000 for trach today, + bowel sounds, abdomen obese, non-tender.\n\nGU: Foley to gravity, draining clear yellow urine, receiving lasix 40 mg IV q8h.\n\nEndo: Regular insulin gtt presently at 6 units/hr.\n\nSkin: See vareview, awaiting skin care nurse consult.\n\nPlan: Trach today, keep SBP<140, wean vent as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-13 00:00:00.000", "description": "Report", "row_id": 1620698, "text": "RESP CARE NOTE\nPT REMAINED ON AC 16/650/+8/40% OVERNIGHT. BS COARSE T/O. SUCTIONING MOD-LG AMTS OF THICK YELLOW SECRETIONS. ALB/ATR MDI GIVEN Q4 AND QVAR . NO MORNING RSBI DUE TO OR FOR TRACH.\nPLAN: TRACH, CONT MDI'S AS ORDERED.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-13 00:00:00.000", "description": "Report", "row_id": 1620699, "text": "7a-7p\nNeuro: Pt , mae's, follows commands. Pt mouthing words. C/o anxiety once during shift versed given with good relief.\n\nCV: sr with short burst of sb to 55, np aware lopressor dose decreased to 12.5mg tid. Goal sbp<140, prn hydralazine as needed. pulses dopperable\n\nResp: Ls clear/dim, rr20's, Recieved on ac 40%, changed to cpap see flowsheet for abg, changed np to increase c02, due to hx of copd. Awaiting trach this afternoon.\n\nGI/GU: abd obese, + bs, since mn for or today, foley to gravity draining adequate amounts of urine.\n\nEndo: regular insulin drip\n\nSkin: skin care nurse in to assess legs, barrier cream tid apply to legs bilat, sacrum continue with criticaid barrier cream, when pt is in chair needs roho cushion.\n\nSocial: wife called per pt and updated on poc today\n\nPlan: for trach in or today, skin care consult/reccomendations, wean insulin drip when tube feeds restarted or feeding as pt tolerates, sbp<140 per team.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-04-13 00:00:00.000", "description": "Report", "row_id": 1620700, "text": "Resp Care\nPt currently in OR for trach placement. Vent settings weaned to PSV prior to OR pt tolerated well abgs wnl. BLBS diminished, suctioned for mod amt thick yellow secretions, mdis given per order.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-10 00:00:00.000", "description": "Report", "row_id": 1620688, "text": "See and carevue for detailed documentation\n\nNeuro: Rec'd patient on propofol, follow commnads, moving with good strength. Patient extubated, oriented x2-3 (difficulty with time) but disorieted to environment. Aware he is in hospital but unable to recall RN name, asking for his mother to be called, stating he was talking with people that were not present. Uncooperative with care at times. Continually trying to reposition self, unable to get comfortable. Fentnyl versed given with some improvement. Patient placed on non invasive CPAP, pulling off mask and then more lethargic over time. Reintubated, now sedated with propofol.\n\nResp: Rec'd on vent, BS clear, good aeration. RSBI 30, extubated to face tent. Patient pulling at mask. Change to NC with SAT >91. Moist productive cough, good aeration. Initial ABG stable. Thru afternoon patient increasingly restless. Patient with tachycardia, hypertension and acute desat to 60's, placed on non rebreather with SAT to 70. Placed on CPAP. CO2 rising on abg, Patient pulling off mask. Fentanyl, versed given with slight improvement, remained restless. PaCO2 continued to rise despite vent support. Reintubated without difficulty. Sedated with propofol. TOl ETT well.\n\nCV: Rec'd in SB with rare PAC/ PVC. Extubated with improved HR. Patient became tachy with hypertension with desat. Now SB with PVC with ETT in place, on proofol. Patient afebrile. Potassium repleted thru day. Patient pulled out aline, replaced without difficulty.\n\nGI/Endo: Feeds off off extubation, Insulin gtt off briefly, restart.\nMaintained per CVICU protocol.\n\nGU: Foley to gravity with good urine output s/p lasix.\n\nSocial: Wife updated by phone in am. Attempt to call in afternoon, nessage left without return. CVICU team to call and update re reintubation.\n\nPlan: Continue cardiopulmonary monitoring. Maintain ETT, adjust vent per abg. Keep sedated with propfol overnight.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-11 00:00:00.000", "description": "Report", "row_id": 1620689, "text": "S/P ENDOVASCULAR AA REPAIR ON COMPLICATED BY RESPIRATORY FAILURE REQUIRING REINTUBATION ON AND .\n\nNEURO: ORALLY INTUBATED, SEDATED ON PROPOFOL GTT AT 30-40MCG/KG OVER NIGHT. ATTEMPTING TO OPEN EYES ON COMMAND, MAE, FOLLOWS OTHER COMMANDS. INTERMITTENT DOSES OF FENTANYL IVP FOR PAIN CONTROL.\n\nPULM: CMV MODE, VT 650, FIO2 0.5, PEEP 10, RATE 20, ABG WNL(PO2 121), FIO2 DECREASED TO 0.4 AT 0430. LUNGS COARSE, SX'D FOR THICK YELLOW SECRETIONS.\n\nCV: SINUS BRADY, HR 39-50, NO BETABLOCKERS GIVEN THIS SHIFT DT BRADYCARDIA. OCCASIONAL PAC'S, RARE PVC. HEMODYNAMICALLY STABLE, + PEDAL PULSES DOPPLED X 4. 4+ LE EDEMA. CVP ~10.\n\nENDO: INSULIN GTT FOR BS CONTROL.\n\nGI: ABDOMEN OBESE, + BS. OGT PLACEMENT CHECKED Q4H, NUTREN PULMONARY TUBE FEEDS STARTED AT , NO RESIUDUALS, ADVANCED TO GOAL OF 50CC/HR.\n\nRENAL: CREATININE PENDING FOR THIS AM, LAST 1.3. FAIR RESPONSE TO LASIX 40MG IV BID. LYTES REPLETED PER LABS.\n\nSOCIAL: WIFE AND DAUGHTER VISITED AT , VOICING CONCERN OVER NOT BEING INFORMED OF CHANGES IN PT'S STATUS. UPDATED BY RN THAT PT WAS STABLE, EXTUBATED, CAME IN TO VISIT AND FOUND HIM REINTUBATED. DAUGHTER SPOKE OPENLY TO VASCULAR RESIDENT ABOUT THESE CONCERNS.\n\nPLAN: WEAN OFF PROPOFOL, ATTEMPT TO WEAN AND EXTUBATE FROM VENT AGAIN TODAY. CONTINUE NUTRITIONAL SUPPORT. HOLD BETABLOCKERS WHILE HR IS SO LOW. ? HYDRALAZINE FOR BP CONTROL IF NEEDED. ? START ACE. EMOTIONAL SUPPORT OF FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-06 00:00:00.000", "description": "Report", "row_id": 1620670, "text": "Neuro:Recieved patient lightly sedate on fentannyl & versed per csurg pa/ md. Answers questions appropriately with nonverbal cues.MAE and PERRL.\n\nCV:SB/NSR mid 50's-80's ocassional PVC,rare triplets/couplets.SBP<140 at rest. With exertion SBP increased 150-180 successfully tx with titrated doses of on/off IV Nitroglycerin .MAP>60,CVP dampened . Peripheral pulses + by doppler bilaterally,cool csm.\n\nResp:Received patient on SIMV + PS, 550 x28/PEEP12/IPS 5/FiO2 .50.Increased metabolic alkolosis->decreasing RR 24 NP.PaO2 improved 90s-80, from 70s. O2 sat >98.Suctioned small amounts of thick yellow/ tan sputum.Sputum spec sent.Upper lobes clear and lower lobes diminished bilaterally.\n\nGU/GI:diuresed well after IV Lasix given u/o >40ml/hr.OGT drained small amounts of bilious drainage to continuous low wall suction.Hypoactive bowel sounds.Abdomen is obese,soft,nontender.No Bm for several days MD. \n\nPain: No c/o pain.\n\nID:Low grade max temp 99.9. Tx IV Zosyn. cx pnd\n\nSkin:LE edematous bilaterally due to PVD + venous statsis-> open to air, critic aid applied, adaptic to draining excoriated venous stasis ulcer on RLE. Bilateral femoral wounds not draining and clean. excoriated skin in both groins tx fungugal cream.Large red/purple decub on coccyx open to air-critic ointment.Patient rotated by the bed every 20 minutes.Small bleeding mole on upper back covered by dsd dressing. elevate heels off bed\n\nPlan: Monitor neuro status,titrate IV Nitroglycerin to keep SBP<140,wean sedation & wean ventilator as tol,monitor ABG's, hemodynamic status and ? more diurese with lasix,wound care RLE,Monitor bowel/nuitrional status status.\n\n" }, { "category": "Nursing/other", "chartdate": "2101-04-20 00:00:00.000", "description": "Report", "row_id": 1620731, "text": "CVICU NPN 0700-1900\nNeuro: , following commands, mouths words, able to communicate needs effectively, afebrile, PERRL, denies pain. OOB to chair x 1 hour with standby assist of 2, tolerated well. Presently not pulling at lines, soft limb immobilizers off for now.\n\nResp: Has been on trach mask for entire shift, tolerating well, O2 sats >90%. Suctioning large amounts of thick bloody sputum, very good cough effort, trach care done.\n\nCV: NSR with rare PVC's, SBP 100's-140's, unable to give po meds at present (no FT). Heparin gtt continues at 2400 units/hr.\n\nGI: FT out, second attempt to insert Dobhoff this afternoon, awaiting CXR results. Abdomen obese, non-tender, + bowel sounds.\n\nGU: Foley draining adequate amounts of clear yellow uring, receiving IV lasix tid.\n\nEndo: Scheduled glargine and sliding scale regular insulin per orders.\n\nSkin: Stage 1 on coccyx, no change, criticaid applied. See careview for detailed skin report.\n\nSocial: Wife phoned today, informed her of transfer to TCU tomorrow.\n\nPlan: Restart TF and meds when Dobhoff placement confirmed. PICC placement (1st on list for AM), continue TM & PMV trials, monitor VS and electolytes. Transfer to tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-10 00:00:00.000", "description": "Report", "row_id": 1620685, "text": "S/P ENDOVASCULAR AA REPAIR ON COMPLICATED BY RESPIRATORY FAILURE REQUIRING REINTUBATION . FAILURE TO WEAN D/T RUNS OF VT ON , NOW BRADYCARDIC.\n\nNEURO: ORALLY INTUBATED, SEDATED ON PROPOFOL GTT. MAE SPONTANEOULSY AND TO COMMANDS, FOLLOWS COMMANDS ON 30 MCG/KG PROPOFOL.\n\nPULM: RESTING FOR NIGHT ON CMV MODE, FIO2 0.5, VT 650CC, RATE 20, PEEP 10, ABG WNL. NO VENT CHANGES THIS SHIFT. LUNGS CLEAR THROUGHOUT, MINIMAL THICK TAN SECRETIONS WITH SXING.\n\nCV: SINUS BRADY 38-46 BRIEF RUNS(3-5 BEATS) ? ATRIAL FIB, RARE MFPVC. HEMODYNAMICALLY STABLE OFF PRESSORS. EXTERNAL PACING PADS REMAIN IN PLACE. BETABLOCKER HELD. R RADIAL ALINE POSITIONAL, DAMPENED, LEAKING BUT ABLE TO ASPIRATE BLOOD FROM LINE. PEDAL PULSES DOPPLED X 4.\n\nENDO: INSULIN GTT STARTED FOR BS 187-220 AFTER SC DOSE INSULIN.\n\nGI: ABDOMEN OBESE, SOFT, + BS. OGT PLACEMENT CHECKED Q4H, NUTREN RENAL TUBE FEED ADVANCED 10CC Q6H. NO RESIDUALS.\n\nRENAL: BUN 22/CREATININE 1.2. HUO > 50CC/HR.\n\nSOCIAL: WIFE AND DAUGHTER VISITED UNTIL .\n\nPLAN: WEAN OFF PROPOFOL THIS AM, ATTEMPT TO WEAN FROM VENT AND EXTUBATE. HOLD BETABLOCKERS UNTIL HR IMPROVED. KEEP SBP < 140. REWIRE ALINE TODAY. ? RESUME LASIX.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-04-10 00:00:00.000", "description": "Report", "row_id": 1620686, "text": "Respiratory Care: Pt remains on AC20/650/50%/+10. No vent changes during shift. Breath sounds decreased with occasional rhonchi. Suctioned for small to moderate amounts of thick tan secretions. AM abg:7.42/49/98/33/5, MDI's given as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-10 00:00:00.000", "description": "Report", "row_id": 1620687, "text": "Resp. Care Note\nPt received intubated and vented on AC settings as charted on resp flowsheet. RSBI 30. Pt weaned to PSV 5 peep 8 due to pt's size. ABG's good,+cuff leak. Decision to extubate. Pt initially placed on 70% face tent and transitioned to NP at 6L due to pt pulling mask off. Pt has O2 at home at 4L. Pt did well initially but became acutely SOB, diaphoretic. Placed on NIV and appeared more comfortable, less labored. ABG's failed to improve and pt reintubated with 7.5ETT secured at 22 lip. Placed on AC settings that pt was received on. MDIs given as ordered. Cont current settings, follow ABg's.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-21 00:00:00.000", "description": "Report", "row_id": 1620732, "text": "Respiratory Care\nPt presented at the beginning of the shift, wearing a trach collar at 95% FiO2, with blood being coughed out of trach. Pt had normal respiratory drive, with no distress. Pt was then put on vent for overnight rest, tolerated well. Pt had desaturation episode, where PEEP was raised to achieve SpO2 readings in the range of 92-95%. Lung sounds- Course bilaterally, diminished at the bases. Pt still had arterial blood being suctioned out of RN and MD notified. Albuterol/atrovent MDI given, Pt to wean off vent as tolerated, con't current support.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-15 00:00:00.000", "description": "Report", "row_id": 1620708, "text": "7a-7p\nNeuro: Pt , oriented x3 with passimir valve on, mae's follows commands. Pt c/o pain at trach site roxicet given with good relief.\n\nCV: sr with bbb, also flips in/out of sr with 1st degree block, and afib, heparin drip for afib/coumadin given. Dopplerable pulses, goal sbp<140, lopressor dose increased to 25mg, and iv lopressor given. Lytes repleted\n\nResp: Pt recieved on trach collar, Sats 93%, np sats >90 acceptable. Ls coarse/dim, thick secretions sx for thick yellow secretions. Speech and swallow in to assess pt, passimir valve placed. Pt's sats dropped to 80's, rr in 40's sx, sats still remain in 80's. Pt ambu bagged by resp, abg drawn see flowsheet, np aware, placed back on vent see flowsheet. Attempted trach collar later in afternoon, did not tolerate, placed back on vent see flowsheet.\n\nGI/GU: abd obese, dopoff flushed with 250ml of free water every four hours for sodium 158, foley to gravity draining adequate amounts of urine, diuresing well from lasix. Tube feeds continue until goal.\n\nEndo: regular insulin sliding scale\n\nSkin: see flowsheet, continue criticaid to sacrum, barrier cream to bilat extremities, and ? vascular to apply una boots.\n\nSocial: wife called updated on poc\n\nPlan: wean to trach collar trials as pt tolerates, skin care, pulmonary toilet, Heparin drip/coumadin.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-04-14 00:00:00.000", "description": "Report", "row_id": 1620705, "text": "7a-7p\nNeuro: Pt , mae's follows commands. Pt c/o pain roxicet given down og tube, Propofol off fentanyl/versed d/c'd.\n\nCV: sr with 1st degree av block flips in and out of bbb, and short bursts of afib. Had some episodes of sb to 50's, propofol d/c'd sb subsided. Lopressor po/iv given also for sbp 160's, goal sbp<140. Dopplerable pulses\n\nResp: ls clear dim at bases, rr 20's, pt had trach done yesterday , trach care done, sx for thick yellow secretions, and some bloody tinged. Also expectorating secretions. Tolerating trach collar since 0900. Sats>90 Np acceptable.\n\nGI/GU: og tube d/c'd, dopoff placed np , ok to use np. Tube feeds restarted, continue h2o flushes for elevated sodium. foley to gravity draining adequate amounts of urine. Diuresing well from lasix.\n\nEndo: regular insulin drip per cvicu protocol\n\nSkin: wound care nurse reccomendations continue criticaid to sacrum on bari air, roho cushion while in chair, barrier cream tid to legs for moisture, ? with vascular on stockings for legs.\n\nSocial: wife called updated on poc\n\nPlan: Continue trach collar as pt tolerates, skin care, pt, sbp<140. Pain mgmt.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-15 00:00:00.000", "description": "Report", "row_id": 1620706, "text": " B: 7p-7a\nneuro: a+ox3, pt communicates by mouthing words, or rarely writing words. mae, follows commands, assists w/ turns, perrlaa\n\ncv: sr w/ BBB 65-95, no ectopy, sbp 110-150, afeb\n\nresp: right lung coarse thru all lobes, left upper lobe clear, left lower lobe dim, on trach collar per pt preference, fi02 increased to 60% for spo2 88-89%, goal sp02>90% pa02>70, strong productive cough of blood-tinged sputum, suctionned for large amts thick yellow sputum\n\ngi: abdomen obese, bowel sounds present, tolerating tf w/ no residual, currently advancing tube feeds per order, insulin gtt restarted for rising sugars-currently off r/t blood sugar 78 this am\n\ngu: foley to gravity draining clear yellow urine, lasix 40 mg iv once w/ good response\n\nlabs: stable\n\nassess: stable\n\nplan: advance tf to goal (60ml/hr), start lantus in am, to rehab once able\n" }, { "category": "Nursing/other", "chartdate": "2101-04-15 00:00:00.000", "description": "Report", "row_id": 1620709, "text": "Resp Care\nPt remains trached with #8.0 portex. Pt recieved on 50% TM tolerating well speech and swallow evaluation done then pt began to desat into low 80 with incresed WOB and increased lethargy, abg drwan showed resp acidosis so pt was placed back on vent. later this afternoon pt was trailed on TM again however he tolerated <10minutes before desatting with increased WOB. PT currently on PSV 10/8 50% satting >90%. BLBS diminished, suctioned for mod amt thick yellow secretions, mdis given. will continue vent support overnight possibly attempt TM again in the morning.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-16 00:00:00.000", "description": "Report", "row_id": 1620710, "text": "S/P ENDOVASCULAR AA REPAIR ON COMPLICATED BY ONGOING RESPIRATOR FAILURE REQUIRING REINTUBATION X 3 BEFORE BEING TRACHED ON .\n\nNEURO: , , FOLLOWS COMMANDS. SMILING, LAUGHING. COMMUNICATES BY MOUTHING WORDS AND WRITING. COOPERATIVE WITH CARE. ROXICET 5ML X 1 FOR PAIN CONTROL. AWOKE DISORIENTED AT 0500, TRYING TO PUT LEGS OVER RAIL, REORIENTED AND COOPERATIVE BUT NOW WANTS TO \"STAND\" HAVE \" JUICE\" \"MILK\".\n\nPULM: TRACHED, CPAP MODE ALL SHIFT, FI02 0.5, PS 10/PEEP 8. PCO2 50, PO2 79, SATS 90-93%. NO VENT CHANGES. LUNGS FAIRLY CLEAR, SUCTIONED FOR SMALL-MODERATE AMOUNTS THICK YELLOW SECRETIONS.\n\nCV: SINUS RHYTHM WITH BBB, ? JUNCTIONAL RHYTHM AT TIMES, HR 64-90. SBP WNL. RIJ MULTILMEN OOZING SLIGHTLY AT SITE. R RADIAL ALINE DAMPENED, SITE RED, LINE DC'D. HEPARIN GTT INCREASED TO UNITS/HR AT 0430 FOR PTT 37.6. CVP ~ 10.\n\nENDO: Q6H SSRI COVERAGE PER ORDER. 8 UNITS REGULAR INSULIN SC AT 0100 FOR BS 210.\n\nGI: OBESE ABDOMEN, + BS. L NARES DOBHOFF TUBE, TOLERATING TUBE FEED AT GOAL 60CC/HR, RESIDUALS 30-40CC. 250CC FREE H20 BOLUS Q4H FOR HYPERNATREMIA, NA DOWN TO 146 TODAY.\n\nRENAL: BUN 31/CREATININE 1.1. FOLEY TO CD DRAINING QS HUO.\n\nSOCIAL: NO VISITORS OR PHONE INQUIRIES.\n\nPLAN: TRACH COLLAR TODAY WHEN OOB TO CHAIR. PTT AT 1030, ADJUST HEPARIN GTT MD ORDER. AGGRESSIV PULM HYGIENE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-04-05 00:00:00.000", "description": "Report", "row_id": 1620666, "text": "pt had an Endovascular Aortic Aneurysm Repair yesterday remained in PACU until last evening. Was awake alert with good hemodynamics through night until this am when pt developed respiratory distress desaturated to the 60's became hypertensive ashen looking and had some runs of V tach. Code called pt given lasix, labetolol, lopressor intubated and transfered to floor. On arrival pt hypertensive on nitro , propofol for sedation. Nitro was turned off and BP slowly dipped to 70's LR bolus 500cc given and Levo started. Lytes treated as ordered. Pupils noted to be unequal HO aware. Vent changesmade for Respiratory acidosis will repeat in 1 hours. Plan for CTA later today\n" }, { "category": "Nursing/other", "chartdate": "2101-04-15 00:00:00.000", "description": "Report", "row_id": 1620707, "text": "Respiratory Care:\n\nPatient trached with 8.0 Portex. Cuff pressure 25cm with 5cc of air in cuff. Inner cannula changed. BS coarse @ bases with few rhonchi bilaterally. Rhonchi cleared with sxing. Strong cough effort. Albuterol/Atrovent MDI's given x 4 puffs each Q4hr via ambu. Qvar given x 4 puffs. tolerated well. RR low to mid 20's. ABG reveals compensated resp acidosis. Last PaO2 68 on 50% HFN. Fio2 ^ 60%. O2 sats 92-95%.\nCopd/Home O2 @ 4lpm/MDI's/Trached .\nPt. weaned off vent yesterday and continues to do well. Resp status stable.\nPlan: Continue with MDI's Q4hr,Sxing prn and trach management.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-05 00:00:00.000", "description": "Report", "row_id": 1620667, "text": "Nursing 0700-1500\ns/p endovascular stent deployed proximally @ the renal arteries and distally extended in both external illiac arteries. Desat/HTN on floor requiring intub-tx to CVICU.\n\nPt traveled to CT scan this am for CTA of chest. No significant pleural effusions found per team. Currently treating pulm edema w/ivp lasix per team. Cardiac echo done, results reviewed by team. Decision made to hold off placing swan at this time.\n\nNeuro: Pt sedated on propfol (bradycardic/hypotensive), switched to fent/versed gtt for hemodynamic management. PERRL. Pupils no longer unequal. MAE w/stimulation. Does not follow commands. No wake up per team.\nCV: SB, rare-occ pvcs. Transcutaneous pads at bedside. Lytes repleted. Required levo to keep >90, currently off. Goal SBP 90-140. Add'l fluid bolus this am for hypotension/SB. CVP elevated. Dopperable pulses. Bilat groin dsd intact, strong palp pulse. 2nd set cardiac enzymes sent.\nResp: SIMV 60% 12 peep. Resp acidosis resolved. Team accepting paO2 of 60 or higher. Lungs coarse throughout. Suctining for scan tan thick.\nGi: NPO. OGT to LCWS. Absent bowel sounds.\nGu: Adeuate HUO. 1x 40mg ivp lasix admin. Mod diuresis.\nEndo: Insulin gtt started.\nSkin: Skin/wound care consult ordered. Pt has sacral/bilat buttocks purple-black decub (not new, pt admitted w/decub- had at home, last admission as well). Bilat w/?elastoplast from osh for ?venous ulcers/pvd. Strong odor- same as last admission.\nSocial: Wife and daughter into visit. ICU regulations explained to family. ICU consent obtained. This RN updated family.\n\nPlan: Diuresis for pulm edemea. Cycle cardiac enzymes. Monitor bradycardia. ?swan if cardiac function worsens. Skin care consult.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-04-18 00:00:00.000", "description": "Report", "row_id": 1620722, "text": "resp care - Pt trached and on PSV vent support. Settings were weaned per ABGs and . Pt was suctioned Q1 for copious thick, tan secretions. See carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-19 00:00:00.000", "description": "Report", "row_id": 1620723, "text": "Resp care: pt continues trached #8 portex and on ventilatory support with cpap with psv, no vent changes maintaining Vt 500's with Ve 13-16 L, compensated hypercarbia with acceptable oxygenation on fi02 .6; bs rhonchorous, sxn thick yell secretions, rx with mdi albuterol/atrovent/qvar, rsbi 60, will cont slow vent wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-19 00:00:00.000", "description": "Report", "row_id": 1620724, "text": "UPDATE\nNEURO: A&O. RESTLESS DURING NIGHT DESPITE CLONIPIN GIVEN @ HS. SLEPT POORLY. DENIES PAIN.\n\nCV: NSR W/ OCC PVC'S; FEWER THAN LAST NIGHT. BP WNL. CVP 9. PTT THERAPEUTIC ON 2400UNITS HEPARIN. PERSISTENT LE EDEMA. DISTAL PULSES DOPPLERABLE. ON LOPRESSOR.\n\nRESP: SUX FREQ FOR MOD AMTS THICK, TAN SECRETIONS. CONT TO HAVE LOW GRADE TEMPS. SPO2 MID 90'S. PAO2 IMPROVED THIS A.M. AFTER DIURESIS.\n\nG.I.: SIPS H20 AND ICE CHIPS DURING NIGHT. TF @ 60ML/HR. HAD 1 MED SIZED, FORMED B.M. GUIAC NEG.\n\nG.U.: LG DIURESIS NOW ON REGULARLY SCHEDULED LASIX. I& O 2600ML NEGATIVE @ MN.\n\nENDO: REQUIRING MOD AMTS SSRI COVERAGE FOR ELEVATED GLUCOSE.\n\nA/P: OXYGENATING BETTER THIS A.M. PLAN TO DECREASE PEEP TODAY AND TRY TRACH COLLAR IF TOL LOWER PEEP. CONT PULM TOILET AND NUTRITION. NOW ON IV VANCO FOR INFECTIOUS SPUTUM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-04-19 00:00:00.000", "description": "Report", "row_id": 1620725, "text": "Neuro : Awake ,obeys command ,follows instuctions well but at times gets restless and tries to change his position,lines by his own.\n\nResp: changed to trach collar,Fio2 60%, in the morning tolerated well sats stayed stable @ 92-97% copious blood tinged thick secretions suctioned out coughs out well .\n\nCVS: HR 80-95/mt ,bp 100-160/50-70 mmof HG ,unifocal PVC's noted .\nreplaced k and calcium .\n\nGI : positive bowel sounds ,on tube feed @ goal tolerated well ,patient often complaints of being hungry ,no fluids given when on collar.\n\nEndo : fingerstick checked q6h ,changed lantus and sliding scale .\n\nSkin : back skin bluish pressure sore noted ,on bariair bed .\n\nActivity : slided to the chair and was in chair for 4hrs tolerated well.Family at the bedside.\n\nPlan: PT for tomorrow to let him stand at bedside ,weaning further on the fio2.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-19 00:00:00.000", "description": "Report", "row_id": 1620726, "text": "pt extubated early in shift without incidence, positive RSBI and leak test.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-19 00:00:00.000", "description": "Report", "row_id": 1620727, "text": "error... note for different pt\n" }, { "category": "Nursing/other", "chartdate": "2101-04-20 00:00:00.000", "description": "Report", "row_id": 1620728, "text": "CVICU Nursing Progerss Note\nS-Turn the fan off-mouthing the words.\nO-Neuro and cooperative but with freq restlessness/aggitated picking at peditube tape until he removed the tube. Also picking off O2 saturation cable, ECG monitor, NP aware and soft wrist restraints applied. Had received clonazepam .25mg at 2300, with possible side effect confusion. This am found patients legs off the side the bed trying to go to the bathroom.\nCV-VSS hypertensive SBP 160's with aggitation HR 98-100 ST with occ PVC and PAC's. Tolerating lopressor 25mg with HR decrease to 64-72.\nHeparin at 2400 units/hr.\nResp-trach collar at 60% high flow neb requiring 100% with drop in O2 sats < 90%. Copious amounts of thick tan secretions requiring q30 minute suctioning. At 0030 O2 sats 79-85% with ABG 7.31/77/54 placed back on the vent 50% PS 10/PEEP 5 with rr 26-28 vT 350 O2 sats 90-94%\nTrach site red, bleeding and painful to touch.\nID afebrile on vanco\nGU-foley draining 60-300cc/hr receiving lasix 40mg IVB q8hrs.\nGI-As stated above pt removed feeding tube and plan to have this replaced in am. 4 moderate sized BM, brown, hard OB-.\nEndo-elevated blood sugars with change in glargine and SSRI for am. Blood sugars 190-220.\nSkin-buttocks/coccyx eccymotic, BLE venous stasis ulcers dry and non draining. Moderate amount of dead, dry skin with odor, poor hygiene at home. Cleansed legs with skin cleanser with some success of removal of dead skin. Pedal pulses doppler.\nActivity-bedrest but pt able to turn in bed on own.\nAccess-RIJ multi lumen, left radial aline.\nSocial-no phone calls.\nCode Status-Full\nA/P-70yom s/p endovascular AA repair POD#16 c/b ongoing respiratory distress with failed extubation twice now trached . Increase secretions with hypoxia failed trach collar. COntinue with pulmonary toilet and aggressive diruesis. Trach collar while in chair today.\nPossibly change clonazepam to haldol. COntinue to keep pt and family aware of POC as discussed in multi disciplinary rounds.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-04-20 00:00:00.000", "description": "Report", "row_id": 1620729, "text": "Respiratory Care:\n\nPt received on trach collar all day 60-100%. He had few episode of desats which required placement back on vent, See careview. RSBI done ~60. MDI's aadm as ordered with some improvememt asp spasmodic cough. We are sxtn for scant to copious thick tan to blood tinged secretions. Plan: likely back on TC. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-20 00:00:00.000", "description": "Report", "row_id": 1620730, "text": "Resp. care note - Pt. remaines trached, weaned to TM tol ok at this time.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-08 00:00:00.000", "description": "Report", "row_id": 1620680, "text": "Addendum:\n\nTF started back @ 30ml/hr, advance as tolerated - plan is to ext. tomorrow; patient agitated @ 1830, 1mg Versed given;\n" }, { "category": "Nursing/other", "chartdate": "2101-04-14 00:00:00.000", "description": "Report", "row_id": 1620701, "text": "patient s/p Trach portex #8 nonfenestrated.\n\nNEURO: Recieved patient sedate on propofol (brady 40s)- Changed to fentannyl & versed with poor sedation->pt intermitten agitation, htn. Easily arouse to voice, , maex4 to command. Now back on propofol low dose->keep patient sedate MD .\n\nID: wbc trending down. afebrile. no abx ordered\nCV: 1AVB pri 0.21, intermitten SB 40s-50s/occas pacs, rare pvcs, intermitten short burst of afib. held BB d/t sb. no heparin MD x24 post-op. hydralazine x1 given for sbp>140s with effect. still have gen edema.dopplerable pulses. VSS per flowsheet\n\n\nRESP: gas pao2 70s->^peep 10 MD. able to weaned down fio2 to 50% now. Pt maintain sat >93-95%. LS diminishb bases, cta. sxn thick yellow-blood tinged. trach care done. cxr.\n\nGI: belly obese, soft. NT. until am MD> ogt to lcsxn->bilious drg.\nENDO: titrate FS with insulin gtt\nGU: patient diuresis with lasix q8h -adequate huo via foley\nSKIN: both LEs -edema/browny-pink-purple pigmentation, thick skin-areas of dry/scaly->applied moisture barried, waffle boots. Coccyx with thick marroon pigmenation->critic aid ointment, vesta around buttocks->wound care done per wound nurse .\nSOCIAL: no family call . provide support to patient\n\na/p: restart heparin gtt for afib. wean vent as tol. restart TF. transition insulin gtt to ss when tf restarted. oob to chair. wound care.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-09 00:00:00.000", "description": "Report", "row_id": 1620681, "text": "Resp care\nPt maintained on mech vent, this AM pt was uncomfortable and seemed angitated vent settings adjusted see flowsheet, BLBS course rhonchi. Suctioned for moderate thick yellow. plan was to wean to extubate this Am.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-09 00:00:00.000", "description": "Report", "row_id": 1620682, "text": "UPDATE\nNEURO: RESTING WELL MUCH OF NIGHT W/ INTERMITTENT PERIODS OF AGITATION/FRUSTRATION @ INABILITY TO COMMUNICATE. PT TRYING TO TALK AND GESTURE, ATTEMPTING TO REACH ETT ALSO. RESPONDED TO CALM SUPPORT AND SM DOSES MIDAZ. AT APPROX 0545 AGITATION BEGAN TO ESCALATE AND UNABLE TO CALM PT. MIDAZ REPEATED AND PT W/ 100% O2 W/ IMPROVEMENT IN AGITATION. HAD BEEN MAE TO COMMAND AND DENIED PAIN.\n\nCV: SEVERE AGITATION @ 0545 ESCALATED TO TACHYCARDIA 120'S, RR 30'S, SPO2 MID 80'S AND SBP UP TP 200, CVP TO 18. PT DIAPHORETIC AND ATTEMPTING TO SIT UP FURTHER IN BED. DENIED SOB AND PAIN. ABOVE PARAMETERS RETURNED TO BASELINE WHEN PT MANUALLY FOR ~ 5 MIN. FREQUENT PVC APPEARED AS RATE SLOWED. DR. NOTIFIED OF EVENTS. ONCE PT PLACED BACK ON VENT W/ OR W/O AUTO RATE, ABOVE SX BEGAN TO RECUR. DR. HERE TO SEE PT. MIDAZ REPEATED AND IV NTG STARTED BRIEFLY. MAGSULFATE BOLUS STARTED. W/IN MINUTES HR CHANGED TO VT IN 190'S W/ SBP 110 RANGE. NTG OFF AND MORE MIDAZ GIVEN AND PROPOFOL DRIP STARTED. PT CARDIOVERTED X 1 W/ 360 J W/ RETURN TO SR. LIDOCAINE GIVEN AND DRIP ALSO STARTED AS WELL AS NEO TO SUPPORT BP. HR CURRENTLY SR 60'S W/ SBP 140'S AND SPO2 93% ON A/C.\n\nRESP: LUNG SOUNDS CLEAR BUT DIMINISHED @ BASES DURING NIGHT. BREATHING APPEARING COMFORTABLE MOST OF NIGHT ON CPAP, IPS8, PEEP5. ABG DONE REFLECTED PT'S PREVIOUS ABG'S W/ SL IMPROVED PAO2. SOUNDING MORE \"WET\" DURING ABOVE EPISODE. SUX FOR SM-MOD AMTS THICK, PALE YELLOW SECRETIONS INFREQUENTLY DURING NIGHT. CXR DONE ~0700, RESULTS PENDING.\n\nG.I.: TF OFF ~ 0115 IN ANTICIPATION OF A.M. ETT EXTUBATION. HAD LG MUCOUSY STOOL X 1.\n\nG.U.: DIURESING WELL W/ LASIX. I&O APPROX 1400ML NEGATIVE @ MN. CREAT SL DOWN TODAY.\n\nENDO: SSRI FOR GLUCOSE CONTROL.\n\nSKIN: NO CHANGES FROM PREVIOUS DAYS.\n\nA/P: HEMODYNAMIC STATUS NOW STABILIZED AFTER ABOVE MEASURES. SEVERE AGITATION APPEARED TO BE REL TO (?CARDIO)PULMONARY EVENT. AWAITING CXR RESULTS. A.M. LASIX GIVEN EARLY. CONT TO MONITOR VS AND ABG'S CLOSELY. NEED TO HOLD LOPRESSOR WHILE ON PROPOFOL. PLAN FOR EXTUBATION ON HOLD. SEDATION FOR COMFORT.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-04-09 00:00:00.000", "description": "Report", "row_id": 1620683, "text": "Respiratory Care:\nThe plan to extubate was placed on hold after an early AM event of\nV tach with associated discomfort and requiring cardioversion, and\na change to A/C on vent. Though he is apparently much more comfortable\nnow he has remained on A/C to rest today and we will presumably\nresume weaning to extubate on Monday. last ABG = 7.39 51 84 31 3.\nMDI's given and has been Sx'd for small amounts of thick yellow secretions.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-09 00:00:00.000", "description": "Report", "row_id": 1620684, "text": "Neuro: tmax 98; sedated on 30mcg propofol; pupils 3mm & sluggish;\n\nCV: went into stable V-Tach 180's - 190's @ 0652, shocked w/ 360J converted back to NRS 80's, Lidocaine bolus given & Lidocaine gtt started, Neo gtt started briefly for MAP <60; Lidocaine gtt turned off @ 1000 for hr dipping down to 30's, EP came by to evaluate but was not going to do anything for stable hr 40's - suggested & ordered Lasix d/c, aldactone ordered (was not ordered as of yet???, may not do???), & cortisol levels sent (possible adrenal issues???); currently SB 40's, sb/p 110-124, CVP 14-15, +3 edema, doppler pulses;\n\nResp: x-ray this am - wet; #8 ETT taped 22 @ lip; AC 20, Fio2 50%, TV 650, PEEP 10; Sat 98-100%; ph 7.41/ pco2 50/ po2 96; tan, thin-thick, small secretions obtained via in-line sx; lungs coarse bil, dim. bases;\n\nGI: + bowel sounds; Replete w/ fiber started back @ 1200 - currently @ 30ml/hr (goal 80ml/hr); 0 BM; abd. obese & firm;\n\nGU: foley w/ clear, yellow drainage; Lasix d/c;\n\nIV: Rt radial a-line; RIJ; D5W @ 10ml/hr;\n\nLab/Endo: repleted K+; RISS per POE order; finger sticks Q6 hrs.;\n\nSkin: skin dry & flaky; LLE wound w/ dry sterile gauze - D&I; Rt groin w/ steri-strips w/ 2x2 gauze & tegaderm - D&I; coccyx purple w/ deep tissue injury;\n\nPlan: keep MAP <140; keep sedated on propofol; treat labs as needed; inc. TF as tolerated;\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-04-14 00:00:00.000", "description": "Report", "row_id": 1620702, "text": "RESP CARE NOTE\nPT REMAINED ON AC MOST OF NIGHT. ABG ON AC 14/650/+10/50%: 7.43/50/79/34. 8.0 PORTEX PATENT AND SECURE. CUFF PRESSURE 25. BS COARSE T/O. SUCTIONING SMALL/MOD AMTS OF THICK TAN SECRETIONS. ALB/ATR MDI'S GIVEN INLINE Q4 AND QVAR . WEANED TO PSV 10/10/50% WITH VT 500-600 AND RR 20-25. AMBU AT BEDSIDE.\nPLAN: WEAN AS TOLERATED, MDI'S AS ORDERED.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-14 00:00:00.000", "description": "Report", "row_id": 1620703, "text": "ADd:\nLab: hypernatremic NA ^148\nRESP: weaned to cpap/10/10peep->sat >95%, pt tolerates. Awake on 20mcg/kg/min propofol -mouthing words. denies pain\n" }, { "category": "Nursing/other", "chartdate": "2101-04-14 00:00:00.000", "description": "Report", "row_id": 1620704, "text": "Resp Care\nPt remains trached with 8.0 portex DIC in place. Pt taken off vent and placed on TM via high flow this am 9 which he tolerated for the remainder of the shift. fio2 was slowly weaned throughout the day he is currently on 50% satting >92%. BLBS diminished pt has a strong cough, suctioned for thick yellow and some bloody secretions, mdis given per order. Plan to continue TM overnight as toelrated\n" }, { "category": "Nursing/other", "chartdate": "2101-04-17 00:00:00.000", "description": "Report", "row_id": 1620716, "text": "Neuro: tmax 100.6; MAE; FC; very pleasant & cooperative; PERRL;\n\nCV: SR 70's-80's w/ occ. PVC's; sb/p 140's; CVP 13-17; doppler pulses; M Boots in place;\n\nResp: had been left on TC all night, am gas 7.39/64/53; placed back on vent, repeat gas on PS 10, Fio2 50%, Peep 8 was 7.39/65/56; current vent settings PS 10, Fio2 60%, Peep 12, gas 7.39/65/91; #8 trach; lungs clear bil, dim. bases; small, thick, yellow secretions obtained via in-line sx cath; Sat 99-100%;\n\nGI: Lt nare DHT; soft diet, passed swallowing test few days ago - eating 90-100% meals); need to d/c TF @ night (+ I/O's) - discussed w/ ; abd obese, firm, distended; 0 B/N/V;\n\nGU: foley to gravity w/ clear, yellow drainage; d/c Lasix this afternoon, ordered x1 dose diamox for 1800;\n\nIV: Rt IJ; Heparin gtt currently @ 2400 units/hr - PTT due @ 2200;\n\nPlan: rest on vent today, wean in am as tolerated; monitor food intake while on vent; tx labs as needed; d/c TF; activity as tolerated;\n\nLab/Endo: RISS per sheet; Glyburide 5mg ; Lantus ordered for am??? decreased free H20 to 30ml/hr Q6 hr d/t Na+ WNL;\n\nPain: denies pain;\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-04-17 00:00:00.000", "description": "Report", "row_id": 1620717, "text": "resp. care\npt. remains trached/on vent all day. support increased\ndue to poor abg's. now much improved on ps 10 peep 12 and\n60%. plan to rest on vent tonight and wean in a.m.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-18 00:00:00.000", "description": "Report", "row_id": 1620718, "text": "UPDATE\nNEURO: A&O, COOPERATIVE. COMMUNICATES EFFECTIVELY BY MOUTHING WORDS AND USING HAND GESTURES. DENIES PAIN.\n\nCV: NSR W/ OCC PVC'S THROUGHOUT NIGHT. SBP UP TO 150'S EARLIER IN SHIFT BUT 100-120 RANGE AFTER LOPRESSOR. DOPPLERABLE DISTAL PULSES. EXTREMETIES /DRY.\n\nRESP: LUNGS SOUND CLEAR BUT SUX FOR MOD AMTS THICK, TAN SECRETIONS. REMAINED ON CPAP ALL NIGHT. C/O DYSPNEA X 1 AFTER SUX, RESOLVED BY FURTHER SUX TO REMOVE RESIDUAL SECRETIONS. PAO2 DOWN TO 68 THIS A.M. DIAMOX DOSE CURRENTLY INFUSING PER DR. .\n\nG.I.: ON BEDPAN X 1 BUT NO RESULTS. ABD SOFT, DENIES DISCOMFORT. DOBHOFF USED FOR MEDS.\n\nG.U.: ADEQ HUO VIA FOLEY. GD DIURESIS FROM LASIX BUT I&O STILL +400ML @ MN.\n\nI.D.: T SPIKE TO 101.6 PO. DR NOTIFIED. PAN CX DONE.\n\nSKIN: LE'S EDEMATOUS W/ DRY, EXFOLIATING SKIN. ALOE VESTA CREAM APPLIED. RLE ULCER HEALED, INTACT.\n\nSOCIAL: DAUGHTER IN TO VISIT @ EVENING SHIFT CHANGE.\n\nA/P: BORDERLINE OXYGENATION. CONT DIURESIS. TRY TRACH COLLAR FOR SHORTER PERIODS DURING DAY IF PAO2 IMPROVES. CONT PULM TOILET. OOB TO CHAIR. ENC PO INTAKE IF OFF VENT.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-08 00:00:00.000", "description": "Report", "row_id": 1620676, "text": "Respiratory Care\nPt intubated on vent support. Sx for yellow secretions, BS decreased no wheeze. AM RSBI 107, pt 2 decreased from 97% to 91% during RSBI and further desaturated to low 80's on PSV. Settings returned to A/C with improvement in oxygenation with in minutes. ABG metabolically compensated respiratory acidosis with hyperoxia, FiO2 further weaned to 40%.\nPlan; Wean vent support as tol.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-08 00:00:00.000", "description": "Report", "row_id": 1620677, "text": "Neuro Pupils equal and reactive, moving all extremities, following commands. Restarted on fentanyl IV pain given versed 1mg iv q 4hr\nCVS HR as low as 37 having freq Pac first degree avb ekg taken unchanged cpk sent neg. K+ 3.9 tx per scale bp < 140/ skin dry, flaking +3 edema extremities. Given diamox and lasix as ordered neg 3153 yesterday mn to 0600 neg 173. PP dopperable. Has a linear opening in RLL no drainage DSD.\nGI BUN 16 cr 1.4 outputs above\nResp on 50% cpap with 8/8 7.30.73/88/37/6 placed on AC overnight 50%/620/20/8 7.41/55/123/36/8 fio2 decreased to 40%. RISBI 107. Suctioned for sm amt white/yellow sections lungs clear diminished bases\nGI TF progressed as tolerated min. residuals abd obese bowel sounds + given ducalox supp no stool\nskin coccyx area b/l glut dark purple on left and 8x8cm on right deep tissue injury criticare applied\naccess rt radial aline, rij\na. s/p right stent, L stent and b/l hypogastric coil embolization EVAR/ s/p resp distress on floor requiring intubation cxr showing pulm edema\ncopd\nbradycardia\np. continue to diuresis, wean vent as tolerated, replete lytes, hold lopressor monitor closely, increase TF to goal as tolerated, keep sbp <140/\n" }, { "category": "Nursing/other", "chartdate": "2101-04-08 00:00:00.000", "description": "Report", "row_id": 1620678, "text": "Neuro: afebrile; MAE; FC; very approp. & coop.; pupils 3mm & sluggish; able to open eyes fully this afternoon after Fentanyl weaned off @ 1100 (no other pain/sedation given); denies pain & no agitation noted;\n\nCV: SB-SR 54-77 (on 25mg Lopressor ); sb/p 111-136; CVP 17-21; doppler pulses; 3+ edema;\n\nResp: #8 ETT @ 22; Sat 93-97%; resp ; CPAP, Fi02 40%, ; ph 7.32/pc02 66/ p02 76; continuing to wean vent as tolerated; lungs clear bil, dim. bases; thick, tan, small secretions obtained via in-line sx;\n\nGI: OGT currently clamped waiting for possible ext.???; abd obese & firm; + bowel sounds; 0 BM;\n\nGU: foley to gravity w/ clear, yellow drainage; 40mg Lasix ;\n\nIV: Rt radial a-line; Rt IJ; D5W @ 10ml/hr;\n\nLab/Endo: repleted K+ x2 & Ca+ x1; ISS per printed sheet; finger sticks Q6 hr.;\n\nSkin: Lt groin incision w/ 2x2 sterile gauze & tegaderm dsg - D&I; Rt LE wound w/ sterile gauze - D&I; coccyx purple w/ deep tissue injury - criticaid applied;\n\nPlan: continue to diuresis; wean vent as tolerated; keep sb/p <140; treat labs as needed; start back TF (replete w/ fiber - goal rate 80ml/hr) if not ext.???\n" }, { "category": "Nursing/other", "chartdate": "2101-04-08 00:00:00.000", "description": "Report", "row_id": 1620679, "text": "Respiratory Care:\nPt weaned down to PSV 8/8 @ 40%. Seems much more awake this PM.\nProbability of extubation today is fair...but not assured.\nLast ABG = 7.32 66 76 36 4, compatable with chronic CO2 retention.\nWill have an ABG about 1600hrs to monitor. Beclamethasone (QVAR) pfs added today to A/A: due at 2000hrs with the other RT meds.\nWill follow for extubation when ready.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-18 00:00:00.000", "description": "Report", "row_id": 1620719, "text": "Resp: pt on psv 10/12/60%. Pt has #8 portex trach. Inner cannula changed. BS are coarse bilaterally with diminished bases. Suctioning for moderate to copious amounts of thick tan/yellow secretions, sample sent. MDI's administered as ordered alb/atr/Qvar with no adverse reactions. ABG's (see careview) No rsbi due to ^ peep. AM ABG 7.42/58/68/39. Plan: continue with T/C trials as tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-18 00:00:00.000", "description": "Report", "row_id": 1620720, "text": "Neuro - Upon initial assessment, patient is awake and , appropriate and following all commands. She is able to move all extremitiies with equal strength. He has denied pain throughout this shift. He complained of a sore back when he was OOB to the bedside chair but denies further pain. All aspects of his care have been explained to him prior to performing them. Patient is able to communiticate well with RN by mouthing words. Continue to monitor.\n\nCV - Patient has had a low grade fever this shift as documented in the flowsheet. PAN cultured on prior shift, results pending. HR has been NSR in the 60s-80s with PVCs noted, electrolytes as documented. BP has been stable as documented with SBP less than 140mmHg. Patient has edema noted to his lower extremities where he has doppler pulses in his post tibial and pedal locations.\n\nR - Patient continues to be mechanically ventilated via his trach. Patient lung sounds are coarse and contain rhonchi, thick yellow/tan secretions noted. Sats as documented on current vent settings. Plan to wean PEEP and vent as tolerated and transition to trach collar. Trach care done. Continue to monitor patient.\n\nGI - Patient restarted on Nutren Pulmonary with beneprotein via left nare dobbhoff as ordered with a goal set for 60mL/hr, currently at 40mL/hr. Abdomen is largely obese with bowel sounds present. No BM at this time. He denies pain or tenderness in his abdomen. Plan to start patient on PO diet when he is no long on mechanical ventilation and advance as ordered and as tolerated. Patient given regular insulin as ordered as part of the RISS protocol, continue to monitor patient's nutritional status.\n\nGU - Patient given lasix and chlorothiazide to assist with diuresis. Urine output has been adequate, greater than 50mL/hr and appears clear and yellow, draining to gravity via foley catheter. Continue to monitor patient's I and O closely.\n\nI - Patient skin is intact. Coccyx has a purple area due to pressure, patient turned, repositioned and moved OOB to chair to assist with decreasing pressure. Lower extremities have very dry flaky skin, they are within sheepskin covered boots. Otherwise patient has intact skin. Continue to monitor patient's skin and change positions to decrease pressure on certain points.\n\nIV - Patient has left radial artline that has dressing clean, dry and intact. Good waveform noted with adequate blood return and good CSM to distal left hand. Right IJ TLC has dressing intact, CVP as documented with good waveform. All three lumen patent with blood return noted. Continue to monitor patient.\n\nGtts - Patient is on heparin gtt of 2400 units/hr with PTT therapeutic. Plan to monitor PTT, patient started on coumadin, plan to wean off of heparin. D5W infusing as a carrier.\n\nPsycho/Social & Safety - Wife called this shift, updated on patient condition, she plans to visit later this week. Bed remains in the low and locked position with siderails raised and locked. He has a ca\n" }, { "category": "Nursing/other", "chartdate": "2101-04-18 00:00:00.000", "description": "Report", "row_id": 1620721, "text": "(Continued)\nllbell within reach and has utilized it on many occasions this shift.\n\nPlan - Wean vent, monitor labs, advance diet as tolerated as ordered, monitor xrays and continue to monitor for S&S of infection.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-07 00:00:00.000", "description": "Report", "row_id": 1620674, "text": "7P-7A NPN:\n\nROS:\n\nNEURO: PT SEDATED ON IV MIDAZOLAM & FENTANYL GTTS. AT BEGINNING OF SHIFT, PT NOT RESPONDING TO VOICE OR STIMULI WITH SEDATION OFF. EVENTUALLY PT AWOKE, CONSISTENTLY FOLLOWED COMMANDS & MAE. PUPILS SLUGGISH BUT EQUAL. NO FAMILY INQUIRIES .\n\nCV: SB-NSR 50-70S WITH FREQUENT PVCS. EKG DONE, RBBB MD . LYTES REPLETED PRN. IV METOPROLOL HELD . INITIALLY PT BECAME HYPOTENSIVE; SBP 80S ON NTG GTT. GOAL SBP <140, NTG GTT OFF. CVP TRANSDUCED SEE CAREVUE FOR MEASUREMENTS/TRENDS. DOPPLERABLE PULSES BILAT. SQ HEPARIN FOR DVT PROPHYLAXIS. GROSS LE EDEMA BILAT.\n\nRESP: REMAINS ORALLY INTUBATED. PCO2 >50 SEE CAREVUE FOR VENT SETTINGS/CORRELATING ABGS. LS COARSE. SUCTIONED FOR MODERATE AMOUNTS THICK YELLOW SECRETIONS WITH IMPROVEMENT. 02SAT >95%.\n\nGU/GI: FOLEY TO GRAVITY WITH ADEQUATE HUO. IV LASIX & IV DIAMOX WITH (+)DIURESIS. ABD OBESE (-)BS. NO RECENT BM. OGT TO LCWS WITH BILIOUS DRAINAGE; PLACEMENT CONFIRMED.\n\nENDO: GLUCOSE COVERAGE PER RISS PROTOCOL.\n\nID: WBC WNL, IV ZOSYN CONTINUES. CULTURES PENDING. LOW GRADE TEMPS.\n\nSKIN: SEE CAREVUE FOR SKIN ASSESSMENT. ?NEED FOR RE-EVALUTION FROM WOUND CARE RN.\n\nPLAN: CONTINUE DIURESIS. WEAN SEDATION & VENT SETTINGS AS TOLERATED.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-04-07 00:00:00.000", "description": "Report", "row_id": 1620675, "text": "UPDATE\nCV: NSR/SB, OCC 1ST DEG AVB, W/ RARE PVC'S. SBP 120'S, CVP LOW TEENS. EXTREMETIES , DRY. DISTAL PULSES+ BY DOPPLER. IV LOPRESSOR CHANGED TO PO.\n\nNEURO: SEDATION WEANED-> NOW OFF. PT SLOW TO ROUSE. EARLIER IN A.M. PT DID RESPOND TO STIMULATION BY ATTEMPTING TO OPEN EYES(NOT VERY SUCCESSFUL) AND MAE TO COMMAND. NODDED HEAD ALSO, ANSWERING NO TO PAIN. CURRENTLY NOT ABLE TO OPEN EYES OR FOLLOW COMMANDS. STRONG COUGH PRESENT. MOVES MOUTH TO MOUTH CARE.\n\nRESP: FAILED A.M. ATTEMPT TO TRY PS VENTILATION DUE TO BRADYPNEA AND LOW VT'S. CURRENTLY REATTEMPTING CPAP W/ IPS 8/PEEP 8->RR NOW 16, VT'S 500ML RANGE, VE=9. SUX THIS AFTERNOON FOR COPIOUS AMT THICK, YELLOW SECRETIONS. CXR REPORTEDLY SHOWS LUNGS \"WET\" W/PERSISTENT BILAT PLEURAL EFFUSIONS ALSO.\n\nG.I.: ABD OBESE BUT SOFT, + BS. NO B.M. TF RESTARTED VIA OGT.\n\nG.U./RENAL: CREAT=1.3. BUN WNL. DIURESING WELL TO LASIX AND DIAMOX. LASIX DOSE INCREASED.\n\nI.D.: WBC AND TEMP WNL. SPUTUM GM STAIN NEG FOR ORGANISMS, CX STILL PENDING.\n\nENDO: GLUCOSE 130'S. NO TX PER SLIDING SCALE.\n\nSOCIAL: WIFE AND DAUGHTER IN TO VISIT AND UPDATED BY N.P. THEY WERE SATISFIED BY QUESTIONS ANSWERED.\n\nA/P: HEMODYNAMICALLY STABLE. MONITOR RHYTHM CLOSELY DUE TO FLUCTUATING RATE AND PR INTERVAL. TOLERATING VENT WEAN BETTER THIS EVE. WILL RECHECK ABG. NO PLAN TO EXTUBATE TODAY. WILL LIKELY REQUIRE A FEW MORE DAYS DIURESIS. MONITOR LYTES. ASSESS TF TOLERANCE. MONITOR LOC AND CONT TO ORIENT PRN. PLAN TO D/C ABX IF SPUTUM CX IS NEGATIVE.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-06 00:00:00.000", "description": "Report", "row_id": 1620671, "text": "ALTERED RESPIRATORY STATUS\nO: RESP: PLACED ON CPAP 12PEEP/IPS 8, PRESENTLY PEEP5/8IPS,^ LABOR,RR 20'S. ABG TO BE DRAWN AT 1600. SUCTIONED FOR A SMALL AMOUNT OF THICK YELLOW SPUTUM. BS COURSE TO CLEAR UPPER WITH SUCTIONING, DIMINISHED BIBASILAR. O2 SAT TRANSIENTLY TO 88%, SINCE >93% MOSTLY >95%.\n CARDIAC: SR WITH ISOLATED PVC'S, K 3.8 RECEIVED 40 MEQ KCL. EXTREMITIES WARM AND DRY.DOPP PP. R+L FEM DSGS D+I.SBP REQUIRING NTG AT 1 MCQ ^ TO 3 MCQ WHEN CPAP IPS/ .\n NEURO: CALM AND RESPONSIVE ON FENTANYL 150MCQ AND 5 MG VERSED. FOLLOWED COMMANDS ANSWERED APPROPRIATELY TO YES/NO QUESTIONS. WITH WEANING VERSED TO 2 MG TOLERATED WELL, WHEN VERSED OFF PT AGITATED AND TRYING TO GET OOB. PERL. GRASPS STRONG AND EQUAL. MOVES LE ON BED.\n GI: HAS REMAINED WITHOUT TF DUE TO WEANING. ABD SOFT, NONTENDER, HYPOACTIVE BOWEL SOUNDS. NO STOOL.\n GU: RECIEVED DIAMOX AND 40 MG IV LASIX WITH EXCELLENT DIURESIS. CREAT 1.2,\n ENDO: SSI AS PER ORDERS.\n ID: REMAINS AFEBRILE, RECEIVING ZOSYN AS PER ORDERS. SPUTUM C+S PENDING.\n PAIN: REMAINS ON 150 MCQ OF FENTANYL WITH GOOD EFFECT. PT DENIES PAIN WITH NODDING HEAD.\n SOCIAL: WIFE AND DAUGHTER INTO VISIT AND UPDATED\nA: TOLERATED WEAN TO . DIFFICULT ON . DIURESING.\nP: MONITOR COMFORT, HR AND RYTHYM, SBP-WEAN NTG AS TOLERATED TO KEEP SBP<140, PP, DSGS, RIGHT AND LEFT FEM SITES, RESP STATUS-ABG PENDING-CONTINUE TO DIURESE-PULM TOILET,NEURO STATUS-OFFER REASSURANCE AND ENCOURAGEMENT, I+O, LABS PENDING. AS PER ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-06 00:00:00.000", "description": "Report", "row_id": 1620672, "text": "BS coarse crackles. Suctioned for moderate amount thick yellow secretions. Weaned to PSV 5/5, but then developed increased WOB with tachypnea. PSV increased to 12 (per CT team) after PaCO2 94. Repeat PaCO2 79. Placed back on AC.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-07 00:00:00.000", "description": "Report", "row_id": 1620673, "text": "Respiratory Care\nPT intubated on vent support. Several vent adjustments made to correct ABG values. LAst ABG metabolic compensated respiratory acidosis with normoxia, CO2 climbing, possibly related to increased PaO2 and pt significant COPD with Hx CO2 retention. FiO2 decreased, repeat ABG to follow. RSBI attempted but RR irregular with significant periods apnea, RSBI not completed. BS decreased, seemed slightly improved with adm of MDIs.\nPlan: wean vent support as tol.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-16 00:00:00.000", "description": "Report", "row_id": 1620711, "text": "Resp: pt on psv 10/5/50%. Pt has #8 portex trach. BS are coarse to clear with diminished bases. Suctioned for moderate amounts of thick yellow secretions. Inner cannula clear. MDI's administered as ordered alb/atr/qvar with no adverse reactions. VT's 500/RR 27 with 02 sats in 90's. A-line removed this AM. RSBI=51. Plan: continue with T/C trails as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-16 00:00:00.000", "description": "Report", "row_id": 1620712, "text": "CVICU NPN\nO: ROS\n\nNeuro: and mouthing words clearly, oriented and appropriate. Able to assist w/ turning s-s and feed himself. OOB-chair today by pivoting w/ minimal help from 2 assists. Steady gait but needing guidance. OOB x1 1/2 hrs and tol well. Took steps to return to bed. C/O headache and given 5ml roxicet x1.\n\nCV: Stable w/ hr 70-90's nsr, no ectopy. BP 140's/60's. Pedal pulses palpable.\n\nResp: Placed on TM 60% at 0900 and tol well x 3hrs. VSS and srr 30's w/ 02sat 92-94% but pt began to c/o sob. Rested x3 1/2 hrs and placed back on TM at 60%. SRR 25-30, 02sat 92-94%. Strong productive cough of thick yellow and bld tinged sputum. Sxned for meoderate to copious amts of sputums and able to clear lungs w/ sxning. No evidence of aspiration w/ po intake.\n\nRenal: Cont on lasix . U/O 120-140cc/hr. Body balance +700cc. Lytes wnl. Cont on free water boluses for elevated Na.\n\nGI: Pt started on solid food today and tol well w/ no nausea and no evidence of aspiration. TF stopped and will resume at night if needed.\n+BS, no stool today.\n\nEndo: SS insulin coverage 12units and 8units reg for bs 253, 201.\n\nHeme: Cont on heparin gtt increased to 2200u for ptt 42.5 (Goal = 60).\n5mg Coumadin given.\n\nID: Tmax 99.9.\n\nSkin: No change. Cont w/ BLE edema. Sarna lotion applied to dry skin areas. No other skin breakdown. Remains on air bed.\n\nSH: wife and in to visit. Pleased w/ progress, Short visit. wife bring in slippers and pt's walker tomorrow.\n\nA: Failure to wean. Hemodynamically stable. Ready for rehab screening.\n\nP: Cont to monitor. Pulm toilet. TM as tolerated, exercise lungs on TM as tol and rest on vent prn. OOB to chair 1-2x's daily as tolerated w/ wt bearing and increasing ambulation as tolerated. Wife to bring in walker. Increase participation in ADL's. Cont po intake and maintain on aspiration precautions. Monitor intake and d/c TF if adequate. SS insulin. Cont w/ coumadin and heparin. rehab screening.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-16 00:00:00.000", "description": "Report", "row_id": 1620713, "text": "resp. care\npt. remains trached/vented. did 3 hours trach mask\nthis a.m. then rested on vent. now back on trach\nmask. mdi's given. sx'd for cop. thick pale yellow\nsputum. continue vent/trach mask trials as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-17 00:00:00.000", "description": "Report", "row_id": 1620714, "text": "Resp: pt on T/C with hi-flow @ 60%. 02 sats @ 95%. BS are coarse bilaterally and suctioning for copious amounts of thick yellow secretions frequently. MDI's administered alb/atr/ovar as ordered with no adverse reactions. Pt remained on t/c until 02:00. No distress was noted, 02 sats in 90's rr 18-20, although pt was noticably more lethargic. ABG revealed ^ co2 with ph7.2 then placed on vent psv 10/8/50%. Improvement noted pt more awake. co2 @ 62. ph 7.39. RSBI=52. Plan: continue with frequent suctioning and T/C trials.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-21 00:00:00.000", "description": "Report", "row_id": 1620733, "text": " RN 1900-0700\nNeuro: awake, . Follows commands. Able to make needs known through non-verbal communication, mouths words. Denies c/o pain. MAE. . Attempting to get OOB x 3 tonight swinging legs over side of bed. Soft limb immobilizers placed x 3 hours d/t risk pulling at trach site and central lines.\n\nCV: SR HR 80s-90s with PVCs. 40 mEq IV K+ given overnight with decrease in ectopy. SBP 130-140s with episode of hypertensive SBP 160-200s. Pt diaphoretic, tachycardic, and tachypneic. Placed from trach mask to CPAP + PS. 10 mg IV hydralazine given with good effect. SBPs remained 130-140s since hypertensive episode. Heparin continues at 2400 units/hr. Ptt 69.2/INR 1.8 this AM. Difficult to doppler pedal pulses. Afebrile.\n\nResp: LS coarse, diminished at bases. O2 sats > 92% on TM and CPAP+PS . ABG drawn when pt hypertensive/diaphoretic/tachycardic => CO2 = 100, pH 7.22. Placed on CPAP with good improvement in ABG. Will follow. Suctioned three times for moderate amounts bright red thick bloody sputum. Dr. aware. No changes made. MDI per order.\n\nGI/GU: abd obese, NT, ND. (+) BS. Dobhoff d/c'd early in shift d/t placement coiled in esophagus per CXR. Pt given meds crushed in applesauce without difficulty. ? plan for nutrition. Small formed brown BM this evening. observed pt straining with BM. need for bowel regimen. Foley to gd, clear yellow urine with good response from scheduled lasix.\n\nEndo: RISS per pt specific sliding scale.\n\nSkin: venous stasis ulcers to BLE; purple coccyx which remains unchanged. aloe vesta cream applied to buttocks with skin care.\n\nSocial: no calls from family .\n\nPlan: monitor cardiopulmonary status. monitor bloody secretions from trach. pt for PICC line this AM. ? bowel regimen. ? nutrition. continue heparin to bridge for therapeutic INR. ? to rehab today?\n" }, { "category": "Nursing/other", "chartdate": "2101-04-21 00:00:00.000", "description": "Report", "row_id": 1620734, "text": " NPN 0700-1500\nStatus: Discharge today to TCU @ 1500\n\nNeuro: , oriented, MAE, impulsive at times, attempted to climb OOB today, afebrile.\n\nResp: CPAP with trach collar trials successful. PMV trial unsuccessful at this time secondary to secretions, passed speech & swallow eval, no aspiration. Suctioning moderate amounts of thick bloody sputum in am, small amount in afternoon.\n\nCV: NSR/ST with rare PVC's, BP 110's-150's, dopplar pulses, lytes WNL. A-line and TLC d/c'd, single lumen PICC placed by IV team. Heparin off at 0800, coumadin 7.5 mg given prior to discharge.\n\nGI: Abdomen obese, non-tender, cleared by Speech to take PO.\n\nGU: Foley draining adequate amounts of clear yellow urine with TID IV lasix.\n\nEndo: Glargine and sliding scale regular insulin per orders.\n\nID: MRSA + sputum, Vanco to continue in rehab.\n\nSocial: Wife phoned this morning, updated to condition and transfer to NE .\n" }, { "category": "Nursing/other", "chartdate": "2101-04-17 00:00:00.000", "description": "Report", "row_id": 1620715, "text": "npn 7p-7a (please also see carevue flownotes for objective data)\n\ndx: AAA, coiling of hypogastric artery\n readmitted to CSRU after desat on floor\n\n\nRESP:\nhas had repeated failures at extubation; now w/ trach and PEG;\ncurrently attempting to wean from vent;\n\nreceived pt on trach collar, with plan to leave on as long as pt tolerated; reportedly pt w/ copious secretions on day shift, coughs up per self when OOB to chair, needs suctioning when in bed; pt also on lasix to assist w/ taking off extra body fluid which could be preventing wean from vent settings;\n\npt w/ hx COPD, smoker; CO2 retainer;\n\nthis night, pt w/ gradual increasing lethargy, also some increase in b/p;\nABG showed PCO2 up to mid/hi 80's, was in mid 60's when on vent;\n\ntherefore pt returned to vent settings, as above, and will need gradual wean/strengthening plan;\n\nC-V:\npt in NSR most of the night, few infrequent isolated PVC's;\non heparin gtt, subtherapeutic, continues to receive increase in heparin gtt dose, w/ q 6 hr PTT check; last PPT at 04:15 was 57.7, on hep gtt of units per hr, anticipated increase;\n\nG-I:\npt starting to eat w/ Passe-Muir valve; however now ordered for cyclic tube feeding overnight, 12a-6a, to assist w/ pt nutrition/strength for weaning from vent;\n no stool this night;\nabd obese, rounded;\nreceiving glyburide and RISS for blood sugar control;\n\nG-U:\nreceiving lasix q12 hrs, w/ good diuretic effect following; serum creatinine stable;\n\nhyponatremia resolved; needs decrease in free water; currently ordered for 250 mls q 4 hrs;\n\nskin:\nbuttock stage I w/out further progression;\nreceived skin care/turning ; bari-air bed in use;\n\ncomfort:\nreceived tylenol and oxydocone 5 ml 22:00 and 04:00 for comfort;\npain scale via mouthing word acknowledgement and grimace scale;\n\nPLAN:\nfurther plans per rounds\n\n" }, { "category": "Nursing/other", "chartdate": "2101-04-05 00:00:00.000", "description": "Report", "row_id": 1620668, "text": "BS fine crackles. Started on Atrovent MDI's. CT of chest today confirms bibasilar effusions and multiple small pulmonary nodules. Sx'd for small amount thick dark yellow secretions. ABG's acceptable per CT service.\n" }, { "category": "Nursing/other", "chartdate": "2101-04-06 00:00:00.000", "description": "Report", "row_id": 1620669, "text": "Resp Care\nPt remains on vent. Suctioned for mod amt of yellow secretions. RR decreased to compensate for Metabolic alkalosis. Midis given. Will continue to monitor.\n" }, { "category": "Echo", "chartdate": "2101-04-05 00:00:00.000", "description": "Report", "row_id": 86317, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 73\nWeight (lb): 250\nBSA (m2): 2.37 m2\nBP (mm Hg): 103/44\nHR (bpm): 47\nStatus: Inpatient\nDate/Time: at 10:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; basal inferior - dyskinetic; mid inferior - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\nmotion consistent with conduction abnormality/ventricular pacing.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\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.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - body habitus. Suboptimal image\nquality - ventilator. Resting bradycardia (HR<60bpm).\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is mild regional left ventricular\nsystolic dysfunction with a basal inferior aneurysm/dyskinesis and\nmid-inferior and inferoseptal hypokinesis. The remaining segments contract\nnormally (LVEF = 45-50%). Right ventricular chamber size and free wall motion\nare normal. The ascending aorta is mildly dilated. The aortic valve leaflets\n(3) are mildly thickened but aortic stenosis is not present. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen. The pulmonary artery systolic pressure\ncould not be determined. There is no pericardial effusion.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD.\nPreserved right ventricular size and systolic function. Mild mitral\nregurgitation.\n\n\n" }, { "category": "ECG", "chartdate": "2101-04-14 00:00:00.000", "description": "Report", "row_id": 218841, "text": "Normal sinus rhythm. Right bundle-branch block. Left anterior fascicular\nblock. Occasional premature ventricular contractions. Compared to the\nprevious tracing of the left anterior fascicular block is new as are\nthe occasional premature ventricular contractions.\n\n" }, { "category": "ECG", "chartdate": "2101-04-09 00:00:00.000", "description": "Report", "row_id": 218842, "text": "Sinus rhythm. Right bundle-branch block. Non-diagnostic repolarization\nabnormalities. Compared to the previous tracing of multiple\nabnormalities persist without major change.\n\n" }, { "category": "ECG", "chartdate": "2101-04-07 00:00:00.000", "description": "Report", "row_id": 218843, "text": "Probable sinus rhythm. Indeterminate axis. Right bundle-branch block. Low limb\nlead voltage. Compared to the previous tracing of the rate has\nincreased. Other findings are similar.\n\n" }, { "category": "ECG", "chartdate": "2101-04-06 00:00:00.000", "description": "Report", "row_id": 219071, "text": "Sinus rhythm. Indeterminate axis. Right bundle-branch block. Low voltage.\nQ-T interval prolongation. Since the previous tracing of the rate is\nfaster. The Q-T interval is shorter.\n\n" }, { "category": "ECG", "chartdate": "2101-04-04 00:00:00.000", "description": "Report", "row_id": 219072, "text": "Sinus bradycardia. Consider left atrial abnormality. Low limb lead\nQRS voltage is non-specific. Right bundle-branch block. Diffuse ST-T wave\nchanges are primary and are non-specific. Since the previous tracing of \nsinus bradycardia and ST-T wave changes are now present.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2145-08-14 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 770054, "text": " 6:07 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: pt sob with green sputum\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with sob and decreased o2 sats\n REASON FOR THIS EXAMINATION:\n pt sob with green sputum\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath, green sputum.\n\n TECHNIQUE: Portable chest.\n\n Comparison with prior study from .\n\n FINDINGS: There is a left central venous catheter with its tip in the SVC. The\n heart is mildly enlarged. The mediastinum is normal. There are bibasilar areas\n of consolidation with air bronchograms, the right one has increased in the\n interval and the left one is new in the interval. There is blunting of\n bilateral CP angles consistent with small pleural effusions. The bones are\n demineralized.\n\n IMPRESSION: Bibasilar areas of consolidation which is worse on the right and\n new on the left compared to prior study. Findings are suggestive of aspiration\n or pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2145-08-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 770087, "text": " 10:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 40 yo female h/o aspiration pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with resp depressions and hx aspiration pneumonia,\n quadroplegia, interval change?\n REASON FOR THIS EXAMINATION:\n 40 yo female h/o aspiration pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Aspiration pneumonia.\n\n PORTABLE CHEST: Comparison is made to previous films from one day earlier.\n\n There is increased opacity in the right lower hemithorax with associated\n displacement of both the major and minor fissures. The right hemidiaphragm is\n partially obscured and the right heart border is also partially obscured. The\n left cardiac and mediastinal contours are stable in the interval. There\n remains an area of dense opacity with air bronchograms at the left base. A\n small left pleural effusion is noted.\n\n IMPRESSION: Bibasilar consolidation as demonstrated previously, consistent\n with aspiration pneumonia. However, the opacification on the right side is now\n accompanied by volume loss, suggesting a component of collapse within the\n right middle and right lower lobes. This may be due to mucus plugging.\n\n" }, { "category": "Radiology", "chartdate": "2145-08-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 770420, "text": " 9:49 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: new mental status changes. please eval for acute intracrania\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with paraplegia, aspiration pneumonia\n REASON FOR THIS EXAMINATION:\n new mental status changes. please eval for acute intracranial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GDi WED 10:35 PM\n No acute process identified.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status changes and paraplegia. Question intracranial\n process.\n\n Multiple axial images were obtained from base to vertex with intravenous\n contrast administration. Comparison is made to the prior head CT from of .\n\n The examination is limited by repeated motion artifact. There are no space-\n occupying mass lesions seen within the brain. No midline shift, mass, mass\n effect or hemorrhage is noted. The ventricular system is normal and\n symmetrical. There are no extra-axial fluid collections.\n\n IMPRESSION: Limited head CT due to motion artifact. No intraparenchymal\n hemorrhage seen. A repeat examination preferably with patient sedated might be\n of additional value.\n\n" }, { "category": "Radiology", "chartdate": "2145-08-17 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 770266, "text": " 1:25 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: ABD PAIN R/O BILIARY TREE OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with RUQ abdominal pain\n REASON FOR THIS EXAMINATION:\n Biliary tree obstruction,\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40 year old woman with right upper quadrant pain.\n\n TECHNIQUE: Multiple scale images were obtained from the abdomen and\n pelvis.\n\n FINDINGS: In the right lobe of the liver there is a small less than 1 cm\n hemangioma seen. There are no other lesions seen in the liver. There is no\n intra or extrahepatic biliary dilatation. The common bile duct is within\n normal limits. The gallbladder is not seen consistent with the patient's\n history of prior cholecystectomy. The right kidney measures 12 cm and the\n left kidney measures 12 cm. The kidneys have no hydronephrosis,\n calcifications or masses. The spleen is normal in size and homogeneous in\n echo texture. There are small bilateral pleural effusions seen. The\n visualized portion of the pancreas is unremarkable.\n\n IMPRESSION:\n 1) Small right liver lobe hemangioma.\n 2) S/P cholecystectomy.\n 3) Small bilateral pleural effusions.\n\n" }, { "category": "Nursing/other", "chartdate": "2145-08-16 00:00:00.000", "description": "Report", "row_id": 1584567, "text": "End of Shift Report\nNeuro: A0X3, bilat LE paralysis from MVA. Partial movement of RUE, very little movement in LUE.\n\nCV: Sinus Brady in low 50's, HR comes up when pt is awake or active. No ectopy noted. She was Hypotensive yesterday and fluids were increased to 150cc/h and her pressures were in the low teens systolic last night. Trace edema in all extremities. Pulses weak but palpable.\n\nResp: HX asthma, smoking. Lungs sounds are clear to diminished in bases. She has resp tx ordered. They were trying to deep suction her yesterday and were getting thick secretions. We did it once last night with poor result. She has been expectorating copious white/yellow secretions orally. She is unable to use the yankar herself. She is to have a swallow study today. Currently on 100% non-rebreather, sats are high 90's.\n\nGI; chronic constipation, She wants her suppository this am.\n\nGu: diminished output, she is currently 2200 liters positive. Avg output 30cc/h.\n\nInteg: Decube on L scapula and L glut with excoriation. Wet to dry drsg in the shift. I put duoderm alongside each wound to put the tape for the drsgs on because it looked like she was getting tape burns.\n\nPain: Chronic in abd, back, l shoulder. Normally she takes oxycontin. She has MSo4 and Dilaudid ordered but she says the morphine doesn't work. She is refusing all meds by mouth and food because she is afraid she will aspirate.\n\nShe tends to refuse repositioning and oral care. We put her on an air bed last night.\n\nIV access: L Picc place on last admission sometime before . The red port is clotted. The blue port flushes and draws. Iv fluids D5NS at 125/h.\n" }, { "category": "Nursing/other", "chartdate": "2145-08-16 00:00:00.000", "description": "Report", "row_id": 1584568, "text": "micu/sicu nursing progress note\n\nneuro- pt conts to c/o back/rlq pain. according to patient, this is baseline pain for her and has been getting worse over the last few weeks. she receives oxycontin and prn dilaudid. pt still reportsd pain at 8 or 9 out of 10 but is frequently dozing despite this.\n\ncv- temp 94-95 po, ho aware. bp stable throughout day, hr 50-60, dipping to 38-45 frequently while sleeping, bp has been >100 throughout.\n\nresp- pt expectoarting secretions this am, spits into mask because unable to hold and use yankaur. weaned from 100% nrb to 4L nasal cannula, sats 99%. suctioned x1 this am for thick yellow secretions. gag impaired. PT to see pt at some point, has been consulted. conts to have MRSA in sputum.\n\ngi/gu- pt tolerating regular diet w/o difficulty, taking pills, whole in custard, also w/o difficulty. pt had mod soft stool this afternoon.\n\nid- +blood cultures from yesterday, gpc in cocci/pairs. ?d/c picc line, per iv, pt has no other access for triple abx that she is on. team has been debating tcl vs. leaving picc in for now.\n\ncont pulm toileting for chronic pneumonia, anticipate transfer back to nh ? next week.\n" }, { "category": "Nursing/other", "chartdate": "2145-08-15 00:00:00.000", "description": "Report", "row_id": 1584566, "text": "RESP: BS'S HAVE IMPROVED. O2 SATS 99-100%. SUCTIONED Q 2-3HRS FOR THICK YELLOW SECRETIONS. UNABLE TO SUCTION THROUGH TRUMPET. CONTINUES ON 100% NRB.\nGI: REFUSES TO TAKE HER MEDICATIONS TODAY. HO IS AWARE OF THIS. REFUSING ANY FOOD OR DRINK AS WELL. NEEDS REPEAT SWALLOW STUDY AND OR NGT PLACEMENT TOMORROW.\nRENAL: URINE OUTPUTS DROPPING OFF SLIGHTLY THIS PM. IVF'S WERE INCREASED TO 150CC/HR. AFTER RECEIVING 2 FB'S THIS AM.\nCV: HYPOTENSIVE TO 70'S THIS AM. T 2 FB'S GIVEN AND FLUIDS INCREASED.\nHAVE BEEN IN THE 90'S THIS PM, WHICH IS HER NORMAL PRESSURE.\nID: AWAITING CX'S FROM LAST NIGHT. ANTIBIOTICS CONTINUED. AFEBRILE. WBC'S SLIGHTLY ELEVATED.\nNEURO: SLEEPY DURING THE DAY. + ORIENTATED.\nPAIN CONTROL: GIVEN DILAUDID 1MG SC AT NOONTIME.\nENDOC: BS 161 AT 18PM. NO SSI WRITTEN.\nSKIN INTEGRITY: COCCYX DRSG . PACKING NS W-D. ALSO HAS AN AREA ON LEFT SHOULDER NEAR AXILLA-ALSO PACKED WITH NS W-D. CX ALSO OBTAINED FROM THAT AREA. OLD SCABS NOTED ON THIGH WHERE OLD LINE WAS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2145-08-20 00:00:00.000", "description": "Report", "row_id": 1584578, "text": "MICU NPN 1900-0730:\n NEURO: Pt restarted on lower dose oxycontin (20 mg )--she did have some breakthrough backpain around 0000, but this responded well to 650 PO tylenol. Pt also c/o abdominal pain r/t fluid overload/swelling--cold compress applied with + effect. Pt A + O and able to communicate needs. She has spasms with turning--baclofen d/c'd secondary to ? MS changes, tizanidine continues to treat spasms.\n CV: Afebrile. Pt consistantly bradycardic with rate in 30's and 40's. No ectopy. BP stable. Atropine at bedside but pt stable, mentating well with low HR. Pt has been hypernatremic, but level trending down with pt on D5W with 40 meq KCl at 50 cc/hr. K+ repleted yesterday, am level pending.\n Pulm: Pt twice for large amts thin white sputum. She has VERY weak cough and cannot clear large volumes on her own. Lungs rhoncherous with diminished bases. Pt continues on 2 L NP with RR 12-16, sp02 99-100%. She continues on vanco for pneumonia--level at 1830 > 20, so dose at held MD.\n GI: Pt taking pills without difficulty (whole pills with custard, alternating with sips of water). Bowel regimen restarted and pt with small amt brown stool in rectal bag this am.\n GU: Foley draining large amts clear yellow with sediment. Foley to be replaced but awaiting involvement of GU to place specialty catheter (30F, 30 cc balloon).\n Skin: WTD dsg changes to shoulder and gluteal fold decub. Wounds with no drainage, skin around area excoriated and mascerated. Area cleansed/dried/nystatin powder applied. Rectal bag remains in place to help contain stool and keep breakdown clean.\n No inquiries from family.\n" }, { "category": "Nursing/other", "chartdate": "2145-08-20 00:00:00.000", "description": "Report", "row_id": 1584579, "text": "Nursing Note P-MICU\nS-\"When am I leaving here?\" \"The pain is bad\".\n O-Afebrile with WBC-8.7. Treating pneumonia with Vanco-last level was 40. On 2l NC with sat >98-with O2 off Sat > 95. Poor cough seems to swallow some sputum.\n C/o abd. and back pain throughout the day. Constant pain sharp and tearing. Gave oxycodone 30mg this am along with sc and iv dilaudid. Mso4 2mg X1 for break through pain. Restarted Baclofen at 20 mg this afternoon. OOB to chair with use of lift.\n Decub cleansed with NS and Dsgs reapplied. No overall change.\nA-Pneumonia\n Pain\n Alt in Skin Intergrity.\nP-Continue NT Suctioning as needed. Monitor Vanco levels and redose when appropritate.\n Assess pain and evaluate effectiveness of meds. Continue OOB to chair.\n Cont. Dsg changes. Monitor.\n Ready for transfer to floor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2145-08-20 00:00:00.000", "description": "Report", "row_id": 1584580, "text": "Nsg progress note 1530-1800\nAssumed care of pt @ 1530. Pt a+o, anticipating transfer to the floor, however @ 1700 she was accepted back to . Page 2 complete. No new issues. VSS, afebrile. On room are sat 98%. Denies distress. Team aware.\n" }, { "category": "Nursing/other", "chartdate": "2145-08-18 00:00:00.000", "description": "Report", "row_id": 1584574, "text": "NURSING MICU NOTE 2300-7A\n\nNEURO: PT 3, FOLLOWS COMMANDS. PT NOT ABLE TO MOVE BIL LOWER EXTREMITIES OR LEFT ARM, BUT DOES STATE THAT SHE HAS SENSATION IN THOSE EXTREMITIES AND TRUNK AREA. PT IS ABLE TO MOVE RIGHT ARM WEAKLY. PT C/O CHRONIC PAIN IN ABD AND BACK. PT GIVEN PRN IV HYDROMORPHONE X1 IN ADDITION TO ROUTINE PAIN MEDS. PT SLEPT THROUGH OUT NIGHT.\n\nRESP: PT ON 2L NC W/ O2 SATS 96-98%. LS COARSE. PT HAS WEAK PRODUCTIVE COUGH. DENIES ANY SOB. RR MID 20'S. PT HAS MRSA IN SPUTUM.\n\nCV: PT HAS BEEN SINUS BRADY IN MID 40'S, WILL BRIEFLY GO AS LOW AS 35 WHEN ASLEEP. NO ECTOPY. SBP STABLE 120-130'S. PT AFEBRILE.\n\nGI/GU: ABD SOFT/DISTENDED. +BS, +BM. PT HAVING LOOSE STOOL, FECAL BAG INTACT. 2400 LACTULOSE HELD. PT C/O ABD PAIN, STATED RELIEF AFTER PRN MEDS GIVEN. PT TAKES PO WELL, FOLLOWING SPEECH AND SWALLOW'S INSTRUCTIONS THAT ARE POSTED AT BEDSIDE. FOEY INTACT DRAINING YELLOW CLOUDY URINE.\n\nSKIN: LEFT SHOULDER AND LEFT GLUET DRESSING D&I, BOTH CHANGED AT 2200 BY EVENINGS. DECUB ON LEFT SHOULDER TO BE DEBRIDED IN OR. PT T&P OFF LEFT SIDE.\n\nDISPO: PT IS WAITING FOR A FLOOR BED. CONT WITH CURRENT ANTIBOTICS. ?OR DEBRIDMENT OF LEFT SHOULDER DECUB. PT REMAINS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2145-08-18 00:00:00.000", "description": "Report", "row_id": 1584575, "text": "NSG progress note 7a-7p\nNEURO: Pt has had a change in mental status today which has been her main issue. Pt has been easily arousable when calling out her name. Pt knows her name but is confused as to where she is. She did state at one point she was @ but when asked again she didn't know. Pt also calls out strange words without any context and then repeats the answer to your last question over and over. Slept most of day when not stimulated. Pupils equal and reactive 6-7mm somewhat sluggish. All po meds held today d/t risk of aspiration and sedation but most importantly Oxcycodne, hydromorphone, clonazepam, and Baclofen (question if this is the cause of her change). Pt had last received a narcotic @ midnoc and baclofen @ 0600. No improvement in MS throughout the day. A lumbar puncture was planned but consent was unobtainable. CT scan ordered, will go sometime tonight. Family called by team. Pt has a strong gag, and cough has somewhat improved.\nCV:Pt reportedly is sinus brady @ baseline. Her HR has been 30-45 maintain a good Bp >120. Her K+ was 3.6 w/am labs and was started on D5.45ns w/40KCL @75c/hr. Pt is now having some occassional PVC's. Pt is asymptomatic with low HR. Good pedal pulses. IV access left PICC DL.\nRESP: Pt has coarse rhonchi t/o. Requires nasal sx but patient refuses often. Thick white/yellow secretions suctioned. Pt does cough and needs quad coughing and chest pt to expectorate resulting in thin white secretions. On 2l NC sats 97-98% RESP: \nGI: Pt has lg soft abd w/+bos. Had diarrhea overnoc and some this am. Golden yellow in color. C-diff order obtained but no stool since. Lactulose and colace held. No c/o abd pain or any pain t/o. Pt refuse food and drink today and is an aspiration HIGH RISK.\nGU: #30 French foley to gravity w/ yellow sediment urine, adequate amounts.\nSKIN: see careview for documentation. Pt has two stage 3 pressure ulcers packed w/NS wet to dry Last done @ 12 noon. Shoulder ulcer needs OR debriding. Seen by plastics, awaiting OR date. Pt's buttocks are also pink and excoriated.\nDISP: Pt was initially called out today but it needs to be readdressed w/team probably pending CT scan. Little family involvement. Pt is a full code. Resides in an extended care facility.\nID: Pt is only on IV VANCO for MRSA in sputum. Flagyl and Zosyn d/c'd today. Pt also has yeast in sputum, afebrile (temps 95.7 apparently runs low, md level added, pt has adrenal insufficiency) WBC's today 12.8\n" }, { "category": "Nursing/other", "chartdate": "2145-08-19 00:00:00.000", "description": "Report", "row_id": 1584576, "text": "Neuro Pt with mental status change during evening hours. Pt would only state to every question and was very lethargic. Pt to CT scan nothing significant seen to change tx. LP done site intact no issues. No c/o HA. At approx 0300 Pt with full regain of mental status. Pt now baseline. Afebrile awaiting am labs.\nCArd Pt HR dipped to 29bpm during night. MD aware 12 lead ekg done and observed via md. Pt sbp 160's pt asymptomatic atropine at BS. PICC Blue port still continues to flush hard unable to obtain blood back from port. Pt on d5 at 75/hr. Pt LOS 2L+. 255 for 24hr.\nRR Pt weaned off of O2 from 6lnc. Pt percussed Q4hr and NTSX Q4hr. Pt with thick yellow secr. Unable to clear on own.\nGI Pt taking custard and pills without difficulty after able to sit up after LP. Sl stool in rectal bag.\nGU Pt's urine very cloudy with sediment. Urine collected will notify MD and may send to lab.\nSocial. Pt expressing she \"wants to go back home\" meaning nursing home. NO calls, No visiters during the evening hours. Pt may be called out today.\nSKIN Pt to be seen via plastics reguarding decubiti sites. MD in to view sites at time of LP.\n" }, { "category": "Nursing/other", "chartdate": "2145-08-19 00:00:00.000", "description": "Report", "row_id": 1584577, "text": "Micu Progress Nursing Note:\n\nNeuro: Alert and oriented to person, place and season of year, although unsure of month. Can hold up right arm, but cannot move other extremities secondary to quadraplegia. Pupils 4mm and reactive, although right pupil is slightly sluggish.\n\nCV: Asymptomatic SB 30s to 40s; no ectopy. Atropine at bedside. SR at\n~ 1pm, 70s. BP 150s to 160s systolic over 70s to 80s, decreasing to one teens to 130s over 60s at ~1pm. Easily palpable dorsalis pedis pulses; posterior tibialis pulses weakly palpable secondary to plus one edema lower extremities. Extremities warm to touch.\n\nResp: On room air this am with sats mid 90s. Patient does de-sat to low 80s with -pharangeal suctioning. Application of 4 liter, decreased to 2 liters brought her sats back up to high 90s. O2 at 2L maintained secondary to bradycardia. Suctioned for small amounts of white clear secretions. Lung sounds coarse throughout. Given vigourous chest PT by physical therapist.\n\nGI/GU: Foley cath draining yellow urine with sediment. Cath is 30 FR, with 30cc balloon, to be changed. Patient was having diarrhea on previous shifts and rectal bag was applied. Stool is now soft, not liquid, but new rectal bag applied to protect right gluteal fold decubitus. Patient is on aspiration precautions. Takes pills whole with custard and sips of water.\n\nEndrocrine: Patient does not like to take Solu-Cortef as she feels that this makes her face \"puffy\". She refused am Solu-cortef and also her Fludrocortisone. The team did speak to her about the necessity of taking these meds because of her adrenal insufficiency. They did DC her stress level cortisone and institute a Prednisone taper. She did agree to take her Fludrocortisone and did start her first dose of Prednisone today, 20mg. Patient's sodium level >150 today. IV changed to D5W with 40 meq KCL at 50cc/hr for one liter. Labs sent at 1pm, and are pending.\n\nSkin: Patient has two decubiti, stage 3, which have been looked at by Plastics. She is supposed to go for debridement of right shoulder decubitus, date to be set. Dressings were changed for both decubiti. Right shoulder wound base is yellow. Right gluteal fold wound bed is red, draining small amounts of sero-sanguinous drainage. This wound appears clean. Peri area is red, slightly excoriated. Order for Miconozole powder written. Patient needs frequent turning.\n\nPlan: Patient is called out to floor today. Continue with antibiotics for MRSA in sputum. Push PO fluids; hold Baclofen, continue with good pulmonary toilet--suctioning and chest pt.\n\n RN\n" }, { "category": "Nursing/other", "chartdate": "2145-08-17 00:00:00.000", "description": "Report", "row_id": 1584572, "text": "pmicu nursing progress 7a-3p\nreview of systems\nCV-vs have been stable with bp in the 130's/. HR did dip to the low 40's SB with pt asleep but bp was stable.\nRESP-has been on 2 litres NC with good sats.lungs sound coarse throughout.pt has a weak cough, nonproductive.was seen by speech and swallowing RN, please see her note. was not sx yet today,to be seen by CPT this afternoon.NEEDS ASPIRATION PRECAUTIONS!\nGI-had very little to eat, is really thirsty.taking water well.has decreased bowel sounds.c/o RLQ pain and requesting ice packs for that area. no stool today.to start on colace as well as lactulose.went for abd US this afternoon-results pnd.did not have lunch due to US.on protonix.\nID-is hypothermic with temp ~95-96 po. wbc increased to 13 today. on zosyn, vanco and flagyl iv.contact precautions for MRSA in sputum.\nNEURO-is alert and oriented x 3,cooperative.pt told me she could not move her limbs but i was told she could move her arms.she had multiple c/o pain, even while falling asleep. is on oxycontin q 12, also dilaudid .5- 1.0 q 6 hrs prn as well as morphine. asked for dilaudid on the dot of 12.now sleeping.no c/o bladder spasms-can have ditropan.\nF/E- ivf infusing at KVO.has had an adequate urinary output, cloudy light yellow urine.please see labs as listed in carevue.\nSKIN- skin care was done at 6am and i am awaiting the plastics team to eval, debride L scapula and sacrum decub.L shoulder reportedly has brown foul smelling drainage.pt repositioned a few times but needs to have HOB most of the time.has splints on legs.\na-no change, ready for transfer to medical floor.\nP-aspiration precaution guidelines as per speech and swallowing RN posted above her bed.skin care as per plastics team.\nwill continue with pain meds-need to stay on top of bowel meds with so many narcotics.\n" }, { "category": "Nursing/other", "chartdate": "2145-08-17 00:00:00.000", "description": "Report", "row_id": 1584573, "text": "SKIN: continue wet to dry dsg (plastics changed dsg) 1st step air mattress ordered. pt oob to chair via lift, prom x4 extremities.\n\nRESP: cpt following pt. no secretions to sx. continues w/ 2 l n/p O2 sats 96%\n\nID: afebrile continues on Flagyl, Vanco, and Zosyn\n\nGI: good appetite this evening. feed slowly, HOB elevated 90 degrees, keep upright 45 minutes after. taking in sips of liquid\n\nGU: uo good 40 cc/hr foley not leaking. urine yellow, cloudy\n\nNEURO: A+Ox3, napping on/off, pt c/o chronic back pain, requesting her Oxycodone q 12hrs, and prn Hydromorphone 1 mg q 6 hrs.\n\nA/P: awaiting transfer to floor (no beds available) continue CPT, pulm toilet, oob - chair, cont. antibx, aspiration precautions.\n" }, { "category": "Nursing/other", "chartdate": "2145-08-16 00:00:00.000", "description": "Report", "row_id": 1584569, "text": "micu/sicu nursing progress note\n*** patient given her valubles envelope to hold on to for ride over in ambulance to the .\n" }, { "category": "Nursing/other", "chartdate": "2145-08-16 00:00:00.000", "description": "Report", "row_id": 1584570, "text": "nursing update note.\npt arrived from micu east via ambulance at 1725.pt is awake,alert but lethargic at times. oriented x3,pupils perl.remains sb without ectopy with stable bp.dr has been in to evaluate pt orders are being written.breath sounds clear but diminished bibasilar,spo2 97%to 99%,resp rate 13 to 20 on 4lnp.abd large and distended with positive bowel sounds incontinent of small amount of green stool on admission.foley cath to cd draining amber urine.left shoulder decubit dsg changed,base is yellow. decubit near rectum was changed,base was pink,wet to dry dsg .pic line in left arm wnl.\n" }, { "category": "Nursing/other", "chartdate": "2145-08-17 00:00:00.000", "description": "Report", "row_id": 1584571, "text": "Neuro Pt slept most of night. Awoken for assessments. Pt c/o pain whenever in room yet pt sleeping upon reentering with med. Pt with h/o unresponsiveness d/t overmedication. PT on oxycodone Q12. Pt also requests dilaudid after given mso4 this am. WBC yest 9.2 to 13 this am.\n\nCard Pt Bradycardic into 30's during night. Pt stable with it. No intervention this is pt baseline. Atropine at BS. K 3.5 this am. HCT 33. Pt with Lac PICC in place. Blue Port difficult to flush.\n\nRR Pt On 2lnc this am. Pt with cough yet does not clear all secretions mostly spits saliva. Pt sx this am along with percussed obtained thick copious lrg amount yellow sputum. Pt claimed she feels better after sx. Tol well.\n\nGI Pt active bs. C/o abd pain along with back pain. 1 stool in night heme neg gelatenous green. BS wnl.\n\nGU Pt with 30fr foley 30cc balloon cloudy yel urine. I/o adequate.\n\nSKIN Pt upper back area with brown center and foul odor. NEEDS DEBRIDMENT! See flow for rest. Pt will need 1st step mattress if cont to be in hospital.\n" }, { "category": "ECG", "chartdate": "2145-08-19 00:00:00.000", "description": "Report", "row_id": 155246, "text": "Sinus bradycardia. No significant change compared to the previous tracing\nof .\n\n" }, { "category": "ECG", "chartdate": "2145-08-16 00:00:00.000", "description": "Report", "row_id": 155247, "text": "Sinus bradycardia. Since the previous tracing of the rate has slowed\nand Q-T interval has become prolonged.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2122-02-27 00:00:00.000", "description": "MR CHEST/MEDIASTINUM W&W/O CONTRAST", "row_id": 814366, "text": " 2:08 PM\n MR CHEST/MEDIASTINUM W&W/O CONTRAST; MR RECONSTRUCTION IMAGING Clip # \n MR CONTRAST GADOLIN\n Reason: MRI/MRA CHEST TO EVALUATE PATIENT'S AORTIC DISSECTIONExam ne\n Contrast: MAGNEVIST Amt: 20CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n S/P HIGH SPEED MVC ON \n REASON FOR THIS EXAMINATION:\n MRI/MRA CHEST TO EVALUATE PATIENT'S AORTIC DISSECTIONExam needed as TEE not\n available while pt. not in unit - please expidite.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Possible aortic dissection.\n\n TECHNIQUE:\n MRI examination of the chest was performed utilizing T1-weighted and T2-\n weighted sequences, including 3D gradient echo multiphasic dynamic sequences\n without and with intravenous gadolinium contrast.\n\n Multiplanar reformatted images were generated on workstation and reviewed,\n which is essential for delineation of anatomy.\n\n FINDINGS:\n The aorta demonstrates normal morphology, without focal aneurysmal dilatation\n or evidence of dissection. The arch vessels are patent, demonstrating normal\n directional flow. There is no mediastinal hematoma. No mediastinal masses are\n seen.\n\n There are small bilateral pleural effusions, with associated significant\n bibasilar atelectasis.\n\n IMPRESSION:\n No evidence of aortic dissection.\n\n" }, { "category": "Radiology", "chartdate": "2122-02-25 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 814116, "text": " 10:29 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: S/P MVA;MULTIPLE FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with multiple lower extremties injuries\n REASON FOR THIS EXAMINATION:\n preop\n ______________________________________________________________________________\n FINAL REPORT\n Pre-op chest this is a repeat dictation for a previously lost report.\n\n CLINICAL INDICATION: Multiple lower extremity injuries. Pre-operative\n assessment.\n\n The lateral chest radiograph is technically suboptimal due to extensive motion\n artifact and low lung volumes.\n\n The heart size is within normal limits allowing for low lung volumes. The\n mediastinal and hilar contours are normal. Patchy and linear areas of\n opacification are seen in both lower lung zones again note is also made of a\n small left pleural effusion. It is difficult to fully exclude a small right\n pleural effusion on the lateral view. Degenerative changes are noted within\n the spine.\n\n IMPRESSION: Patchy and linear bibasilar opacities, most likely due to\n atelectasis. Small left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2122-02-25 00:00:00.000", "description": "L CT LOW EXT W/O C LEFT", "row_id": 814093, "text": " 8:00 AM\n CT LOW EXT W/O C LEFT; CT RECONSTRUCTION Clip # \n Reason: assess L tibial plateau fx, with fine cuts amd reconstructio\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man s/ pMVA\n REASON FOR THIS EXAMINATION:\n assess L tibial plateau fx, with fine cuts amd reconstructions\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left tibial plateau fracture following MVA.\n\n COMPARISONS: Left lower extremity radiograph dated .\n\n TECHNIQUE: contiguous axial images of the left knee were obtained without IV\n contrast. Sagittal and coronal reconstruction images were also obtained.\n\n LEFT KNEE CT WITHOUT CONTRAST: There is a markedly comminuted fracture of\n both medial and lateral tibial plateau. Fracture lines involve the articular\n surface and extends inferiorly to the medial aspect of the proximal tibial\n diaphysis. No free bone fragments are seen within the joint space. The\n fracture is impacted and shows marked posterior angulation of the distal\n fracture fragment. Also seen is a minimally displaced fracture of the\n proximal fibula. Distal femur and patella are intact.\n\n Sagittal and coronal reconstruction images show marked comminuation and\n angulation of the tibial plateau fracture which extends into the knee joint.\n\n IMPRESSION: Severe comminution and angulation of left tibial plateau fracture\n with intra-articular involvement but no intra-articular free bone fragments.\n Minimally displaced fracture of proximal fibula.\n\n" }, { "category": "Radiology", "chartdate": "2122-02-25 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 814173, "text": " 4:27 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: eval for aortic injury/rib fx/pneumothorax\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with high speed mvc, initial trauma consult just donecreatinine\n 1.2 on at outside hospital\n REASON FOR THIS EXAMINATION:\n eval for aortic injury/rib fx/pneumothorax\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: High speed motor vehicle accident.\n\n TECHNIQUE: Contiguous axial images were obtained from the lung apices through\n the pubic symphysis after the administration of 150 cc of Optiray contrast\n intravenously. Optiray was used per fast bolus protocol. Oblique sagittal\n reformations were obtained through the aorta.\n\n CT CHEST WITH INTRAVENOUS CONTRAST: The heart, pericardium, and great vessels\n are normal. Specifically there is no evidence of aortic injury. There is no\n mediastinal, hilar, or axillary lymphadenopathy. The airways are patent\n through the segmental level bilaterally. There is bibasilar dependent\n atelectasis. There are no pleural effusions or pneumothoraces.\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, gallbladder, spleen,\n pancreas, adrenal glands, kidneys, ureters, and bowel loops are normal. There\n is no free fluid, free air, or lymphadenopathy.\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder is collapsed and a\n Foley catheter is in place. The sigmoid colon and rectum are unremarkable.\n There is no free fluid or lymphadenopathy.\n\n There are no suspicious lytic or sclerotic osseous lesions.\n\n CT REFORMATIONS: Reformations through the aortic arch were useful in\n excluding the possibility of traumatic aortic injury.\n\n IMPRESSION:\n 1. No evidence of aortic injury or pneumothorax.\n 2. No evidence of acute trauma to the abdomen and pelvis.\n 3. Atelectasis at the lung bases bilaterally.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-02-25 00:00:00.000", "description": "CT L-SPINE W/O CONTRAST", "row_id": 814174, "text": " 4:29 PM\n CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: eval for fx/subluxation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with\n REASON FOR THIS EXAMINATION:\n eval for fx/subluxation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post trauma. Evaluate for fracture or subluxation.\n Rationale for exam not entirely clear as apparently no radiographs and no\n localizing history (both thtoracic and lumbar spine imaged).\n\n TECHNIQUE: Multiple axial images of the thoracic and lumbar spine were\n obtained with 1.25 mm collimation. Sagittal and coronal reconstructions.\n\n FINDINGS: The thoracic and lumbar vertebral body heights, disc spaces and\n alignment are within normal limits. There is no effusion, compression\n fracture, or retrolisthesis.\n\n IMPRESSION: Normal.\n\n" }, { "category": "Radiology", "chartdate": "2122-02-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 814381, "text": " 3:45 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o ICH\n Admitting Diagnosis: S/P MVA;MULTIPLE FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man s/p MVC with ?aortic dissection on CTA, mental status is\n off. Please do either before or after MRI planned for 4 pm so pt is moved from\n ICU only once.\n REASON FOR THIS EXAMINATION:\n r/o ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motor vehicle accident with aortic dissection on CTA in the ICU\n with mental status changes.\n\n TECHNIQUE: Axial non-contrast CT scans of the brain were obtained.\n\n FINDINGS:\n\n No previous studies are available for comparison.\n\n Brain parenchymal attenuation is normal. -white matter differentiation is\n preserved. The ventricles are not dilated. There is no shift of intracranial\n structures.\n\n Bone window images reveal no lytic or destructive changes of the skull.\n\n The visualized paranasal sinuses and mastoids are clear.\n\n IMPRESSION: No evidence of intracranial hemorrhage or edema.\n\n" }, { "category": "Radiology", "chartdate": "2122-02-27 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 814324, "text": " 8:40 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: PE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL ADDENDUM\n Addendum: Segmental reconstructions performed by Dr. confirm\n that appearances of ascending aorta are pulsation artefact and not an aortic\n dissection.\n\n\n 8:40 AM\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 52 year old man with high speed mvc, initial trauma consult just\n donecreatinine 1.2 on at outside hospital, desat overnight\n REASON FOR THIS EXAMINATION:\n please r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: High speed MVA on , now with T saturation overnight.\n\n CTA OF THE CHEST WITH AND WITHOUT CONTRAST:\n\n TECHNIQUE: Axial pre and post contrast CT images of the chest with\n multiplanar reformats using the pulmonary CTA protocol.\n\n COMPARISON: .\n\n FINDINGS: There is moderate amount of bibasilar atelectasis. The lungs are\n otherwise clear. There are small bilateral pleural effusions.\n\n The pulmonary arteries enhance in a normal fashion without evidence of\n pulmonary embolus.\n\n Along the medial aspect of the ascending aorta, there is a curvilinear area of\n contrast enhancement which is not directly contiguous with the ascending\n aorta. There is pulsation artifact along the anterior and lateral aspect of\n the aorta and a curvilear lucenct area seen along the medial aspect of the\n ascending aorta could represent pulsation artifact as well. However, this\n cannot be definitively proved at this point and the differential diagnosis\n would include a focal ascending aortic dissection. There is no mediastinal\n hematoma. The aorta otherwise enhances in a normal fashion. Further evaluation\n is recommended, preferably with MRA of the chest. An alternative assessment\n method would be conventional aortic arteriography.\n\n These findings have been directly discussed with Dr. at approximately\n 1:30 p.m. on . He has indicated the request for MR aortogram will be\n placed in the computer system promptly. The findings have also been discussed\n with the MRI service and they are aware of the pending request for MRI.\n\n IMPRESSION:\n\n 1. Area of enhancement adjacent to the medial aspect of the ascending aorta\n which most likely represents pulsation artifact, however, differentiation from\n a focal ascending aortic dissection is not definitively excluded on this study\n and therefore further evaluation with MRA of the chest is recommended (r\n alternatively a conventional aortogram can be performed.)\n\n 2. No pulmonary embolus.\n (Over)\n\n 8:40 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: PE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Moderate bibasilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-03-02 00:00:00.000", "description": "OL TIB/FIB (AP & LAT) IN O.R. LEFT", "row_id": 814617, "text": " 11:11 AM\n TIB/FIB (AP & LAT) IN O.R. LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. LEFTClip # \n KNEE (3 VIEWS) IN O.R. RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. RIGHT\n Reason: ORIF LT TIBIA\n Admitting Diagnosis: S/P MVA;MULTIPLE FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ORIF left tibia.\n\n Fluoroscopic assistance was provided to the surgeon in the O.R., without the\n radiologist present. Eleven spot views were obtained. Although these are all\n labelled by the technologist as left, based on prior films, they appear to\n represent spot views of both the right and left knees. Again, based on prior\n views, there is a comminuted fracture of the right patella with distraction\n and steps during buttress plate fixation of a left-sided tibial plateau\n fracture. Fluoro time was not recorded on the electronic requisition. Slight\n irregularity about the left proximal tibia may indicate the presence of a\n fracture there as well.\n\n" }, { "category": "Radiology", "chartdate": "2122-02-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 814304, "text": " 12:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: patient with fever, hypoxia, eval for infiltrate/effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with\n REASON FOR THIS EXAMINATION:\n patient with fever, hypoxia, eval for infiltrate/effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever and hypoxia.\n\n Comparison: .\n\n PORTABLE CHEST: The lung volumes are low. Accounting for this the heart size\n and pulmonary vasculature are within normal limits. There is blunting of the\n left CPA. Bibasilar opacities, left greater than right persist. There is no\n pneumothorax.\n\n IMPRESSION: Persistent bibasilar atelectasis vs. pneumonia. No definite CHF.\n\n" }, { "category": "Radiology", "chartdate": "2122-03-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 814883, "text": " 11:05 AM\n CHEST (PA & LAT) Clip # \n Reason: pneumonia status, resolving??\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with multiple lower extremties injuries\n\n REASON FOR THIS EXAMINATION:\n pneumonia status, resolving??\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow up pneumonia.\n\n COMPARISON: .\n\n AP AND LATERAL VIEWS OF THE CHEST:\n There is improvement in the lung volumes. There is interval improvement in the\n bibasilar atelectasis/consolidations. There is tiny residual linear\n atelectasis in the left lung base. The heart, mediastinal and hilar contours\n are stable.\n\n IMPRESSION:\n Interval improvement and near-resolution of the bibasilar atelectasis. There\n is tiny residual linear atelectasis in the left base.\n\n" }, { "category": "Radiology", "chartdate": "2122-02-25 00:00:00.000", "description": "B ANKLE (AP, MORTISE & LAT) BILAT", "row_id": 814117, "text": " 10:29 AM\n ANKLE (AP, MORTISE & LAT) BILAT; FOOT AP,LAT & OBL RIGHT Clip # \n KNEE (AP, LAT & OBLIQUE) BILAT; TIB/FIB (AP & LAT) SOFT TISSUE BILAT\n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with multiple lower extremties injuries and pain\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n Hx: Multiple injuries of bilateral lower extremities.\n\n RIGHT KNEE, THREE VIEWS: There is a comminuted and displaced fracture of the\n patella. Tibiofemoral joint appears intact.\n\n LEFT KNEE, THREE VIEWS: There is a comminuted and slightly displaced fracture\n of the proximal left tibia which extends into both its lateral and medial\n articular surfaces. There is also a minimally displaced fracture of the\n proximal left fibula. Patellar and distal femur appear intact.\n\n RIGHT TIB/FIB, TWO VIEWS: There are no fractures or dislocations identified.\n\n LEFT TIB/FIB, TWO VIEWS: There are fractures of the proximal tibia and fibula\n as described above. No fracture or dislocations of the mid-shaft and distal\n tibia and fibula are seen.\n\n RIGHT ANKLE, THREE VIEWS: There is an avulsion fracture of the distal fibula.\n No other fractures or dislocations are seen. Ankle mortise is congruent. Soft\n tissue swelling over the lateral malleolus is present.\n\n LEFT ANKLE, THREE VIEWS: There are no fractures or dislocations. Ankle\n mortise is congruent. Incidentally seen is a plantar spur.\n\n IMPRESSION: Multiple fractures involving the right patella, left proximal\n tibia and fibula, and distal right fibula.\n\n" }, { "category": "Radiology", "chartdate": "2122-02-25 00:00:00.000", "description": "L SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT", "row_id": 814118, "text": " 10:29 AM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT Clip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with multiple lower extremties injuries and pain\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left shoulder pain.\n\n LEFT SHOULDER, THREE VIEWS: Exam is normal. There are no fractures or\n dislocations. Bone mineralization is normal. Soft tissues are unremarkable.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-02-28 00:00:00.000", "description": "Report", "row_id": 1349583, "text": "Nursing Process Note: 1900-0700\nNEURO: A&O X3. Cooperative with care except with leg immobilizers; states causes too much pain. Anxious/restless at times c/o generalized body pain/discomfort. Received Dilaudid IV for pain and one dose of Ativan 1mg PO for slight hand tremors and generalized anxiety. Denies specific headache or tactile issues. States no appetite but no c/o nausea. Also received Benadryl 25mg PO for insomnia with little effect; dozing intermittently throughout shift.\n\nRESP: LS cta, sats mid to high 90s on 3L nasal cannula. Desats to 80s when O2 removed.\n\nC/V: BP stable on PO Lopressor; SBP 120-130s, HR 80s, no ectopy. D5 1/2 NS @ 80/hr. Hct 28.2.\n\nGI/GU: Abdomen soft, present sounds. No BM. Continues NPO (per transfer orders). Foley patent for cyu.\n\nSKIN: Multiple bruises throughout; left leg raised on pillow (patient states immobilizer too uncomfortable and removes).\n\nSOCIAL: Patient spoke with friends on telephone regarding plan for surgery.\n\nDISPO: Full code; call out to floor.\n" }, { "category": "Nursing/other", "chartdate": "2122-02-28 00:00:00.000", "description": "Report", "row_id": 1349584, "text": "nursing note\npt to be transfer to cc607,stable,please see transfer note.\n" }, { "category": "Nursing/other", "chartdate": "2122-02-27 00:00:00.000", "description": "Report", "row_id": 1349582, "text": "MICU NURSING ADMIT NOTE:\n Please see handwritten note in chart.\n" }, { "category": "ECG", "chartdate": "2122-02-28 00:00:00.000", "description": "Report", "row_id": 194432, "text": "Sinus rhythm\nNonspecific ST-T wave changes\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2122-02-25 00:00:00.000", "description": "Report", "row_id": 194433, "text": "Sinus rhythm. Borderline P-R interval. Probably within normal limits. Slight\ninferolateral T wave changes are non-specific. No previous tracing available\nfor comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2163-03-20 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1179980, "text": " 10:09 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: eval for ileus vs obstruction\n Admitting Diagnosis: DIVERTICULITIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with ?aspiration pneumonia and increased abdominal distension\n post op day 5 after s/p lap assisted-open sigmoid colectomy\n REASON FOR THIS EXAMINATION:\n eval for ileus vs obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN ON \n\n HISTORY: 76-year-old woman with possible aspiration pneumonia and increased\n abdominal distention.\n\n IMPRESSION: Three frontal views of the supine abdomen and two of the left\n decubitus abdomen demonstrate moderate, proportionate dilatation of large and\n small bowel with fluid levels indicating stasis, probably due to a paralytic\n ileus. There is no free intraperitoneal gas.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-03-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1179981, "text": " 10:09 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for PNA\n Admitting Diagnosis: DIVERTICULITIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with ?aspiration pneumonia\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: Possible aspiration, rule out pneumonia.\n\n IMPRESSION: AP chest compared to , through :\n\n Severe cardiomegaly is longstanding, but along with mediastinal vascular\n engorgement has increased since . Pulmonary vasculature is normal and\n there is no pulmonary edema or appreciable pleural effusion. Bilateral\n infrahilar consolidation is worsening, but in light of the low lung volumes\n could be atelectasis. Stomach is distended with air and fluid. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-03-15 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1179265, "text": " 12:48 PM\n PORTABLE ABDOMEN Clip # \n Reason: MISSING INSTRUMENT\n Admitting Diagnosis: DIVERTICULITIS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Missing surgical instrument in the OR.\n\n STUDY: Supine frontal view of the abdomen.\n\n FINDINGS:\n\n The patient has undergone surgery with a drain within the pelvis from a left\n pelvic approach and surgical skin staples overlying the lower abdomen and\n central pelvis. The inferior most 1-2 cm of the pelvis is not included on the\n study nor are the lateral 1-2 cm of the flanks bilaterally and all of the\n diaphragm, however, as the missing surgical instrument was a large pair of\n clamps measuring 20 cm in length, it is not possible that thiscould be on the\n excluded portions of the abdomen or pelvis. Lower lumbar spinal hardware is\n noted.\n\n Findings were discussed by Dr. with Dr. , who was in the\n operating room, at 13:05 on .\n\n" }, { "category": "Radiology", "chartdate": "2163-03-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1179276, "text": " 1:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement, evaluation of thoracic aorta\n Admitting Diagnosis: DIVERTICULITIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with refractory hypotension following sigmoid colectomy\n REASON FOR THIS EXAMINATION:\n ETT placement, evaluation of thoracic aorta\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old female with refractory hypotension during sigmoid\n colectomy. Evaluate endotracheal tube placement and thoracic aorta.\n\n COMPARISON: and CT dated .\n\n TECHNIQUE: Single AP radiograph of the chest was obtained with the patient in\n the supine position.\n\n FINDINGS: The endotracheal tube is visualized with tip approximately 5 cm\n above the carina. A right internal jugular line is seen with tip in the low\n SVC. Lung volumes are low. There is cardiomegaly, which is similar-appearing\n compared to prior. The mediastinum is widened, which was visualized\n previously; however, on most recent prior, the trachea is deviated to the\n right, and on current exam, the trachea is midline. This raises concern for\n acute process in the right mediastinum shifting and the trachea to the left.\n Possibilities include acute ascending aortic pathology. The left costophrenic\n angle is not included in this view. There is no right pleural effusion or\n pneumothorax.\n\n IMPRESSION: Persistently widened mediastinum with interval shift of the\n trachea from the right to the midline, concerning for ascending aortic\n pathology.\n\n These findings were extensively discussed with Dr. by Dr. \n by telephone at 2:40 p.m. on . Further evaluation of the aorta with\n CT or echocardiography is strongly recommended.\n\n" }, { "category": "Radiology", "chartdate": "2163-03-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1179483, "text": " 1:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: any acute process?\n Admitting Diagnosis: DIVERTICULITIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with sudden fever and delirium\n REASON FOR THIS EXAMINATION:\n any acute process?\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Fever and delirium.\n\n Comparison is made with prior study, .\n\n Cardiomegaly and widened mediastinum are unchanged. Increasing bibasilar\n opacities are likely increasing atelectasis, but superimposed infection cannot\n be excluded. There are lower lung volumes. There is no pneumothorax or large\n pleural effusions. Right IJ catheter tip is in the upper SVC.\n\n\n" }, { "category": "ECG", "chartdate": "2163-03-14 00:00:00.000", "description": "Report", "row_id": 277374, "text": "Sinus rhythm. Biphasic to inverted T waves in leads V2-V5 similar to that\nrecorded on . No diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2163-03-18 00:00:00.000", "description": "Report", "row_id": 277372, "text": "Sinus rhythm. There is an RSR' pattern in lead V1 which is probably normal.\nNon-specific ST-T wave changes. Low voltage in the precordial leads.\nCompared to the previous tracing of there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2163-03-16 00:00:00.000", "description": "Report", "row_id": 277373, "text": "Sinus rhythm. The Q-T interval is prolonged. There is an RSR' pattern in\nlead V1 that is probably normal. Non-specific ST-T wave changes. Low voltage in\nthe precordial leads. Compared to the previous tracing of ST-T wave\nchanges are more extensive and precordial lead voltage has decreased.\n\n" }, { "category": "ECG", "chartdate": "2163-03-20 00:00:00.000", "description": "Report", "row_id": 277151, "text": "Sinus rhythm. Compared to the previous tracing there is no change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2163-03-20 00:00:00.000", "description": "Report", "row_id": 277152, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nRSR' pattern is similar.\nTRACING #1\n\n" } ]

[ { "category": "Nursing", "chartdate": "2119-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591672, "text": "Synopsis per prior nursing note:\n Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Hypernatremia (high sodium)\n Assessment:\n Na 146, k 3.6.\n Action:\n Received 2^nd L of D5W @ 100cc/hr. Given 1L D5W with 40mEq potassium @\n 100cc/hr, started @ 0200. NGT with residuals of 600cc x2. NGT placed on\n intermittent suction. Given lactulose enema.\n Response:\n Repeat Na . Stool output ~2L, liquid stool.\n Plan:\n Monitor electrolytes.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 97-153 while on insulin gtt.\n Action:\n NPO. FS monitored q1hr while on insulin gtt. Given evening dose of\n lantus. Insulin gtt turned off @ 0100, FS 153 and given 7units(half\n dose) of humalog.\n Response:\n Plan:\n Monitor FS q4hrs.\n Cirrhosis of liver, alcoholic\n Assessment:\n Confused, garbled speech, not following commands, purposeful movements\n of extremities, occasionally combative, +ascites.\n Action:\n Attempted to reorient. Soft wrist restraints continued d/t patient\n attempting to pull out lines. Given PR lactulose.\n Response:\n No change in mental status.\n Plan:\n Lactulose PR .\n" }, { "category": "Physician ", "chartdate": "2119-08-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 591771, "text": "Chief Complaint:\n 24 Hour Events:\n Liver following - gave albumin, lactulose\n - In ICU for insulin drip - will d/c drip tonight. plan to c/o to floor\n tomorrow.\n - NGT placed, good placement\n - Hypernatremia - another 1L of D5W\n - Ordered TSH, will discuss synthroid tomorrow\n - Lactulose from NGT held for high residuals\n - large BM x1 after lactulose enema.\n - Discontinued coumadin given INR>3\n No change MS\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Piperacillin - 02:46 AM\n Ciprofloxacin - 10:19 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:18 AM\n Heparin Sodium (Prophylaxis) - 11:46 PM\n Morphine Sulfate - 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 07:47 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: 36.2\nC (97.1\n HR: 110 (90 - 128) bpm\n BP: 132/90(101) {108/82(91) - 169/104(118)} mmHg\n RR: 15 (14 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 92.2 kg (admission): 90.6 kg\n Height: 67 Inch\n Total In:\n 3,487 mL\n 926 mL\n PO:\n TF:\n IVF:\n 3,087 mL\n 926 mL\n Blood products:\n 50 mL\n Total out:\n 1,363 mL\n 1,305 mL\n Urine:\n 763 mL\n 155 mL\n NG:\n 600 mL\n 1,150 mL\n Stool:\n Drains:\n Balance:\n 2,124 mL\n -379 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n Cardiovascular: NG tube in place\n PERRLA, unable to follow commands+language\n CVS: RRR, no MRG, S1S2 clear\n Rhonchorous throughout lung fields.\n abd:+ve bs/ tense/ tympanic/ round.\n little urine, hematuria, no clots\n wwp\n Labs / Radiology\n 147 K/uL\n 10.5 g/dL\n 137 mg/dL\n 3.1 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 44 mg/dL\n 109 mEq/L\n 147 mEq/L\n 32.6 %\n 13.0 K/uL\n [image002.jpg]\n 02:56 AM\n 09:58 AM\n 02:35 PM\n 10:00 PM\n 03:09 AM\n 04:45 AM\n WBC\n 7.1\n 9.4\n 13.0\n Hct\n 30.0\n 30.6\n 32.6\n Plt\n 102\n 108\n 147\n Cr\n 2.9\n 2.9\n 2.8\n 3.0\n 2.8\n 3.1\n Glucose\n 191\n 195\n 188\n 183\n 660\n 137\n Other labs: PT / PTT / INR:36.7/39.4/3.8, ALT / AST:, Alk Phos / T\n Bili:120/1.5, Differential-Neuts:84.7 %, Lymph:8.5 %, Mono:2.9 %,\n Eos:3.6 %, Albumin:4.8 g/dL, LDH:273 IU/L, Ca++:10.6 mg/dL, Mg++:2.1\n mg/dL, PO4:3.2 mg/dL\n Imaging: no imaging today. NG tube in place\n Microbiology: 4 blood cx pending.\n UCx pending.\n Peritoneal fluid:gram stain negative, no growth preliminary.\n Toxo Ab pending.\n ECG: none\n Assessment and Plan\n INEFFECTIVE COPING\n HYPERNATREMIA (HIGH SODIUM)\n LIVER FUNCTION ABNORMALITIES\n CIRRHOSIS OF LIVER, ALCOHOLIC\n DIABETES MELLITUS (DM), TYPE II\n ACUTE CONFUSION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Leukocytosis: From 9.0 this am to 13.-0 without fever. Pt admitted with\n suspected infection given hyperglycemia, and treated empirically, only\n now developing infection. Regarding source, SBP v.unlikely since just\n had unremarkable diagnostic tap and on cipro prophylaxis, UTI possible\n given new hematuria on exam today (however INR3.8), line infection, PNA\n to be considered. Difficult to invoke CNS infection given MS \nted to hepatic encephalopathy, continue to consider. On multiple\n abx, consider c.diff.\n -d/c superfluous/inciting abx (ciprofloxacin)\n - Stool Cx\n -Sputum Cx\n CXR\n -cont zosyn, vanc. Consider flagyll\n Altered mental status:\n Head CT negative. Abd u/s unchanged. Diagnostic para not revealing.\n Hypernatremic. Hyperglycemia and enceph suggests possibility of\n infection. Pt originally presented with abdominal pain that was not\n notable on exam but uncomfortable to patient, even in setting of no\n encephalopathy; pt currently moaning mournfully consistent with past\n presentation.\n has had haldol on the floor, continuing this as prn; not clear whether\n this will be helpful other than as sedative, and will consider very low\n dose morphine as trial of pain relief; Tylenol at low dose also.\n - covering w vanc/zosyn\n - gently correcting hypernatremia though doubt this is major\n contributor, with D5W for free water deficit.\n -Continue lactulose enema\n - f/u 4 blood cx pending, Ucx pending, peritoneal fluid gram stain\n negative, no growth preliminary.\n Liver failure\n Not yet listed for transplant. Transplant committee asking for\n colonoscopy and outpatient relapse therapy. Liver today indicated\n continue on this course. DC\nd midodrine given HTN. Specific\n interventions: albumin; lactulose.\n Tense/ obese ascetic abdomen with compartment syndrome possibly\n contributing to ileus and renal failure however unable to remove large\n volumes given risk rapid fluid shifts. Remove 2.5 L ascitic fluid,\n while giving albumin,\n Hyperglycemia / diabetes\n Likely secondary to infection given change over last several days\n coinciding w worsening encephalopathy. GFS ranged 49-153 on insulin\n drip, 170s when drip dc\n -Continue q4 GFS\n - continue lantus/HISS\n Hypernatremia\n Likely 2.2 poor intake.\n NS did nothing to correct this, consistent w\n high sodium avidity. Currently on D5W with free water deficit of 0.7L.\n Once completes this L of D5W, check lytes, consider whether needs\n further.\n Renal failure: 2.8 today from 3.0 y/d.\n ?Abdominal compartment syndrome vs s/p drug toxicity, unclear etiology.\n Liver failure likely contributing to some degree of pre-renal failure\n although the degree of resolution suggests against HRS. Continue\n albumin as per floor team. Follow Cr and urine output closely. No\n urgent indication for HD. Renal following, will follow up recs.\n Hematuria likely related to supratherapeutic INR however in setting\n leukocytosis without source, check UA, U Cx.\n Hypothyroidism\n Mild hypothyroidism from tests from . Team discontinued prior\n synthroid, not clear why from notes; will discuss with them in AM.\n Coagulopathy/anticoagulation\n Hold warfarin given supratherapeutic INR 3.8\n Check daily INR.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n ICU Care\n Nutrition: via NGT\n Glycemic Control:lantus, HISS\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Pantoprazole\n VAP:\n Comments:\n Communication: Comments: with wife\n status: Full Code\n Disposition: In ICU for now. Following paracentesis, if stable, to\n floor\n" }, { "category": "Physician ", "chartdate": "2119-08-18 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 591778, "text": "Chief Complaint: hepatic encephalopathy, hyperglycemia\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 Off insulin drip\n NGT placed for lactulose - +++ residuals\n Still encephalopathic\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Piperacillin - 02:46 AM\n Ciprofloxacin - 10:19 AM\n Piperacillin/Tazobactam (Zosyn) - 08:14 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:18 AM\n Heparin Sodium (Prophylaxis) - 11:46 PM\n Morphine Sulfate - 05:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:41 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: 36.3\nC (97.4\n HR: 118 (97 - 128) bpm\n BP: 152/104(116) {108/82(91) - 169/104(118)} mmHg\n RR: 17 (14 - 30) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 92.2 kg (admission): 90.6 kg\n Height: 67 Inch\n Total In:\n 3,487 mL\n 1,161 mL\n PO:\n TF:\n IVF:\n 3,087 mL\n 1,161 mL\n Blood products:\n 50 mL\n Total out:\n 1,363 mL\n 1,335 mL\n Urine:\n 763 mL\n 185 mL\n NG:\n 600 mL\n 1,150 mL\n Stool:\n Drains:\n Balance:\n 2,124 mL\n -172 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Gen: dishelved moaning in bed\n CV: RR\n Chest: poor air movement no wheeze\n Abd: tesne ascites, hypoactigve BS\n Ext: trace edema\n Neuro: altered, only groans, asterixis\n Labs / Radiology\n 10.5 g/dL\n 147 K/uL\n 137 mg/dL\n 3.1 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 44 mg/dL\n 109 mEq/L\n 147 mEq/L\n 32.6 %\n 13.0 K/uL\n [image002.jpg]\n 02:56 AM\n 09:58 AM\n 02:35 PM\n 10:00 PM\n 03:09 AM\n 04:45 AM\n WBC\n 7.1\n 9.4\n 13.0\n Hct\n 30.0\n 30.6\n 32.6\n Plt\n 102\n 108\n 147\n Cr\n 2.9\n 2.9\n 2.8\n 3.0\n 2.8\n 3.1\n Glucose\n 191\n 195\n 188\n 183\n 660\n 137\n Other labs: PT / PTT / INR:36.7/39.4/3.8, ALT / AST:, Alk Phos / T\n Bili:120/1.5, Differential-Neuts:84.7 %, Lymph:8.5 %, Mono:2.9 %,\n Eos:3.6 %, Albumin:4.8 g/dL, LDH:273 IU/L, Ca++:10.6 mg/dL, Mg++:2.1\n mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPERNATREMIA (HIGH SODIUM)\n LIVER FUNCTION ABNORMALITIES\n CIRRHOSIS OF LIVER, ALCOHOLIC\n DIABETES MELLITUS (DM), TYPE II\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ALTERED MENTAL STATUS\n attributable to hepatic encephalopathy.\n Precipitants likely multifactorial, including hypernatremia,\n hypokalemia, and contribution of renal failure, on background of prior\n TIPS (increased incidence of encephalopathy). Lactulose and Rifaximin\n has been planned per NGT\n but now with residuals will need lactulose\n enema to manage encephalopathy.\n RENAL FAILURE\n worsening Cr today- HRS versus ATN, check repeat\n bladder pressure. Monitor uo, BUN, creatinine. Check urine lytes, UA.\n Continue midodrine, albumin as per Liverl consultation.\n Ileus: in setting of massive ascites but Abd CT on showed gastric\n outlet obstruction\n need to speak with GI about any further work up\n for this\n he is not in good shape for lying flat for abd ct or egd\n right now but may be necessary to pursue if does not resolve as it\n clrearly outs him at risk for massive aspiration limits meds and\n nutrition. We can do small volume tap t see if improves ilues at all\n but not large as we do not want to exacerbate volume shifts and worsen\n ARF\n HYPERNATREMIA\n requires ongoing free water repletion. Monitor Na.\n HYPERGLYCEMIA\n poorly controlled diabetes. Unclear precipitant, but\n concern for infection. No evidence for DKA. folllwing now iff\n insulin drip and getting humalog and lantus but without sig po only d5\n as nutrition/\n PORTAL VEIN THROMBOSIS\n continue anticoagulation. PT/INR.\n NUTRITIONAL SUPPORT\n NPO while encephalopathic, high aspiration risk.\n CIRRHOSIS\n not transplant candidate at present but may be in future.\n Continue supportive care.\n Plans otherwise as outlined per Resident note.\n ICU Care\n Nutrition: NPO for now given high residuals\n if do not resolve may\n need TPN/PPN\n Glycemic Control: humalog and lantus\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n Prophylaxis:\n DVT: couamdin\n Stress ulcer: PPI\n Communication: with wife\n met with interpreter yesterday\n Code status: Full code\n Disposition : ICu for now\n but may be floor ready after tap need to\n speak with Dr further\n" }, { "category": "Nursing", "chartdate": "2119-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591867, "text": "Synopsis per prior nursing note:\n Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Hypernatremia (high sodium)\n Assessment:\n Na 144, k 3.9.\n Action:\n NGT to IWS. Given lactulose enema.\n Response:\n Repeat Na. Repeat K. Very large, liquid stool after enema. Continues\n to put out small amt bilious fluid from NGT.\n Plan:\n Monitor electrolytes. Monitor stool/NGT output.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 125-130.\n Action:\n NPO. FS monitored q4hrs. Given evening dose of lantus. FS treated with\n humalog per ISS.\n Response:\n 0400 FS-47, given\n amp D50, repeat FS 92.\n Plan:\n Monitor FS q4hrs, next FS due at 0800.\n Cirrhosis of liver, alcoholic\n Assessment:\n Confused, garbled speech, not following commands, purposeful movements\n of extremities, occasionally combative, +ascites.\n Action:\n Attempted to reorient. Soft wrist restraints continued d/t patient\n attempting to pull out lines. Given PR lactulose.\n Response:\n No change in mental status.\n Plan:\n Lactulose PR . Monitor change in mental status.\n" }, { "category": "Physician ", "chartdate": "2119-08-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 591764, "text": "Chief Complaint:\n 24 Hour Events:\n Liver following - gave albumin, lactulose\n - In ICU for insulin drip - will d/c drip tonight. plan to c/o to floor\n tomorrow.\n - NGT placed, good placement\n - Hypernatremia - another 1L of D5W\n - Ordered TSH, will discuss synthroid tomorrow\n - Lactulose from NGT held for high residuals\n - large BM x1 after lactulose enema.\n - Discontinued coumadin given INR>3\n No change MS\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Piperacillin - 02:46 AM\n Ciprofloxacin - 10:19 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:18 AM\n Heparin Sodium (Prophylaxis) - 11:46 PM\n Morphine Sulfate - 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 07:47 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: 36.2\nC (97.1\n HR: 110 (90 - 128) bpm\n BP: 132/90(101) {108/82(91) - 169/104(118)} mmHg\n RR: 15 (14 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 92.2 kg (admission): 90.6 kg\n Height: 67 Inch\n Total In:\n 3,487 mL\n 926 mL\n PO:\n TF:\n IVF:\n 3,087 mL\n 926 mL\n Blood products:\n 50 mL\n Total out:\n 1,363 mL\n 1,305 mL\n Urine:\n 763 mL\n 155 mL\n NG:\n 600 mL\n 1,150 mL\n Stool:\n Drains:\n Balance:\n 2,124 mL\n -379 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n Cardiovascular: NG tube in place\n PERRLA, unable to follow commands+language\n CVS: RRR, no MRG, S1S2 clear\n Rhonchorous throughout lung fields.\n abd:+ve bs/ tense/ tympanic/ round.\n little urine, hematuria, no clots\n wwp\n Labs / Radiology\n 147 K/uL\n 10.5 g/dL\n 137 mg/dL\n 3.1 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 44 mg/dL\n 109 mEq/L\n 147 mEq/L\n 32.6 %\n 13.0 K/uL\n [image002.jpg]\n 02:56 AM\n 09:58 AM\n 02:35 PM\n 10:00 PM\n 03:09 AM\n 04:45 AM\n WBC\n 7.1\n 9.4\n 13.0\n Hct\n 30.0\n 30.6\n 32.6\n Plt\n 102\n 108\n 147\n Cr\n 2.9\n 2.9\n 2.8\n 3.0\n 2.8\n 3.1\n Glucose\n 191\n 195\n 188\n 183\n 660\n 137\n Other labs: PT / PTT / INR:36.7/39.4/3.8, ALT / AST:, Alk Phos / T\n Bili:120/1.5, Differential-Neuts:84.7 %, Lymph:8.5 %, Mono:2.9 %,\n Eos:3.6 %, Albumin:4.8 g/dL, LDH:273 IU/L, Ca++:10.6 mg/dL, Mg++:2.1\n mg/dL, PO4:3.2 mg/dL\n Imaging: no imaging today. NG tube in place\n Microbiology: 4 blood cx pending.\n UCx pending.\n Peritoneal fluid:gram stain negative, no growth preliminary.\n Toxo Ab pending.\n ECG: none\n Assessment and Plan\n INEFFECTIVE COPING\n HYPERNATREMIA (HIGH SODIUM)\n LIVER FUNCTION ABNORMALITIES\n CIRRHOSIS OF LIVER, ALCOHOLIC\n DIABETES MELLITUS (DM), TYPE II\n ACUTE CONFUSION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Leukocytosis: From 9.0 this am to 13.-0 without fever. Pt admitted with\n suspected infection given hyperglycemia, and treated empirically, only\n now developing infection. Regarding source, SBP v.unlikely since just\n had unremarkable diagnostic tap and on cipro prophylaxis, UTI possible\n given new hematuria on exam today (however INR3.8), line infection, PNA\n to be considered. Difficult to invoke CNS infection given MS \nted to hepatic encephalopathy, continue to consider. On multiple\n abx, consider c.diff.\n -d/c superfluous/inciting abx (ciprofloxacin)\n - Stool Cx\n -Sputum Cx\n CXR\n -cont zosyn, vanc. Consider flagyll\n Altered mental status:\n Head CT negative. Abd u/s unchanged. Diagnostic para not revealing.\n Hypernatremic. Hyperglycemia and enceph suggests possibility of\n infection. Pt originally presented with abdominal pain that was not\n notable on exam but uncomfortable to patient, even in setting of no\n encephalopathy; pt currently moaning mournfully consistent with past\n presentation.\n - covering w vanc/zosyn\n - gently correcting hypernatremia though doubt this is major\n contributor\n - has had haldol on the floor, continuing this as prn; not clear\n whether this will be helpful other than as sedative, and will consider\n very low dose morphine as trial of pain relief; Tylenol at low dose\n also.\n - likely to need to hold POs currently, pt not w mental status to\n cooperate w POs; consider NG tube for nutrition and meds if not\n clearing by mid-morning.\n - lactulose enema\n - f/u micro data, cultures pending\n Liver failure\n Not yet listed for transplant. Transplant committee asking for\n colonoscopy and outpatient relapse therapy. Specific interventions:\n midodrine, albumin; lactulose.\n Hyperglycemia / diabetes\n Likely secondary to infection given change over last several days\n coinciding w worsening encephalopathy. Doing insulin drip to manage\n this. Will d/ in AM\nthey are following\nto discuss both acute\n management and long-term plan for insulin/ antihyperglycemic regimen.\n Hypernatremia\n Likely 2.2 poor intake.\n NS did nothing to correct this, consistent w\n high sodium avidity. Will do D5W with insulin drip titrated to\n accommodate the extra sugar load.\n Renal failure\n ?Abdominal compartment syndrome vs s/p drug toxicity, unclear etiology.\n Liver failure likely contributing to some degree of pre-renal failure\n although the degree of resolution suggests against HRS. Continue\n midodrine, albumin as per floor team. Follow Cr and urine output\n closely. No urgent indication for HD. Renal following, will follow up\n recs.\n Hypothyroidism\n Mild hypothyroidism from tests from . Team discontinued prior\n synthroid, not clear why from notes; will discuss with them in AM.\n Coagulopathy/anticoagulation\n Continuing warfarin for portal vein thrombosis which has been a problem\n for pt in the past.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Pantoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2119-08-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 591766, "text": "Chief Complaint:\n 24 Hour Events:\n Liver following - gave albumin, lactulose\n - In ICU for insulin drip - will d/c drip tonight. plan to c/o to floor\n tomorrow.\n - NGT placed, good placement\n - Hypernatremia - another 1L of D5W\n - Ordered TSH, will discuss synthroid tomorrow\n - Lactulose from NGT held for high residuals\n - large BM x1 after lactulose enema.\n - Discontinued coumadin given INR>3\n No change MS\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Piperacillin - 02:46 AM\n Ciprofloxacin - 10:19 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:18 AM\n Heparin Sodium (Prophylaxis) - 11:46 PM\n Morphine Sulfate - 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 07:47 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: 36.2\nC (97.1\n HR: 110 (90 - 128) bpm\n BP: 132/90(101) {108/82(91) - 169/104(118)} mmHg\n RR: 15 (14 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 92.2 kg (admission): 90.6 kg\n Height: 67 Inch\n Total In:\n 3,487 mL\n 926 mL\n PO:\n TF:\n IVF:\n 3,087 mL\n 926 mL\n Blood products:\n 50 mL\n Total out:\n 1,363 mL\n 1,305 mL\n Urine:\n 763 mL\n 155 mL\n NG:\n 600 mL\n 1,150 mL\n Stool:\n Drains:\n Balance:\n 2,124 mL\n -379 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n Cardiovascular: NG tube in place\n PERRLA, unable to follow commands+language\n CVS: RRR, no MRG, S1S2 clear\n Rhonchorous throughout lung fields.\n abd:+ve bs/ tense/ tympanic/ round.\n little urine, hematuria, no clots\n wwp\n Labs / Radiology\n 147 K/uL\n 10.5 g/dL\n 137 mg/dL\n 3.1 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 44 mg/dL\n 109 mEq/L\n 147 mEq/L\n 32.6 %\n 13.0 K/uL\n [image002.jpg]\n 02:56 AM\n 09:58 AM\n 02:35 PM\n 10:00 PM\n 03:09 AM\n 04:45 AM\n WBC\n 7.1\n 9.4\n 13.0\n Hct\n 30.0\n 30.6\n 32.6\n Plt\n 102\n 108\n 147\n Cr\n 2.9\n 2.9\n 2.8\n 3.0\n 2.8\n 3.1\n Glucose\n 191\n 195\n 188\n 183\n 660\n 137\n Other labs: PT / PTT / INR:36.7/39.4/3.8, ALT / AST:, Alk Phos / T\n Bili:120/1.5, Differential-Neuts:84.7 %, Lymph:8.5 %, Mono:2.9 %,\n Eos:3.6 %, Albumin:4.8 g/dL, LDH:273 IU/L, Ca++:10.6 mg/dL, Mg++:2.1\n mg/dL, PO4:3.2 mg/dL\n Imaging: no imaging today. NG tube in place\n Microbiology: 4 blood cx pending.\n UCx pending.\n Peritoneal fluid:gram stain negative, no growth preliminary.\n Toxo Ab pending.\n ECG: none\n Assessment and Plan\n INEFFECTIVE COPING\n HYPERNATREMIA (HIGH SODIUM)\n LIVER FUNCTION ABNORMALITIES\n CIRRHOSIS OF LIVER, ALCOHOLIC\n DIABETES MELLITUS (DM), TYPE II\n ACUTE CONFUSION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Leukocytosis: From 9.0 this am to 13.-0 without fever. Pt admitted with\n suspected infection given hyperglycemia, and treated empirically, only\n now developing infection. Regarding source, SBP v.unlikely since just\n had unremarkable diagnostic tap and on cipro prophylaxis, UTI possible\n given new hematuria on exam today (however INR3.8), line infection, PNA\n to be considered. Difficult to invoke CNS infection given MS \nted to hepatic encephalopathy, continue to consider. On multiple\n abx, consider c.diff.\n -d/c superfluous/inciting abx (ciprofloxacin)\n - Stool Cx\n -Sputum Cx\n CXR\n -cont zosyn, vanc. Consider flagyll\n Altered mental status:\n Head CT negative. Abd u/s unchanged. Diagnostic para not revealing.\n Hypernatremic. Hyperglycemia and enceph suggests possibility of\n infection. Pt originally presented with abdominal pain that was not\n notable on exam but uncomfortable to patient, even in setting of no\n encephalopathy; pt currently moaning mournfully consistent with past\n presentation.\n has had haldol on the floor, continuing this as prn; not clear whether\n this will be helpful other than as sedative, and will consider very low\n dose morphine as trial of pain relief; Tylenol at low dose also.\n - covering w vanc/zosyn\n - gently correcting hypernatremia though doubt this is major\n contributor, with D5W for free water deficit.\n -Continue lactulose enema\n - f/u 4 blood cx pending, Ucx pending, peritoneal fluid gram stain\n negative, no growth preliminary.\n Liver failure\n Not yet listed for transplant. Transplant committee asking for\n colonoscopy and outpatient relapse therapy. Liver today indicated\n continue on this course. DC\nd midodrine given HTN. Specific\n interventions: albumin; lactulose.\n Tense/ obese ascetic abdomen with compartment syndrome possibly\n contributing to ileus and renal failure however unable to remove large\n volumes given risk rapid fluid shifts. Remove 2.5 L ascitic fluid,\n while giving albumin,\n Hyperglycemia / diabetes\n Likely secondary to infection given change over last several days\n coinciding w worsening encephalopathy. GFS ranged 49-153 on insulin\n drip, 170s when drip dc\n -Continue q4 GFS\n - continue lantus/HISS\n Hypernatremia\n Likely 2.2 poor intake.\n NS did nothing to correct this, consistent w\n high sodium avidity. Currently on D5W with free water deficit of:\n ******************\n Renal failure: 2.8 today from 3.0 y/d.\n ?Abdominal compartment syndrome vs s/p drug toxicity, unclear etiology.\n Liver failure likely contributing to some degree of pre-renal failure\n although the degree of resolution suggests against HRS. Continue\n albumin as per floor team. Follow Cr and urine output closely. No\n urgent indication for HD. Renal following, will follow up recs.\n Hypothyroidism\n Mild hypothyroidism from tests from . Team discontinued prior\n synthroid, not clear why from notes; will discuss with them in AM.\n Coagulopathy/anticoagulation\n Continuing warfarin for portal vein thrombosis which has been a problem\n for pt in the past.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Pantoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2119-08-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 592019, "text": "Mr. is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistent tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Neuro: Alert, orientation difficult to assess due to language\n barrier. Pleasant and cooperative with care. OOB to chair this AM\n with supervision. Per wife at baseline mental status\n Resp: LSTCA bilaterally. Respirations even and unlabored sats 98-100%\n on RA\n Cardiac: BP 140-150/80\ns. Tele SR-ST 80-100\ns without ectopy. No\n edema\n GI: NGT in place. Tolerating soft solid diet. Abdomen with ascites.\n Hypoactive bowel sounds. BM x 3 so far today loose\n Renal: Foley draining adequate amounts of clear yellow urine.\n Tunneled line to left chest. BUN/Creat stable no HD since . Renal\n following\n Skin: Paracentesis site to LLQ draining serosang fluid. Otherwise\n skin intact\n Social: Wife in to visit most of day yesterday. Pleasant and\n cooperative. Full Code\n Access: 18 gauge IV to LL forearm dated from \n Cirrhosis of liver, alcoholic\n Assessment:\n Pt remains with large amount of ascites. Mental status at baseline,\n afebrile. No ataxia noted. Pt with three large BM\ns overnight.\n Action:\n AM lactulose given (30), NGT remains in place, although tolerated soft\n solids for breakfast. S/P paracentesis yesterday with 4 liters of pink\n thick fluid removed. Cultures with no growth to date.\n Response:\n Pts mental status at baseline,\n Plan:\n Continue with lactulose titrate to three BM\ns daily. Continue with\n ANBX for SBP prophylaxis. Monitor mental status\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS well controlled overnight 100-150\n Action:\n 30 units of lantus given overnight. Sliding scale decreased yesterday\n due to NPO status and episode of hypoglycemia .\n Response:\n Pts FS well controlled on current regimen\n Plan:\n Continue to monitor FS with meals and at HS. ? need to titrate sliding\n scale up now that pt tolerating PO\n" }, { "category": "Physician ", "chartdate": "2119-08-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 592024, "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 63 yo man with ETOH cirrhosis, ARF, encephalopathy, hyperglycemia.\n Mental status much improved. Had\n paracentesis yesterday - removed 4L.\n 24 Hour Events:\n PARACENTESIS - At 02:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:14 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:14 AM\n Other medications:\n protonix\n albumin\n rifaxamin\n lantis 30/SSI\n lactulose\n synthroid\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) Fever\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Integumentary (skin): No(t) Jaundice\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Allergy / Immunology: No(t) Immunocompromised\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:18 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: 36.1\nC (97\n HR: 84 (70 - 96) bpm\n BP: 145/88(103) {104/56(66) - 159/98(111)} mmHg\n RR: 16 (15 - 27) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.2 kg (admission): 90.6 kg\n Height: 67 Inch\n Bladder pressure: 17 (17 - 17) mmHg\n Total In:\n 1,620 mL\n 831 mL\n PO:\n 120 mL\n 520 mL\n TF:\n IVF:\n 1,450 mL\n 311 mL\n Blood products:\n Total out:\n 670 mL\n 480 mL\n Urine:\n 670 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 950 mL\n 351 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\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: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 9.4 g/dL\n 104 K/uL\n 123 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 38 mg/dL\n 107 mEq/L\n 141 mEq/L\n 29.0 %\n 4.9 K/uL\n [image002.jpg]\n 09:58 AM\n 02:35 PM\n 10:00 PM\n 03:09 AM\n 04:45 AM\n 12:16 PM\n 07:30 PM\n 03:54 AM\n 04:42 PM\n 03:59 AM\n WBC\n 9.4\n 13.0\n 11.6\n 4.9\n Hct\n 30.6\n 32.6\n 30.3\n 29.0\n Plt\n 108\n 147\n 170\n 104\n Cr\n 2.9\n 2.8\n 3.0\n 2.8\n 3.1\n 3.1\n 3.1\n 3.1\n 2.9\n 2.6\n Glucose\n 195\n 188\n 183\n 660\n 137\n 81\n 121\n 40\n 183\n 123\n Other labs: PT / PTT / INR:32.2/47.0/3.2, ALT / AST:, Alk Phos / T\n Bili:118/1.9, Differential-Neuts:84.7 %, Lymph:8.5 %, Mono:2.9 %,\n Eos:3.6 %, Lactic Acid:2.8 mmol/L, Albumin:4.8 g/dL, LDH:248 IU/L,\n Ca++:9.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPERNATREMIA (HIGH SODIUM)\n LIVER FUNCTION ABNORMALITIES\n CIRRHOSIS OF LIVER, ALCOHOLIC\n DIABETES MELLITUS (DM), TYPE II\n ACUTE CONFUSION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Overall much improved. MS according to family. Will\n removed NGT.\n Acute renal failure: improving\n hyperglycemia: much improved.\n Can stop vanco/zosyn and switch to PO cipro\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n 18 Gauge - 01:31 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\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": "2119-08-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 592029, "text": "Chief Complaint:\n 24 Hour Events:\n PARACENTESIS - At 02:00 PM\n -patient's wife here late morning, early afternoon, reports substantial\n improvement in mental status, she reports he is at baseline.\n -paracentesis performed - removed 4 L of turbid fluid. WBC 125.\n -no residuals to NG tube, multiple bowel movements.\n -calm and cooperative during the day yesterday, did well with liquid\n diet in the evening.\n -NG tube still in place, will remove this morning.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:19 AM\n Vancomycin - 11:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:14 AM\n Heparin Sodium (Prophylaxis) - 12:12 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 07:05 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: 36.4\nC (97.6\n HR: 79 (70 - 96) bpm\n BP: 144/87(100) {104/56(66) - 159/98(111)} mmHg\n RR: 16 (14 - 27) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.2 kg (admission): 90.6 kg\n Height: 67 Inch\n Bladder pressure: 17 (17 - 17) mmHg\n Total In:\n 1,620 mL\n 230 mL\n PO:\n 120 mL\n 60 mL\n TF:\n IVF:\n 1,450 mL\n 170 mL\n Blood products:\n Total out:\n 670 mL\n 360 mL\n Urine:\n 670 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 950 mL\n -130 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n Calm, cooperative, oriented, comfortable\n Lungs with decreased breath sounds, CTAB\n RRR, no audible murmurs.\n Abdomen distended, tense, but non-tender, with +BS. Paracentesis site\n dressing clean, dry.\n Trace pedal edema.\n Labs / Radiology\n 104 K/uL\n 9.4 g/dL\n 123 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 38 mg/dL\n 107 mEq/L\n 141 mEq/L\n 29.0 %\n 4.9 K/uL\n [image002.jpg]\n 09:58 AM\n 02:35 PM\n 10:00 PM\n 03:09 AM\n 04:45 AM\n 12:16 PM\n 07:30 PM\n 03:54 AM\n 04:42 PM\n 03:59 AM\n WBC\n 9.4\n 13.0\n 11.6\n 4.9\n Hct\n 30.6\n 32.6\n 30.3\n 29.0\n Plt\n 108\n 147\n 170\n 104\n Cr\n 2.9\n 2.8\n 3.0\n 2.8\n 3.1\n 3.1\n 3.1\n 3.1\n 2.9\n 2.6\n Glucose\n 195\n 188\n 183\n 660\n 137\n 81\n 121\n 40\n 183\n 123\n Other labs: PT / PTT / INR:32.2/47.0/3.2, ALT / AST:, Alk Phos / T\n Bili:118/1.9, Differential-Neuts:84.7 %, Lymph:8.5 %, Mono:2.9 %,\n Eos:3.6 %, Lactic Acid:2.8 mmol/L, Albumin:4.8 g/dL, LDH:248 IU/L,\n Ca++:9.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPERNATREMIA (HIGH SODIUM)\n LIVER FUNCTION ABNORMALITIES\n CIRRHOSIS OF LIVER, ALCOHOLIC\n DIABETES MELLITUS (DM), TYPE II\n ACUTE CONFUSION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n \n Leukocytosis: Remains afebrile\n leukocytosis stable. Transferred to\n ICU with suspected infection given hyperglycemia, and treated\n empirically. However, he has remained afebrile and improved\n clinically. Yesterday 4 liters of turbid peritoneal fluid were removed\n by paracentesis. Procedure tolerated well, cell count negative for SBP\n only 125 WBC.\n - DC vanco/Zosyn, back to Cipro for SBP prophylaxis.\n - follow pending cultures.\n Altered mental status:\n AMS likely due to hepatic encephalopathy, but very much improved during\n the day yesterday and overnight. His wife reports that he is at his\n baseline, he responds to questions appropriately with translation,\n tolerated paracentesis very well. No residuals with NG tube, tolerated\n soft diet in the evening. Regular bowel movements yesterday.\n - gently correcting hypernatremia though doubt this is major\n contributor, with D5W for free water deficit.\n -Continue lactulose per NGT at decreased dose, now with frequent bowel\n movements.\n Liver failure - Not yet listed for transplant. Transplant committee\n asking for colonoscopy and outpatient relapse therapy.\n -Continuing lactulose and albumin.\n -Paracentesis performed yesterday\n 4 L removed, 25 g albumin given (6\n g/L as recommended by hepatology.\n Hyperglycemia / diabetes\n marked hyperglycemia on transfer to MICU,\n initially on insulin drip. Now sugars under much better control, with\n one hypoglycemic episode yesterday morning. Sliding scale adjusted\n given lack of PO intake.\n - recs reviewed.\n -likely will need further adjustment today, with resumption of PO\n intake.\n Hypernatremia - D5W with potassium yesterday given for high sodium, low\n potassium. Labs this morning improved.\n Renal failure: creatinine stably elevated with slight improvement\n today.\n -urine osm high, bladder pressure 17 before paracentesis.\n - Liver failure likely contributing to some degree of pre-renal failure\n although the degree of resolution suggests against HRS.\n -renal following\n Hypothyroidism\n -restarted home Synthroid.\n Coagulopathy/anticoagulation\n -Holding warfarin given supratherapeutic INR - reduced today from 3.9\n to 3.2\n -Continue to check daily INR.\n ICU Care\n Nutrition:\n Glycemic Control: Lantus, sliding scale\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n 18 Gauge - 01:31 PM\n Prophylaxis:\n DVT: elevated INR as above, boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: full code\n Disposition: call out to floor\n" }, { "category": "Nursing", "chartdate": "2119-08-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 592033, "text": "Mr. is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistent tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Neuro: Alert, orientation difficult to assess due to language\n barrier. Pleasant and cooperative with care. OOB to chair this AM\n with supervision. Per wife at baseline mental status\n Resp: LSTCA bilaterally. Respirations even and unlabored sats 98-100%\n on RA\n Cardiac: BP 140-150/80\ns. Tele SR-ST 80-100\ns without ectopy. No\n edema\n GI: NGT D/C\nd Tolerating soft solid diet. Abdomen with ascites.\n Hypoactive bowel sounds. BM x 3 so far today loose\n Renal: Foley draining adequate amounts of clear yellow urine.\n Tunneled line to left chest. BUN/Creat stable no HD since . Renal\n following\n Skin: Paracentesis site to LLQ draining serosang fluid. Otherwise\n skin intact\n Social: Wife in to visit most of day yesterday. Pleasant and\n cooperative. Full Code\n Access: 18 gauge IV to LL forearm dated from \n Cirrhosis of liver, alcoholic\n Assessment:\n Pt remains with large amount of ascites. Mental status at baseline,\n afebrile. No ataxia noted. Pt with 6 large BM\ns today.\n Action:\n AM lactulose given (30), NGT D/C\nd tolerating soft solid diet S/P\n paracentesis yesterday with 4 liters of pink thick fluid removed.\n Cultures with no growth to date.\n Response:\n Pts mental status at baseline\n Plan:\n Continue with lactulose titrate to three BM\ns daily. Continue with\n ANBX for SBP prophylaxis. Monitor mental status\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS well controlled overnight 100-150\n Action:\n 30 units of lantus given overnight. Sliding scale decreased yesterday\n due to NPO status and episode of hypoglycemia .\n Response:\n FS at noon 233, given 8 units of humalog\n Plan:\n Continue to monitor FS with meals and at HS. ? need to titrate sliding\n scale up now that pt tolerating PO\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n ASCITES, HYPOGLYCEMIA\n Code status:\n Height:\n 67 Inch\n Admission weight:\n 90.6 kg\n Daily weight:\n 92.2 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Liver Failure\n CV-PMH:\n Additional history: Alcoholic cirrhosis known varices, portal vein\n thrombosis, s/p TIPS, DM, hypothyroid, pituitary mass, h/o\n nephrolithiasis, h/o +PPD\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:131\n D:86\n Temperature:\n 97.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 105 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,047 mL\n 24h total out:\n 580 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 03:59 AM\n Potassium:\n 3.5 mEq/L\n 03:59 AM\n Chloride:\n 107 mEq/L\n 03:59 AM\n CO2:\n 22 mEq/L\n 03:59 AM\n BUN:\n 38 mg/dL\n 03:59 AM\n Creatinine:\n 2.6 mg/dL\n 03:59 AM\n Glucose:\n 123 mg/dL\n 03:59 AM\n Hematocrit:\n 29.0 %\n 03:59 AM\n Finger Stick Glucose:\n 233\n 12:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 688\n Transferred to: 1017\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2119-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 592002, "text": "Synopsis per prior nursing note:\n Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 156.\n Action:\n Took moderate amt of PO intake. Given evening dose of lantus. FS\n treated with humalog per new ISS.\n Response:\n 0400 FS 118.\n Plan:\n Monitor FS. Encourage PO intake.\n Cirrhosis of liver, alcoholic\n Assessment:\n Alert, oriented. Moving all extremities weakly. Follows commands. Able\n to let basic needs be known. Helps move self in bed. Jaundice,\n +Ascites.\n Action:\n Held PO lactulose d/t multiple loose, stools. NGT in place through\n night while monitoring mental status.\n Response:\n No change in mental status. Had multiple loose, brown stools.\n Plan:\n Lactulose for 3BM/day. Monitor change in mental status. ? remove NGT\n today.\n" }, { "category": "Physician ", "chartdate": "2119-08-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 592009, "text": "Chief Complaint:\n 24 Hour Events:\n PARACENTESIS - At 02:00 PM\n -patient's wife here late morning, early afternoon, reports substantial\n improvement in mental status, she reports he is at baseline.\n -paracentesis performed - removed 4 L of turbid fluid. WBC 125.\n -no residuals to NG tube, several bowel movements.\n -calm and cooperative during the day yesterday, did well with liquid\n diet in the evening.\n -NG tube still in place, will consider DC if remains stable.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:19 AM\n Vancomycin - 11:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:14 AM\n Heparin Sodium (Prophylaxis) - 12:12 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 07:05 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: 36.4\nC (97.6\n HR: 79 (70 - 96) bpm\n BP: 144/87(100) {104/56(66) - 159/98(111)} mmHg\n RR: 16 (14 - 27) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.2 kg (admission): 90.6 kg\n Height: 67 Inch\n Bladder pressure: 17 (17 - 17) mmHg\n Total In:\n 1,620 mL\n 230 mL\n PO:\n 120 mL\n 60 mL\n TF:\n IVF:\n 1,450 mL\n 170 mL\n Blood products:\n Total out:\n 670 mL\n 360 mL\n Urine:\n 670 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 950 mL\n -130 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 104 K/uL\n 9.4 g/dL\n 123 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 38 mg/dL\n 107 mEq/L\n 141 mEq/L\n 29.0 %\n 4.9 K/uL\n [image002.jpg]\n 09:58 AM\n 02:35 PM\n 10:00 PM\n 03:09 AM\n 04:45 AM\n 12:16 PM\n 07:30 PM\n 03:54 AM\n 04:42 PM\n 03:59 AM\n WBC\n 9.4\n 13.0\n 11.6\n 4.9\n Hct\n 30.6\n 32.6\n 30.3\n 29.0\n Plt\n 108\n 147\n 170\n 104\n Cr\n 2.9\n 2.8\n 3.0\n 2.8\n 3.1\n 3.1\n 3.1\n 3.1\n 2.9\n 2.6\n Glucose\n 195\n 188\n 183\n 660\n 137\n 81\n 121\n 40\n 183\n 123\n Other labs: PT / PTT / INR:32.2/47.0/3.2, ALT / AST:, Alk Phos / T\n Bili:118/1.9, Differential-Neuts:84.7 %, Lymph:8.5 %, Mono:2.9 %,\n Eos:3.6 %, Lactic Acid:2.8 mmol/L, Albumin:4.8 g/dL, LDH:248 IU/L,\n Ca++:9.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPERNATREMIA (HIGH SODIUM)\n LIVER FUNCTION ABNORMALITIES\n CIRRHOSIS OF LIVER, ALCOHOLIC\n DIABETES MELLITUS (DM), TYPE II\n ACUTE CONFUSION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n \n Leukocytosis: Remains afebrile\n leukocytosis stable. Transferred to\n ICU with suspected infection given hyperglycemia, and treated\n empirically. However, he has remained afebrile and improved\n clinically. Yesterday 4 liters of turbid peritoneal fluid were removed\n by paracentesis. Procedure tolerated well, cell count negative for SBP\n only 125 WBC.\n - currently on vanco/Zosyn.\n - Stool Cx pending\n -Sputum Cx pending\n -CXR showed no evidence for infection.\n Altered mental status:\n AMS likely due to hepatic encephalopathy, but very much improved during\n the day yesterday and overnight. His wife reports that he is at his\n baseline, he responds to questions appropriately with translation,\n tolerated paracentesis very well. No residuals with NG tube, tolerated\n soft diet in the evening. Regular bowel movements yesterday.\n - gently correcting hypernatremia though doubt this is major\n contributor, with D5W for free water deficit.\n -Continue lactulose per NGT.\n f/u 4 blood cx pending, Ucx pending, peritoneal fluid gram stain\n negative, no growth preliminary.\n Liver failure - Not yet listed for transplant. Transplant committee\n asking for colonoscopy and outpatient relapse therapy. Continuing\n lactulose and albumin.\n Paracentesis performed yesterday\n 4 L removed, 25 g albumin given (6\n g/L as recommended by hepatology.\n Hyperglycemia / diabetes\n marked hyperglycemia on transfer to MICU,\n initially on insulin drip. Now sugars under much better control, with\n one hypoglycemic episode yesterday morning. Sliding scale adjusted\n given lack of PO intake.\n recs reviewed.\n Hypernatremia - D5W with potassium yesterday given for high sodium, low\n potassium. Labs this morning...\n Renal failure: creatinine stably elevated though slightly improved\n today, FeNa < 1, urine sodium very low.\n -urine osm high, bladder pressure 17 before paracentesis.\n - Liver failure likely contributing to some degree of pre-renal failure\n although the degree of resolution suggests against HRS.\n -renal following\n Hypothyroidism\n -restarted home Synthroid.\n Coagulopathy/anticoagulation\n -Holding warfarin given supratherapeutic INR - reduced today from 3.9\n to 3.2\n -Continue to check daily INR.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n 18 Gauge - 01:31 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2119-08-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591482, "text": "Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline. He has had frequent admissions for increased confusion and\n presented with right sided abdominal pain and increased ascites In\n ED his lactate 9.1 wbc 21.3 cr 7.6 and a glucose of 15. He is on liver\n transplant list. He has been receiving HD. Over several days he has\n become increasingly agitated with mental status changes. He was\n transferred to MICU secondary to increase agitation and aggressive\n behavior toward staff requiring 4 point restraints with persistant\n tachycardia, hypertension and blood sugar of 450.\n Acute Confusion\n Assessment:\n Patiient moaning not engaging, moving all extremities, not following\n commands, tachycardic when awake to 130\n Action:\n Given haldol .5mg IV x 2, given lactulose enema x1\n Response:\n Patient not engaging\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\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": "2119-08-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591496, "text": "Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline. He has had frequent admissions for increased confusion and\n presented with right sided abdominal pain and increased ascites In\n ED his lactate 9.1 wbc 21.3 cr 7.6 and a glucose of 15. He is on liver\n transplant list. He has been receiving HD. Over several days he has\n become increasingly agitated with mental status changes. He was\n transferred to MICU secondary to increase agitation and aggressive\n behavior toward staff requiring 4 point restraints with persistant\n tachycardia, hypertension and blood sugar of 450. PMH alcoholic\n cirrhosis known varices, portal vein thrombosis, s/p TIOS, DM 2,\n hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD\n Acute Confusion\n Assessment:\n Patiient moaning not engaging, moving all extremities, not following\n commands, tachycardic when awake to 130\n Action:\n Given haldol .5mg IV x 2, given lactulose enema x1\n Response:\n Patient moaning, HR 90\ns nsr when given haldol then increases up to\n 137 ST when awake and agitated, he did open his eyes and engage briefly\n Plan:\n Unclear if agitation is from pain or encephalopathy,\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Temp 96.9 wbc\n Action:\n Given vanco and zoysn\n Response:\n Plan:\n Vanco, zoysn and cipro IV, monitor lactate, temp, wbc, await cx results\n Diabetes Mellitus (DM), Type II\n Assessment:\n First arrived in micu blood sugar 415\n Action:\n He was given 10u regular insulin sq and started on a insulin gtt\n Response:\n Blood sugar slowly coming down\n Plan:\n Continue insulin gtt monitor anion gag, blood sugars q 1hr titrate prbn\n" }, { "category": "Nutrition", "chartdate": "2119-08-17 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 591614, "text": "Subjective\n per wife patient had poor pos since admit to hospital\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm (per patient\ns wife)\n 90.6 kg\n 28.2 (based on UBW)\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 122%\n 70.8 kg (based on UBW)\n 81.8 kg (per wife patient\ns dry wt)\n %\n Diagnosis: ascites\n PMHx: EtOH cirrhosis, c/b ascites and varices, s/p banding, s/p TIPS,\n portal vein thrombosis, on coumadin goal INR , diabetes mellitus,\n hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD\n Food allergies and intolerances: no known food allergies\n Pertinent medications: insulin drip, dextrose 5@ 100 ml/hr, IV abx,\n protonix, heparin, others noted\n Labs:\n Value\n Date\n Glucose\n 195 mg/dL\n 09:58 AM\n Glucose Finger Stick\n 197\n 02:00 PM\n BUN\n 47 mg/dL\n 09:58 AM\n Creatinine\n 2.9 mg/dL\n 09:58 AM\n Sodium\n 148 mEq/L\n 09:58 AM\n Potassium\n 3.9 mEq/L\n 09:58 AM\n Chloride\n 113 mEq/L\n 09:58 AM\n TCO2\n 21 mEq/L\n 09:58 AM\n Calcium non-ionized\n 10.3 mg/dL\n 09:58 AM\n Phosphorus\n 3.4 mg/dL\n 09:58 AM\n Magnesium\n 2.2 mg/dL\n 09:58 AM\n Total Bilirubin\n 1.0 mg/dL\n 02:56 AM\n WBC\n 7.1 K/uL\n 02:56 AM\n Hgb\n 9.6 g/dL\n 02:56 AM\n Hematocrit\n 30.0 %\n 02:56 AM\n Current diet order / nutrition support: low sodium, diabetic\n GI: firm, distended, hypoactive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet, ascites\n Estimated Nutritional Needs\n Calories: 1770- (BEE x or / 25-28 cal/kg)\n Protein: 71-85 (1-1.2 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: Inadequate per patient\ns wife\n Estimation of current intake: Inadequate due to NPO status\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2119-08-17 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 591615, "text": "Subjective\n per wife patient had poor pos since admit to hospital\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm (per patient\ns wife)\n 90.6 kg\n 28.2 (based on UBW)\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 122%\n 70.8 kg (based on UBW)\n 81.8 kg (per wife patient\ns dry wt)\n %\n Diagnosis: ascites\n PMHx: EtOH cirrhosis, c/b ascites and varices, s/p banding, s/p TIPS,\n portal vein thrombosis, on coumadin goal INR , diabetes mellitus,\n hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD\n Food allergies and intolerances: no known food allergies\n Pertinent medications: insulin drip, dextrose 5@ 100 ml/hr, IV abx,\n protonix, heparin, others noted\n Labs:\n Value\n Date\n Glucose\n 195 mg/dL\n 09:58 AM\n Glucose Finger Stick\n 197\n 02:00 PM\n BUN\n 47 mg/dL\n 09:58 AM\n Creatinine\n 2.9 mg/dL\n 09:58 AM\n Sodium\n 148 mEq/L\n 09:58 AM\n Potassium\n 3.9 mEq/L\n 09:58 AM\n Chloride\n 113 mEq/L\n 09:58 AM\n TCO2\n 21 mEq/L\n 09:58 AM\n Calcium non-ionized\n 10.3 mg/dL\n 09:58 AM\n Phosphorus\n 3.4 mg/dL\n 09:58 AM\n Magnesium\n 2.2 mg/dL\n 09:58 AM\n Total Bilirubin\n 1.0 mg/dL\n 02:56 AM\n WBC\n 7.1 K/uL\n 02:56 AM\n Hgb\n 9.6 g/dL\n 02:56 AM\n Hematocrit\n 30.0 %\n 02:56 AM\n Current diet order / nutrition support: low sodium, diabetic\n GI: firm, distended, hypoactive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet, ascites\n Estimated Nutritional Needs\n Calories: 1770- (BEE x or / 25-28 cal/kg)\n Protein: 71-85 (1-1.2 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: Inadequate per patient\ns wife\n Estimation of current intake: Inadequate due to NPO status\n Specifics: He was transferred to MICU secondary to increase agitation\n and aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2119-08-17 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 591618, "text": "Subjective\n per wife patient had poor pos since admit to hospital\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm (per patient\ns wife)\n 90.6 kg\n 28.2 (based on UBW)\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 122%\n 70.8 kg (based on UBW)\n 81.8 kg (per wife patient\ns dry wt)\n %\n Diagnosis: ascites\n PMHx: EtOH cirrhosis, c/b ascites and varices, s/p banding, s/p TIPS,\n portal vein thrombosis, on coumadin goal INR , diabetes mellitus,\n hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD\n Food allergies and intolerances: no known food allergies\n Pertinent medications: insulin drip, dextrose 5@ 100 ml/hr, IV abx,\n protonix, heparin, others noted\n Labs:\n Value\n Date\n Glucose\n 195 mg/dL\n 09:58 AM\n Glucose Finger Stick\n 197\n 02:00 PM\n BUN\n 47 mg/dL\n 09:58 AM\n Creatinine\n 2.9 mg/dL\n 09:58 AM\n Sodium\n 148 mEq/L\n 09:58 AM\n Potassium\n 3.9 mEq/L\n 09:58 AM\n Chloride\n 113 mEq/L\n 09:58 AM\n TCO2\n 21 mEq/L\n 09:58 AM\n Calcium non-ionized\n 10.3 mg/dL\n 09:58 AM\n Phosphorus\n 3.4 mg/dL\n 09:58 AM\n Magnesium\n 2.2 mg/dL\n 09:58 AM\n Total Bilirubin\n 1.0 mg/dL\n 02:56 AM\n WBC\n 7.1 K/uL\n 02:56 AM\n Hgb\n 9.6 g/dL\n 02:56 AM\n Hematocrit\n 30.0 %\n 02:56 AM\n Current diet order / nutrition support: low sodium, diabetic\n GI: firm, distended, hypoactive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet, ascites\n Estimated Nutritional Needs\n Calories: 1770- (BEE x or / 25-28 cal/kg)\n Protein: 71-85 (1-1.2 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: Inadequate per patient\ns wife\n Estimation of current intake: Inadequate due to NPO status\n Specifics: 63 year old male was admitted on to ICU with\n right sided abdominal pain, ascites, lactic acidosis thought to be\n perhaps secondary to metformin toxicity, and renal failure requiring\n emergent dialysis. Once on floor HD was stopped, last session was\n . He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. Patient is\n now on insulin drip. Due to poor mental status NGT was placed awaiting\n CXR results. Tube feeding recommendations below.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Once placement confirmed recommend Nutren Pulmonary @ 20 ml/hr\n advance to goal of 50 ml/hr = 1800 kcals/ 82 g protein\n 2. Check residuals q 4-6 hours hold if greater than 200 cc\n 3. Change to non dextrose IVF\n 4. Check chem. 10 daily and replete prn\n 5. Will follow page with questions\n" }, { "category": "Physician ", "chartdate": "2119-08-18 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 591738, "text": "Chief Complaint: hepatic encephalopathy, hyperglycemia\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 Off insulin drip\n NGT placed for lactulose\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Piperacillin - 02:46 AM\n Ciprofloxacin - 10:19 AM\n Piperacillin/Tazobactam (Zosyn) - 08:14 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:18 AM\n Heparin Sodium (Prophylaxis) - 11:46 PM\n Morphine Sulfate - 05:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:41 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: 36.3\nC (97.4\n HR: 118 (97 - 128) bpm\n BP: 152/104(116) {108/82(91) - 169/104(118)} mmHg\n RR: 17 (14 - 30) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 92.2 kg (admission): 90.6 kg\n Height: 67 Inch\n Total In:\n 3,487 mL\n 1,161 mL\n PO:\n TF:\n IVF:\n 3,087 mL\n 1,161 mL\n Blood products:\n 50 mL\n Total out:\n 1,363 mL\n 1,335 mL\n Urine:\n 763 mL\n 185 mL\n NG:\n 600 mL\n 1,150 mL\n Stool:\n Drains:\n Balance:\n 2,124 mL\n -172 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Gen: dishelved moaning in bed\n CV: RR\n Chest: poor air movement no wheeze\n Abd: tesne ascites, hypoactigve BS\n Ext: trace edema\n Neuro: altered, only groans, asterixis\n Labs / Radiology\n 10.5 g/dL\n 147 K/uL\n 137 mg/dL\n 3.1 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 44 mg/dL\n 109 mEq/L\n 147 mEq/L\n 32.6 %\n 13.0 K/uL\n [image002.jpg]\n 02:56 AM\n 09:58 AM\n 02:35 PM\n 10:00 PM\n 03:09 AM\n 04:45 AM\n WBC\n 7.1\n 9.4\n 13.0\n Hct\n 30.0\n 30.6\n 32.6\n Plt\n 102\n 108\n 147\n Cr\n 2.9\n 2.9\n 2.8\n 3.0\n 2.8\n 3.1\n Glucose\n 191\n 195\n 188\n 183\n 660\n 137\n Other labs: PT / PTT / INR:36.7/39.4/3.8, ALT / AST:, Alk Phos / T\n Bili:120/1.5, Differential-Neuts:84.7 %, Lymph:8.5 %, Mono:2.9 %,\n Eos:3.6 %, Albumin:4.8 g/dL, LDH:273 IU/L, Ca++:10.6 mg/dL, Mg++:2.1\n mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPERNATREMIA (HIGH SODIUM)\n LIVER FUNCTION ABNORMALITIES\n CIRRHOSIS OF LIVER, ALCOHOLIC\n DIABETES MELLITUS (DM), TYPE II\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ALTERED MENTAL STATUS\n attributable to hepatic encephalopathy.\n Precipitants likely multifactorial, including hypernatremia,\n hypokalemia, and contribution of renal failure, on background of prior\n TIPS (increased incidence of encephalopathy). Lactulose and Rifaximin\n per NGT and enema to manage encephalopathy.\n RENAL FAILURE\n worsening Cr today- HRS versus ATN, check repeat\n bladder pressure. Monitor uo, BUN, creatinine. Check urine lytes, UA.\n Continue midodrine, albumin as per Renal consultation.\n Ileus: in setting of massive ascitesbut Abd CT on showed gastric\n outlet obstruction\n need to speak with GI about any furter work up for\n this\n he is not in good shape for lying flat for abd ct or egd right\n now but may be necessary t pursue if does not resolve. Can do small\n volume tap t see if imprves.\n HYPERNATREMIA\n requires ongoing free water repletion. Monitor Na.\n HYPERGLYCEMIA\n poorly controlled diabetes. Unclear precipitant, but\n concern for infection. No evidence for DKA. Plan monitor glucose,\n resume insulin continuous infusion, maintain glucose <150. \n Consultation.\n PORTAL VEIN THROMBOSIS\n continue anticoagulation. PT/INR.\n NUTRITIONAL SUPPORT\n NPO while encephalopathic, high aspiration risk.\n CIRRHOSIS\n not transplant candidate. Continue supportive care.\n Plans otherwise as outlined per Resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2119-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591671, "text": "Synopsis per prior nursing note:\n Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Hypernatremia (high sodium)\n Assessment:\n Na 146, k 3.6.\n Action:\n Received 2^nd L of D5W @ 100cc/hr. Given 1L D5W with 40mEq potassium @\n 100cc/hr. NGT with residuals of 600cc x2. NGT placed on intermittent\n suction. Given lactulose enema.\n Response:\n Repeat Na . Stool output ~2L, liquid stool.\n Plan:\n Monitor electrolytes.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 97-153 while on insulin gtt.\n Action:\n NPO. FS monitored q1hr while on insulin gtt. Given evening dose of\n lantus. Insulin gtt turned off @ 0100, FS 153 and given 7units(half\n dose) of humalog.\n Response:\n Plan:\n Monitor FS q4hrs.\n Cirrhosis of liver, alcoholic\n Assessment:\n Confused, garbled speech, not following commands, purposeful movements\n of extremities, occasionally combative, +ascites.\n Action:\n Attempted to reorient. Soft wrist restraints continued d/t patient\n attempting to pull out lines. Given PR lactulose.\n Response:\n No change in mental status.\n Plan:\n Lactulose PR .\n" }, { "category": "Physician ", "chartdate": "2119-08-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 591732, "text": "Chief Complaint:\n 24 Hour Events:\n Liver following - gave albumin, lactulose\n - In ICU for insulin drip - will d/c drip tonight. plan to c/o to floor\n tomorrow.\n - NGT placed, good placement\n - Hypernatremia - another 1L of D5W\n - Ordered TSH, will discuss synthroid tomorrow\n - Lactulose from NGT held for high residuals\n - Monstrous BM x1 after lactulose enema.\n - Discontinued coumadin given INR>3\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Piperacillin - 02:46 AM\n Ciprofloxacin - 10:19 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:18 AM\n Heparin Sodium (Prophylaxis) - 11:46 PM\n Morphine Sulfate - 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 07:47 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: 36.2\nC (97.1\n HR: 110 (90 - 128) bpm\n BP: 132/90(101) {108/82(91) - 169/104(118)} mmHg\n RR: 15 (14 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 92.2 kg (admission): 90.6 kg\n Height: 67 Inch\n Total In:\n 3,487 mL\n 926 mL\n PO:\n TF:\n IVF:\n 3,087 mL\n 926 mL\n Blood products:\n 50 mL\n Total out:\n 1,363 mL\n 1,305 mL\n Urine:\n 763 mL\n 155 mL\n NG:\n 600 mL\n 1,150 mL\n Stool:\n Drains:\n Balance:\n 2,124 mL\n -379 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n Cardiovascular: NG tube in place\n PERRLA, unable to follow commands+language\n CVS: RRR, no MRG, S1S2 clear\n Rhonchorous throughout lung fields.\n abd:+ve bs/ tense/ tympanic/ round.\n little urine, hematuria, no clots\n wwp\n Labs / Radiology\n 147 K/uL\n 10.5 g/dL\n 137 mg/dL\n 3.1 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 44 mg/dL\n 109 mEq/L\n 147 mEq/L\n 32.6 %\n 13.0 K/uL\n [image002.jpg]\n 02:56 AM\n 09:58 AM\n 02:35 PM\n 10:00 PM\n 03:09 AM\n 04:45 AM\n WBC\n 7.1\n 9.4\n 13.0\n Hct\n 30.0\n 30.6\n 32.6\n Plt\n 102\n 108\n 147\n Cr\n 2.9\n 2.9\n 2.8\n 3.0\n 2.8\n 3.1\n Glucose\n 191\n 195\n 188\n 183\n 660\n 137\n Other labs: PT / PTT / INR:36.7/39.4/3.8, ALT / AST:, Alk Phos / T\n Bili:120/1.5, Differential-Neuts:84.7 %, Lymph:8.5 %, Mono:2.9 %,\n Eos:3.6 %, Albumin:4.8 g/dL, LDH:273 IU/L, Ca++:10.6 mg/dL, Mg++:2.1\n mg/dL, PO4:3.2 mg/dL\n Imaging: no imaging today. NG tube in place\n Microbiology: 4 blood cx pending.\n UCx pending.\n Peritoneal fluid:gram stain negative, no growth preliminary.\n Toxo Ab pending.\n ECG: none\n Assessment and Plan\n INEFFECTIVE COPING\n HYPERNATREMIA (HIGH SODIUM)\n LIVER FUNCTION ABNORMALITIES\n CIRRHOSIS OF LIVER, ALCOHOLIC\n DIABETES MELLITUS (DM), TYPE II\n ACUTE CONFUSION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Altered mental status:\n Head CT negative. Abd u/s unchanged. Diagnostic para not revealing.\n Hypernatremic. Hyperglycemia and enceph suggests possibility of\n infection. Pt originally presented with abdominal pain that was not\n notable on exam but uncomfortable to patient, even in setting of no\n encephalopathy; pt currently moaning mournfully consistent with past\n presentation.\n - covering w vanc/zosyn\n - gently correcting hypernatremia though doubt this is major\n contributor\n - has had haldol on the floor, continuing this as prn; not clear\n whether this will be helpful other than as sedative, and will consider\n very low dose morphine as trial of pain relief; Tylenol at low dose\n also.\n - likely to need to hold POs currently, pt not w mental status to\n cooperate w POs; consider NG tube for nutrition and meds if not\n clearing by mid-morning.\n - lactulose enema\n - f/u micro data, cultures pending\n Liver failure\n Not yet listed for transplant. Transplant committee asking for\n colonoscopy and outpatient relapse therapy. Specific interventions:\n midodrine, albumin; lactulose.\n Hyperglycemia / diabetes\n Likely secondary to infection given change over last several days\n coinciding w worsening encephalopathy. Doing insulin drip to manage\n this. Will d/ in AM\nthey are following\nto discuss both acute\n management and long-term plan for insulin/ antihyperglycemic regimen.\n Hypernatremia\n Likely 2.2 poor intake.\n NS did nothing to correct this, consistent w\n high sodium avidity. Will do D5W with insulin drip titrated to\n accommodate the extra sugar load.\n Renal failure\n ?Abdominal compartment syndrome vs s/p drug toxicity, unclear etiology.\n Liver failure likely contributing to some degree of pre-renal failure\n although the degree of resolution suggests against HRS. Continue\n midodrine, albumin as per floor team. Follow Cr and urine output\n closely. No urgent indication for HD. Renal following, will follow up\n recs.\n Hypothyroidism\n Mild hypothyroidism from tests from . Team discontinued prior\n synthroid, not clear why from notes; will discuss with them in AM.\n Coagulopathy/anticoagulation\n Continuing warfarin for portal vein thrombosis which has been a problem\n for pt in the past.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Pantoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2119-08-18 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 591736, "text": "Chief Complaint: hepatic encephalopathy, hyperglycemia\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 Off insulin drip\n NGT placed for lactulose\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Piperacillin - 02:46 AM\n Ciprofloxacin - 10:19 AM\n Piperacillin/Tazobactam (Zosyn) - 08:14 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:18 AM\n Heparin Sodium (Prophylaxis) - 11:46 PM\n Morphine Sulfate - 05:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:41 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: 36.3\nC (97.4\n HR: 118 (97 - 128) bpm\n BP: 152/104(116) {108/82(91) - 169/104(118)} mmHg\n RR: 17 (14 - 30) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 92.2 kg (admission): 90.6 kg\n Height: 67 Inch\n Total In:\n 3,487 mL\n 1,161 mL\n PO:\n TF:\n IVF:\n 3,087 mL\n 1,161 mL\n Blood products:\n 50 mL\n Total out:\n 1,363 mL\n 1,335 mL\n Urine:\n 763 mL\n 185 mL\n NG:\n 600 mL\n 1,150 mL\n Stool:\n Drains:\n Balance:\n 2,124 mL\n -172 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\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 10.5 g/dL\n 147 K/uL\n 137 mg/dL\n 3.1 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 44 mg/dL\n 109 mEq/L\n 147 mEq/L\n 32.6 %\n 13.0 K/uL\n [image002.jpg]\n 02:56 AM\n 09:58 AM\n 02:35 PM\n 10:00 PM\n 03:09 AM\n 04:45 AM\n WBC\n 7.1\n 9.4\n 13.0\n Hct\n 30.0\n 30.6\n 32.6\n Plt\n 102\n 108\n 147\n Cr\n 2.9\n 2.9\n 2.8\n 3.0\n 2.8\n 3.1\n Glucose\n 191\n 195\n 188\n 183\n 660\n 137\n Other labs: PT / PTT / INR:36.7/39.4/3.8, ALT / AST:, Alk Phos / T\n Bili:120/1.5, Differential-Neuts:84.7 %, Lymph:8.5 %, Mono:2.9 %,\n Eos:3.6 %, Albumin:4.8 g/dL, LDH:273 IU/L, Ca++:10.6 mg/dL, Mg++:2.1\n mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPERNATREMIA (HIGH SODIUM)\n LIVER FUNCTION ABNORMALITIES\n CIRRHOSIS OF LIVER, ALCOHOLIC\n DIABETES MELLITUS (DM), TYPE II\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ALTERED MENTAL STATUS\n attributable to hepatic encephalopathy.\n Precipitants likely multifactorial, including hypernatremia,\n hypokalemia, and contribution of renal failure, on background of prior\n TIPS (increased incidence of encephalopathy). No evidence for GI bleed\n or protein load in gut. Medication effect possible. Also need to\n consider possibility of infection, but no localizing signs or symptoms\n or line infection or SBP (no evidence for SBP by recent paracentesis).\n Plan provide free water, replete K, avoid sedating medications.\n Monitor for infection, await cultures (including C. Diff)\n empirical\n antimicrobials. Monitor airway, with low threshold for intubation to\n protect airway. Lactulose per NGT and enema to manage encephalopathy.\n LACTIC ACIDOSIS\n unclear etiology, variable levels. No obvious signs\n of infection. Consider thiamine repletion. Monitor.\n RENAL FAILURE\n Recovering ATN. No longer requiring renal replacement\n therapy. Monitor uo, BUN, creatinine. Check urine lytes, UA.\n Continue midodrine, albumin as per Renal consultation.\n HYPERNATREMIA\n requires free water repletion. Monitor Na.\n HYPERGLYCEMIA\n poorly controlled diabetes. Unclear precipitant, but\n concern for infection. No evidence for DKA. Plan monitor glucose,\n resume insulin continuous infusion, maintain glucose <150. \n Consultation.\n ELEVATED TSH\n unclear whether this represents hypothyroidism or\n consequences of critical illness. Monitor closely on synthroid or\n consider discontinuing.\n PORTAL VEIN THROMBOSIS\n continue anticoagulation. PT/INR.\n NUTRITIONAL SUPPORT\n NPO while encephalopathic, high aspiration risk.\n CIRRHOSIS\n not transplant candidate. Continue supportive care.\n Plans otherwise as outlined per Resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2119-08-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591661, "text": "Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Hypernatremia (high sodium)\n Assessment:\n Pt with Na 152\n Action:\n Received with\n NS infusing and was switched over to D5W at 100cc/hr\n x3L, received 1L this shift.\n Response:\n Repeat Na 149.\n Plan:\n Continue with D5W for 2 more liters. Next set of labs at 2200.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt with history of diabetes was transferred to MICU 6 for management of\n high sugars with insulin gtt. Finger sticks ranging 121-250.\n Action:\n Pt\ns insulin gtt titrated closely to josslyn guidelines.\n Response:\n Continues on insulin gtt at 4units/hr.\n Plan:\n Continue with D5W infusion, cover pt with PM lantus dose at 2200 and\n turn off gtt 3 hours later, check finger sticks q4hour after lantus\n dose and cover per sliding scale.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt with history of ETOH cirrhosis, pt encephalopathic, confused,\n combative (grabbing at and pinching staff) and uncooperative.\n Action:\n NGT placed for pt to received PO rifaximin and lactulose. Pt of Dr\n has started work up for liver transplant. Wife at bedside and pt\n remains restrained in bed for safety and patency of invasive lines.\n Response:\n No BM at this point, remains restrained, confused and combative.\n Plan:\n Lactulose QID, lactulose enema if needed.\n Ineffective Coping\n Assessment:\n Pt\ns wife at bedside is very tearful.\n Action:\n Pt\n wife, RN and MD spoke at length with help of interpreter. Spoke\n about disease process, POC, and other concerns. Social work is\n involved.\n Response:\n Although pt\ns wife does remain tearful she expressed appreciation for\n the meeting.\n Plan:\n Continue to provide support to pt and wife.\n" }, { "category": "Nursing", "chartdate": "2119-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591724, "text": "Synopsis per prior nursing note:\n Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Hypernatremia (high sodium)\n Assessment:\n Na 146, k 3.6.\n Action:\n Received 2^nd L of D5W @ 100cc/hr. Started 1L of D5W with 40mEq\n potassium. NGT with residuals of 600cc x2. NGT placed on intermittent\n suction. Given lactulose enema.\n Response:\n Repeat Na 147. Repeat K 4.2. Stool output ~2L, liquid stool.\n Continues to put out bilious fluid from NGT.\n Plan:\n Monitor electrolytes. Monitor stool/NGT output.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 97-153 while on insulin gtt.\n Action:\n NPO. FS monitored q1hr while on insulin gtt. Given evening dose of\n lantus. Insulin gtt turned off @ 0100, FS 153 and given 7units(half\n dose) of humalog.\n Response:\n FS 170, covered w/ humalog.\n Plan:\n Monitor FS q4hrs, next FS due at 0800.\n Cirrhosis of liver, alcoholic\n Assessment:\n Confused, garbled speech, not following commands, purposeful movements\n of extremities, occasionally combative, +ascites.\n Action:\n Attempted to reorient. Soft wrist restraints continued d/t patient\n attempting to pull out lines. Given PR lactulose. INR 3.8(2).\n Warfarin d/c\nd. Given morphine for agitation/discomfort.\n Response:\n No change in mental status.\n Plan:\n Lactulose PR . Monitor change in mental status.\n" }, { "category": "Physician ", "chartdate": "2119-08-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 591947, "text": "Chief Complaint:\n 24 Hour Events:\n C.diff sent. recommended changing insulin from q4 to Q6 HISS\n since insulin stacks in renal disease and lantus to 30 from 26.\n Ciprofloxacin dc'd.\n am labs showed increase Na, K+ low, thus started on D5W in 40meq KCl.\n Therapeutic tap deferred.\n CXR showed stable bilateral lower lobe atelectasis associated with low\n lung volumes. No new consolidation or pneumothorax.\n Toxo pos IgG/neg IgM result\n Blood/urine cultures pending\n u cx growing yeast\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Piperacillin - 02:46 AM\n Ciprofloxacin - 10:19 AM\n Piperacillin/Tazobactam (Zosyn) - 08:07 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:08 AM\n Dextrose 50% - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.2\nC (97.1\n HR: 76 (76 - 119) bpm\n BP: 133/80(91) {109/55(69) - 169/107(121)} mmHg\n RR: 13 (13 - 19) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.2 kg (admission): 90.6 kg\n Height: 67 Inch\n Total In:\n 2,742 mL\n 253 mL\n PO:\n TF:\n IVF:\n 2,542 mL\n 203 mL\n Blood products:\n 200 mL\n Total out:\n 1,850 mL\n 150 mL\n Urine:\n 500 mL\n 150 mL\n NG:\n 1,350 mL\n Stool:\n Drains:\n Balance:\n 892 mL\n 103 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///20/\n Physical Examination\n Calm, cooperative, mental status much improved today. Wife reports he\n is at baseline.\n Lungs with bilateral expiratory crackles.\n RRR, no audible murmur.\n Abdomen markedly distended, tense, with very faint bowel sounds.\n No pedal edema.\n Labs / Radiology\n 170 K/uL\n 9.9 g/dL\n 40 mg/dL\n 3.1 mg/dL\n 20 mEq/L\n 3.2 mEq/L\n 43 mg/dL\n 109 mEq/L\n 146 mEq/L\n 30.3 %\n 11.6 K/uL\n [image002.jpg]\n 02:56 AM\n 09:58 AM\n 02:35 PM\n 10:00 PM\n 03:09 AM\n 04:45 AM\n 12:16 PM\n 07:30 PM\n 03:54 AM\n WBC\n 7.1\n 9.4\n 13.0\n 11.6\n Hct\n 30.0\n 30.6\n 32.6\n 30.3\n Plt\n 102\n 108\n 147\n 170\n Cr\n 2.9\n 2.9\n 2.8\n 3.0\n 2.8\n 3.1\n 3.1\n 3.1\n 3.1\n Glucose\n 191\n 195\n 188\n 183\n 1\n 40\n Other labs: PT / PTT / INR:37.5/44.7/3.9, ALT / AST:, Alk Phos / T\n Bili:118/1.9, Differential-Neuts:84.7 %, Lymph:8.5 %, Mono:2.9 %,\n Eos:3.6 %, Lactic Acid:2.8 mmol/L, Albumin:4.8 g/dL, LDH:248 IU/L,\n Ca++:10.3 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPERNATREMIA (HIGH SODIUM)\n LIVER FUNCTION ABNORMALITIES\n CIRRHOSIS OF LIVER, ALCOHOLIC\n DIABETES MELLITUS (DM), TYPE II\n ACUTE CONFUSION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Leukocytosis: Remains afebrile\n leukocytosis stable. Pt admitted with\n suspected infection given hyperglycemia, and treated empirically.\n Unclear source with previous paracentesis negative for SBP, UTI\n possible given new hematuria on exam today (however INR3.8), line\n infection, PNA to be considered. Difficult to invoke CNS infection\n given MS to hepatic encephalopathy, continue to\n consider. On multiple abx, consider c.diff.\n - cipro discontinued, now treating with vanco, Zosyn.\n - Stool Cx pending\n -Sputum Cx pending\n -CXR showed no evidence for infection.\n Altered mental status:\n Improved today, more cooperative and near baseline according to wife.\n AMS likely due to hepatic encephalopathy. Head CT negative. Abd u/s\n unchanged. Hypernatremia yesterday and overnight, but mild, unlikely\n related.\n - covering w vanc/zosyn\n - gently correcting hypernatremia though doubt this is major\n contributor, with D5W for free water deficit.\n -Continue lactulose enema\n - f/u 4 blood cx pending, Ucx pending, peritoneal fluid gram stain\n negative, no growth preliminary.\n Liver failure\n Not yet listed for transplant. Transplant committee asking for\n colonoscopy and outpatient relapse therapy. Liver today indicated\n continue on this course. DC\nd midodrine given HTN. Continuing lactulose\n and albumin.\n Tense/ obese ascetic abdomen with compartment syndrome possibly\n contributing to ileus and renal failure. Paracentesis initially\n planned for yesterday, but deferred until today. Liver recommends\n removing 3-4 liters today, treating with albumin\n 6 g per liter\n removed.\n Hyperglycemia / diabetes\n Likely secondary to infection given change over last several days\n coinciding w worsening encephalopathy. GFS more controlled over past\n 24 hours, with one hypoglycemic episode.\n - recs yesterday\n insuline regimen adjusted.\n Hypernatremia - D5W with potassium yesterday\n labs this morning\n still with low sodium, high potassium. Will continue D5W with K for\n repletion.\n Renal failure: creatinine stably elevated, FeNa < 1, urine sodium very\n low.\n -renal advises to check urine osm, check bladder pressure to evaluate\n for abd compartment syndrome.\n - Liver failure likely contributing to some degree of pre-renal failure\n although the degree of resolution suggests against HRS.\n -renal following\n Hypothyroidism\n -Mild hypothyroidism from tests from . restarted home Synthroid.\n Coagulopathy/anticoagulation\n -Hold warfarin given supratherapeutic INR 3.9\n -Check daily INR.\n ICU Care\n Nutrition:\n Glycemic Control: ISS\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n 18 Gauge - 01:31 PM\n Prophylaxis:\n DVT: boots, INR supratherapeutic\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: with patient and wife\n status: full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2119-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591718, "text": "Synopsis per prior nursing note:\n Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Hypernatremia (high sodium)\n Assessment:\n Na 146, k 3.6.\n Action:\n Received 2^nd L of D5W @ 100cc/hr. Started 1L of D5W with 40mEq\n potassium @ 100cc/hr. NGT with residuals of 600cc x2. NGT placed on\n intermittent suction. Given lactulose enema.\n Response:\n Repeat Na 147. Repeat K 4.2. Stool output ~2L, liquid stool.\n Continues to put out bilious fluid from NGT.\n Plan:\n Monitor electrolytes. Monitor stool/NGT output.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 97-153 while on insulin gtt.\n Action:\n NPO. FS monitored q1hr while on insulin gtt. Given evening dose of\n lantus. Insulin gtt turned off @ 0100, FS 153 and given 7units(half\n dose) of humalog.\n Response:\n FS 170, covered w/ humalog.\n Plan:\n Monitor FS q4hrs, next FS due at 0800.\n Cirrhosis of liver, alcoholic\n Assessment:\n Confused, garbled speech, not following commands, purposeful movements\n of extremities, occasionally combative, +ascites.\n Action:\n Attempted to reorient. Soft wrist restraints continued d/t patient\n attempting to pull out lines. Given PR lactulose. INR 3.8(2). Given\n morphine for agitation/discomfort.\n Response:\n No change in mental status.\n Plan:\n Lactulose PR . Monitor change in mental status.\n" }, { "category": "Physician ", "chartdate": "2119-08-17 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 591541, "text": "Chief Complaint: altered mental status\n HPI:\n Mr. was previously known to the MICU team when he was\n admitted on with right sided abdominal pain, ascites, lactic\n acidosis thought to be perhaps secondary to metformin toxicity, and\n renal failure requiring emergent dialysis. Then (and since then)\n diagnostic paracenteses did not show evidence for SBP (para done\n earlier today shows WBC 300 but in setting of RBC ). In MICU\n stay, dialysis was initiated. Since he has been on the floor, he\n has been able to stop dialysis for a time, with last session on 8.21\n per housestaff notes. He has had urine output of 600 as of the morning\n of . A diabetic who has been on insulin only during this admission,\n he has had difficult-to-control glucose, remaining in the 300s-400s for\n much of the last day despite an aggressive sliding scale. He triggered\n on the floor both the night of transfer and the night prior for\n agitation and altered mental status. The evening prior to transfer, the\n MICU resident was notified by the liver-kidney resident that Mr.\n \ns status was troubling and that a transfer might be necessary;\n on the second trigger overnight, nightfloat and MICU residents agreed\n to transfer Mr. to the MICU for insulin drip and closer\n monitoring in the setting of ongoing encephalopathy, intermittent\n agitation, and difficult to control blood sugar. The liver attending\n was contact by the nightfloat covering team, and reportedly\n recommended insulin drip and suggested the possibility of infection.\n At time of transfer, Mr. was tachycardic and hypertensive. He\n was alternating between periods of sleep and periods of agitated\n moaning, consistent with the mournful moans of the encephalopathic\n periods of his prior MICU stay.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Infusions:\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Haloperidol (Haldol) - 01:50 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n EtOH cirrhosis, c/b ascites and varices, s/p banding\n s/p TIPS ()-->redo for narrowing --> failure of TIPS\n noted in past admissions w d/c summaries noting decision not to redo\n TIPS further given diminished returns\n recent prior admission including 5L paracentesis\n portal vein thrombosis, on coumadin goal INR \n diabetes mellitus\n hypothyroidism\n pituitary mass\n h/o nephrolithiasis\n h/o +PPD\n Mother deceased at age 50, CVA. Father deceased, age 62, \"stomach\n problems\". One brother and two sisters, all living and in good health.\n Occupation: retired\n Drugs: no\n Tobacco: non\n Alcohol: quit \n Other:\n Review of systems:\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Emesis\n Endocrine: History of thyroid disease\n Pain: Unable to answer\n Flowsheet Data as of 03:08 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.9\nC (96.7\n HR: 105 (105 - 122) bpm\n BP: 149/87(101) {141/87(101) - 169/95(113)} mmHg\n RR: 18 (17 - 18) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1 mL\n 315 mL\n PO:\n TF:\n IVF:\n 1 mL\n 315 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1 mL\n 315 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n General Appearance: Agitated, moaning mournfully; when going back to\n sleep often sleeping on side\n Eyes / Conjunctiva: PERRL, staring into space, not clearly registering\n his examiners(s)\n Cardiovascular: (S1: Normal), (S2: Normal), regular rate and rhythm, no\n m/r/g appreciated\n Lungs: clear to auscultation on anterior exam\n Abdominal Large distended abdomen, some tympany at top, less taut than\n on initial presentation to MICU on \n Peripheral Vascular: radial pulses present bilaterally; distal pulses\n not appreciated\n Skin: not jaundiced; no petichiae\n Neurologic: Open eyes, some response to voice, responds to painful\n stimuli, does not respond to loud\ncomo estais\n or other attempts to\n communicate; moving all four extremities\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Altered mental status:\n Head CT negative. Abd u/s unchanged. Diagnostic para not revealing.\n Hypernatremic. Hyperglycemia and enceph suggests possibility of\n infection. Pt originally presented with abdominal pain that was not\n notable on exam but uncomfortable to patient, even in setting of no\n encephalopathy; pt currently moaning mournfully consistent with past\n presentation.\n - covering w vanc/zosyn\n - gently correcting hypernatremia though doubt this is major\n contributor\n - has had haldol on the floor, continuing this as prn; not clear\n whether this will be helpful other than as sedative, and will consider\n very low dose morphine as trial of pain relief; Tylenol at low dose\n also.\n - likely to need to hold POs currently, pt not w mental status to\n cooperate w POs; consider NG tube for nutrition and meds if not\n clearing by mid-morning.\n - lactulose enema\n - f/u micro data, cultures pending\n Liver failure\n Not yet listed for transplant. Transplant committee asking for\n colonoscopy and outpatient relapse therapy. Specific interventions:\n midodrine, albumin; lactulose.\n Hyperglycemia / diabetes\n Likely secondary to infection given change over last several days\n coinciding w worsening encephalopathy. Doing insulin drip to manage\n this. Will d/ in AM\nthey are following\nto discuss both acute\n management and long-term plan for insulin/ antihyperglycemic regimen.\n Hypernatremia\n Likely 2.2 poor intake.\n NS did nothing to correct this, consistent w\n high sodium avidity. Will do D5W with insulin drip titrated to\n accommodate the extra sugar load.\n Renal failure\n ?Abdominal compartment syndrome vs s/p drug toxicity, unclear etiology.\n Liver failure likely contributing to some degree of pre-renal failure\n although the degree of resolution suggests against HRS. Continue\n midodrine, albumin as per floor team. Follow Cr and urine output\n closely. No urgent indication for HD. Renal following, will follow up\n recs.\n Hypothyroidism\n Mild hypothyroidism from tests from . Team discontinued prior\n synthroid, not clear why from notes; will discuss with them in AM.\n Coagulopathy/anticoagulation\n Continuing warfarin for portal vein thrombosis which has been a problem\n for pt in the past.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 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": "Nursing", "chartdate": "2119-08-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591658, "text": "Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Hypernatremia (high sodium)\n Assessment:\n Pt with Na 152\n Action:\n Received with\n NS infusing and was switched over to D5W at 100cc/hr\n x3L, received 1L this shift.\n Response:\n Repeat Na 149.\n Plan:\n Continue with D5W for 2 more liters. Next set of labs at 2200.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt with history of diabetes was transferred to MICU 6 for management of\n high sugars with insulin gtt. Finger sticks ranging 121-250.\n Action:\n Pt\ns insulin gtt titrated closely to josslyn guidelines.\n Response:\n Continues on insulin gtt at 4units/hr.\n Plan:\n Continue with D5W infusion, cover pt with PM lantus dose at 2200 and\n turn off gtt 3 hours later, check finger sticks q4hour after lantus\n dose and cover per sliding scale.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt with history of ETOH cirrhosis, pt encephalopathic, confused,\n combative (grabbing at and pinching staff) and uncooperative.\n Action:\n NGT placed for pt to received PO rifaximin and lactulose. Pt of Dr\n has started work up for liver transplant. Wife at bedside and pt\n remains restrained in bed for safety and patency of invasive lines.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2119-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591713, "text": "Synopsis per prior nursing note:\n Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Hypernatremia (high sodium)\n Assessment:\n Na 146, k 3.6.\n Action:\n Received 2^nd L of D5W @ 100cc/hr. Started 1L of D5W with 40mEq\n potassium @ 100cc/hr. NGT with residuals of 600cc x2. NGT placed on\n intermittent suction. Given lactulose enema.\n Response:\n Repeat Na . Stool output ~2L, liquid stool. Continues to put out\n bilious fluid from NGT.\n Plan:\n Monitor electrolytes.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 97-153 while on insulin gtt.\n Action:\n NPO. FS monitored q1hr while on insulin gtt. Given evening dose of\n lantus. Insulin gtt turned off @ 0100, FS 153 and given 7units(half\n dose) of humalog.\n Response:\n FS 170, covered w/ humalog.\n Plan:\n Monitor FS q4hrs.\n Cirrhosis of liver, alcoholic\n Assessment:\n Confused, garbled speech, not following commands, purposeful movements\n of extremities, occasionally combative, +ascites.\n Action:\n Attempted to reorient. Soft wrist restraints continued d/t patient\n attempting to pull out lines. Given PR lactulose. INR 3.8(2). Given\n morphine for agitation/discomfort.\n Response:\n No change in mental status.\n Plan:\n Lactulose PR .\n" }, { "category": "Nursing", "chartdate": "2119-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591843, "text": "Synopsis per prior nursing note:\n Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Hypernatremia (high sodium)\n Assessment:\n Na 144, k 3.9.\n Action:\n NGT to IWS. Given lactulose enema.\n Response:\n Repeat Na. Repeat K. Very large, liquid stool after enema. Continues\n to put out small amt bilious fluid from NGT.\n Plan:\n Monitor electrolytes. Monitor stool/NGT output.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 125-130.\n Action:\n NPO. FS monitored q4hrs. Given evening dose of lantus. FS treated with\n humalog per ISS.\n Response:\n Plan:\n Monitor FS q4hrs, next FS due at 0800.\n Cirrhosis of liver, alcoholic\n Assessment:\n Confused, garbled speech, not following commands, purposeful movements\n of extremities, occasionally combative, +ascites.\n Action:\n Attempted to reorient. Soft wrist restraints continued d/t patient\n attempting to pull out lines. Given PR lactulose.\n Response:\n No change in mental status.\n Plan:\n Lactulose PR . Monitor change in mental status.\n" }, { "category": "Physician ", "chartdate": "2119-08-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 589990, "text": "Chief Complaint:\n 24 Hour Events:\n DIALYSIS CATHETER - START 11:27 PM\n right IJ dialysis cath placed\n with VIP port\n o/n events: R IJ HD catheter placed and HD started for lactic\n acidosis.\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 07:03 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: 36.7\nC (98.1\n HR: 73 (61 - 77) bpm\n BP: 66/43(49) {66/43(49) - 125/67(82)} mmHg\n RR: 16 (15 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,033 mL\n 147 mL\n PO:\n 90 mL\n TF:\n IVF:\n 275 mL\n 57 mL\n Blood products:\n 1,758 mL\n Total out:\n 91 mL\n 309 mL\n Urine:\n 91 mL\n 109 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,942 mL\n -162 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\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 99 mg/dL\n 7.5 mg/dL\n 5.6 mEq/L\n 87 mg/dL\n [image002.jpg]\n 11:47 PM\n Cr\n 7.5\n Glucose\n 99\n Other labs: Lactic Acid:8.7 mmol/L, Mg++:3.4 mg/dL\n Imaging: CXR- R IJ in place, atelectesis\n CT abd/pelvis prelim- large ascites, ? gastric outlet obstruction, and\n no evidence of bowel ischemia.\n KUB - pending read\n Microbiology: Bcx pending\n Ucx pending\n Ascites analysis pending, gram stain negative\n Assessment and Plan\n This is a 63 year old Portuguese-speaking man with end-stage liver\n disease and stenosed TIPS, recurrent admissions for hepatic\n encephalopathy, now here with abdominal pain and a WBC of 21.3 with a\n neutrophil predominance.\n ASCITES\n Likely related to massive ascites likely hepatorenal syndrome. No\n evidence of SBP given low WBC on diagnostic tap; tap appears bloody;\n most likely coagulopathy, though consistent appearance of this\n finding might suggest hemoperitoneum from another process rather than\n from trauma from tap; CT apparently offers no obvious suspect. No sign\n of perf on CT scan. Surgery evaluating per ED request. Possible gastric\n outlet obstruction seen on CT scan; may improve w decrease in ascitic\n fluid.\n - appreciate surgery recs; tplant service will follow\n - will give albumin per liver recs p HD per renal recs; albumin will\n also be provided by FFP needed for HD line placement\n - consider tx tap if renal function improves\n - NGT if not tolerating clears, emesis, etc\n - clear liquid diet for now\n Leukocytosis\n Unclear source. Concern for abdominal source but as above this is not\n clear after dx tap and CT abd/pelvis. I am underwhelmed by CXR but do\n make note of RLL opacity; hard to account for this degree of WBC with\n this small PNA though relative immune suppression of liver/renal\n failure may diminish inflammatory response. High WBC out of proportion\n to symptoms, with abd pain, in pt w multiple hospitalizations, raises\n special concern for c. diff though obvious colitis not seen on CT.\n - covering gram-negatives w zosyn; add vanco and flagyl if worsening\n - Bcx, Ucx pending\n - send c. diff given mult recent hospitalizations\n LIVER CIRRHOSIS, ETOH, w/ encephalopathy\n Hepatorenal syndrome worsens prognosis. Could have been precipitated by\n large volume tap on prior admission, though pt has tolerated similar\n (~5L) in the past. (Note: I initially believed this to have been 10L,\n this was in fact ~5L). Pt has been on transplant list. MELD on\n admission = 41.\n - abd U/S w doppler to eval TIPS stenosis, eval portal circulation\n - daily MELD labs\n - transplant surgery and liver services following, appreciate recs\n - octreotide and midodrine\n - regular lactulose at home dose\n - continue home rifaximin\n - PPI\n - will restart pt's outpt propranolol after completion of HD and\n stabilization of BP\n - hold pt's home diuretics\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely hepatorenal syndrome, perhaps large volume tap on last\n admission; vs change in hemodynamics infection. FeNa on admission\n 0.6.\n - HD tonight per renal, appreciate renal involvement and placement of\n HD line w VIP port\n - holding metformin\n - continue midodrine, Octreotide\n - f/u Bcx, Ucx as above\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Per family report, patient currently appears to have intact MS,\n however, appears confused at times, with mumbling and groaning on.\n Possibly due to hepatic encephalopathy (NH3 = 66 on admission) vs\n infection, UTI vs SBP, vs acidemia. Remains afebrile\n - Be alert for harmful behavior, use soft restraints if pt begins to\n pull on lines\n - lactulose 30mg PO TID\n - await fluid results from paracentesis, including gram stain, WBC, and\n cx\n - UA\n - holding metforming for lactic acidosis\n - trend lactate\n LACTIC ACIDOSIS\n Most likely liver failure itself, though metformin toxicity in\n setting of new renal failure may also be responsible. Mesenteric\n ischemia could be culprit; no positive evidence for this at this point,\n but should follow closely.\n - Abd U/S w doppler as above\n - holding metformin and follow lactate as above.\n - follow lactate\n - guaiac stool\n DIABETES\n Holding oral antihyperglycemics based on low blood sugar in ED today.\n ISS alone for now. Has had more issues with high blood sugar than low\n in the past.\n - cont. ISS\n - check FSBG\n COAGULOPATHY\n Assoc w liver failure. Got 6U FFP for HD line placement. Holding\n coumadin for now.\n - continue to trend coags\n - give vit K for goal INR <2.\n - consider FFP for procedures\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:48 PM\n Dialysis Catheter - 11:27 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Family speaks Portuguese, communication with\n family.\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2119-08-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 589998, "text": "Chief Complaint: abdominal discomfort\n HPI:\n This is a 63 year old Portuguese-speaking man with extensive history of\n alcoholic cirrhosis, frequent admissions at , now here with\n right-sided abdominal pain, and increased ascites. Starting on\n Wednesday () he began having right-sided abdominal pain. His wife\n reported that he had increased fatigue, abdominal pain, abdominal\n girth, and one episode of non-bloody emesis. His wife and cousin denied\n that he had any episodes of confusion. They explained that he had \"pain\n where they took the water out\" on the right. They explained and he\n affirmed that he has been urinating less. I confirmed the essentials of\n this history with him during a brief Portuguese interpreter phone\n interview.\n .\n In the emergency department his initial vitals were: 97.9, 111/63, 18,\n 98% on room air. He was found to be guaiaic negative; and he had labs\n notable for lactate 9.1, WBC 21.3, Cr 7.6, Glu 15. With low glucose, a\n D5 drip was started. With consideration of ischemic colitis, the ED\n sent him for CT scan, ordered without contrast given his renal\n function; this did not show any signs of ischemia. Additionally, he\n received: 4.5 gm IV zosyn, octreotide 50 mcg IV and octreotide 25\n mcg/hr gtt; as well as 1 amp of calcium gluconate. Liver and kidney\n services were consulted in the ED; liver fellow left recs in the ED\n chart and renal fellow planned for HD in the unit. A diagnostic\n paracentesis was performed in the ED; the liver service recommended\n against therapeutic tap for now. He was admitted to the MICU service\n for further management.\n Patient admitted from: ER\n History obtained from Interpreter\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Octreotide - 25 mcg/hour\n Other ICU medications:\n Other medications:\n HOME MEDICATIONS\n Calcium Carbonate 500 mg tid\n Vitamin D3 800 units daily\n Glipizide 10 mg daily.\n Lactulose 60 mL PO QID\n Levothyroxine 100 mcg Tablet DAILY\n Metformin 1,000 mg Tablet DAILY\n Omeprazole 20 mg DAILY\n Propranolol 40 mg TID\n Rifaximin 400 TID\n Warfarin 3 mg qHS\n Past medical history:\n Family history:\n Social History:\n - ETOH cirrhosis, complicated by ascites and varices, s/p banding\n * s/p TIPS () -> redo for narrowing -> failure of TIPS\n noted in past admissions w/ d/c summaries noting decision not to redo\n tips further given diminished returns\n * recent admission including 5L paracentesis (note: originally\n thought this was 10L, past records appear to confirm 5L)\n - Portal vein thrombosis: on coumadin goal INR \n - Diabetes mellitus\n - Hypothyroidism\n - Pituitary mass\n - h/o nephrolithiasis\n - h/o + PPD\n Mother deceased, age 50, CVA. Father deceased, age 62, stomach\n problems. One brother living and in good health. Two sisters, both\n living and in good health.\n .\n Occupation: retired\n Drugs: no\n Tobacco: none\n Alcohol: quit \n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema\n Respiratory: Tachypnea, Wheeze\n Gastrointestinal: Abdominal pain, Nausea, Emesis\n Integumentary (skin): No(t) Jaundice\n Endocrine: History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy\n Flowsheet Data as of 03:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 73 (61 - 74) bpm\n BP: 91/45(55) {91/45(55) - 125/67(82)} mmHg\n RR: 21 (15 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,300 mL\n 313 mL\n PO:\n TF:\n IVF:\n 542 mL\n 313 mL\n Blood products:\n 1,758 mL\n Total out:\n 91 mL\n 80 mL\n Urine:\n 91 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,209 mL\n 233 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: Anxious; distended abdomen;\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal, Fixed) SEM heard best at\n RUSB\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n scattered crackles at bases, Diminished: )\n Abdominal: Extremely distended; dull to percussion at bulging flanks;\n bulging umbilicus\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, No(t) Cyanosis\n Skin: Warm\n Neurologic: Interactive, appropriate in initial interview, Responds to:\n Verbal stimuli, Oriented (to): , Movement: Not assessed, Tone: Normal\n + asterixis\n Labs / Radiology\n 99 mg/dL\n 7.5 mg/dL\n 87 mg/dL\n 5.6 mEq/L\n [image002.jpg]\n \n 5:00p\n PERITONEAL RT SIDE PARACENTESIS FLUID\n Other Body Fluid Hematology:\n WBC: 33\n RBC: 6340\n Polys: 25\n Lymphs: 14\n Monos: 18\n Mesothe: 11\n Macro: 32\n \n 3:42p\n _______________________________________________________________________\n Lactate:9.1\n \n 2:55p\n _______________________________________________________________________\n Lactate:9.1\n \n 2:33 A8/14/ 11:47 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 Cr\n 7.5\n Glucose\n 99\n Other labs: Lactic Acid:8.7 mmol/L, Mg++:3.4 mg/dL\n Other Blood Chemistry:\n Ammonia: 66\n 133\n [image004.gif]\n 95\n [image004.gif]\n 86\n [image006.gif]\n 15\n AGap=35\n [image007.gif]\n 6.5\n [image004.gif]\n 10\n [image004.gif]\n 7.6\n [image009.gif]\n CK: 40\n MB: Notdone\n Ca: 11.9 Mg: 3.9 P: 8.7\n ALT: 28\n AP: 391\n Tbili: 0.7\n Alb: 3.9\n AST: 44\n LDH:\n Dbili:\n TProt:\n :\n Lip: 94\n 90\n 21.3\n [image009.gif]\n 11.8\n [image006.gif]\n 248\n [image010.gif]\n [image006.gif]\n 34.7\n [image009.gif]\n N:90.0 L:5.9 M:3.6 E:0.3 Bas:0.2\n PT: 40.6\n PTT: 39.9\n INR: 4.3\n STUDIES:\n .\n CT ABD/PELVIS *WET READ*\n Limited ascites and lack of contrast.\n Marked distention of the stomach and prox duodenum. ? gastric outlet\n obstruction of unclear etiology, new since .\n Large ascites, Cirrhosis\n left 2-3 mm nonobstructive renal calc\n No definite wall thickening or pneumatosis or portal venous gas to\n suggest bowel ischemia.\n appendix partially seen\n .\n CT ABD/PELVIS\n 1. Findings compatible with cirrhosis and portal hypertension without\n evidence of focal mass lesion in the liver.\n 2. Conventional hepatic vascular anatomy without evidence of occlusion.\n 3. Liver volume 1233 cm3.\n .\n CARDIAC PERFUSION PERSANTINE\n 1. Normal myocardial perfusion, estimated LVEF of 57%.\n .\n Stress\n 1. No anginal symptoms or ischemic ST segment changes. Nuclear\n report sent separately.\n .\n LIVER OR GALLBLADDER US (SINGLE ORGAN)\n 1. TIPS with elevated velocities at the mid and distal portion\n concerning for stenosis.\n 2. Ascites is similar to the previous study and is large in amount.\n 3. Unchanged appearance of the right anterior portal vein with\n hepatopetal flow. Non-visualized left portal vein\n .\n ECHO\n The left atrium is mildly dilated. There is mild symmetric left\n ventricular hypertrophy with normal cavity size and global systolic\n function (LVEF>55%). Due to suboptimal technical quality, a focal wall\n motion abnormality cannot be fully excluded. Right ventricular chamber\n size and free wall motion are normal. The diameters of aorta at the\n sinus, ascending and arch levels are normal. The aortic valve leaflets\n (3) appear structurally normal with good leaflet excursion and no\n aortic regurgitation. The mitral valve leaflets are structurally\n normal. There is no mitral valve prolapse. Very mild (1+) mitral\n regurgitation is seen. There is borderline pulmonary artery systolic\n hypertension. There is no pericardial effusion.\n Assessment and Plan\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O ASCITES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n .H/O HEPATIC ENCEPHALOPATHY\n .H/O RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O HYPOGLYCEMIA\n ASSESSMENT AND PLAN\n This is a 63 year old Portuguese-speaking man with end-stage liver\n disease and stenosed TIPS, recurrent admissions for hepatic\n encephalopathy, now here with abdominal pain and a WBC of 21.3 with a\n neutrophil predominance.\n .\n ABDOMINAL PAIN\n Likely related to massive ascites likely hepatorenal syndrome. No\n evidence of SBP given low WBC on diagnostic tap; tap appears bloody;\n most likely coagulopathy, though consistent appearance of this\n finding might suggest hemoperitoneum from another process rather than\n from trauma from tap; CT apparently offers no obvious suspect. No sign\n of perf on CT scan. Surgery evaluating per ED request. Possible gastric\n outlet obstruction seen on CT scan; may improve w decrease in ascitic\n fluid.\n - appreciate surgery recs; tplant service will follow\n - will give albumin per liver recs p HD per renal recs; albumin will\n also be provided by FFP needed for HD line placement\n - consider tx tap if renal function improves\n - NGT if not tolerating clears, emesis, etc\n - clear liquid diet for now\n .\n LEUKOCYTOSIS\n Unclear source. Concern for abdominal source but as above this is not\n clear after dx tap and CT abd/pelvis. I am underwhelmed by CXR but do\n make note of RLL opacity; hard to account for this degree of WBC with\n this small PNA though relative immune suppression of liver/renal\n failure may diminish inflammatory response. High WBC out of proportion\n to symptoms, with abd pain, in pt w multiple hospitalizations, raises\n special concern for c. diff though obvious colitis not seen on CT.\n - covering gram-negatives w zosyn; add vanco and flagyl if worsening\n - cxs pending; additionally send c. diff given mult recent\n hospitalizations\n .\n LIVER FAILURE\n Hepatorenal syndrome worsens prognosis. Could have been precipitated by\n large volume tap on prior admission, though pt has tolerated similar\n (~5L) in the past. (Note: I initially believed this to have been 10L,\n this was in fact ~5L). Pt has been on transplant list.\n - abd U/S w doppler to eval TIPS stenosis, eval portal circulation\n - daily MELD labs\n - transplant surgery and liver services following, appreciate recs\n - octreotide and midodrine\n - regular lactulose at home dose\n - PPI\n - will restart pt's outpt propranolol after completion of HD and\n stabilization of BP\n - continue home rifaximin\n - continuing to hold pt's past diuretics\n .\n RENAL FAILURE\n Likely hepatorenal syndrome, perhaps large volume tap on last\n admission; vs change in hemodynamics infection.\n - HD tonight per renal, appreciate renal involvement and placement of\n HD line w VIP port\n - holding metformin\n .\n LACTIC ACIDOSIS\n Most likely liver failure itself, though metformin toxicity in\n setting of new renal failure may also be responsible. Mesenteric\n ischemia could be culprit; no positive evidence for this at this point,\n but should follow closely.\n - Abd U/S w doppler as above\n - holding metformin\n - follow lactate\n .\n DIABETES\n Holding oral antihyperglycemics based on low blood sugar in ED today.\n ISS alone for now. Has had more issues with high blood sugar than low\n in the past.\n .\n COAGULOPATHY\n Assoc w liver failure. Got FFP for HD line placement. Holding coumadin\n for now.\n ICU Care\n Nutrition: Clears, consistent carbs; clears until para\n Glycemic Control:\n Lines:\n 18 Gauge - 06:48 PM\n Dialysis Catheter - 11:27 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held Comments: cousin and wife present\n status: Full code\n Disposition: ICU overnight ; if stable, to liver-kidney floor for\n further management\n -- MD\n / PGY3 / MICU \n" }, { "category": "Physician ", "chartdate": "2119-08-05 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 590001, "text": "Chief Complaint: renal failure, liver 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 63 yr old Porteguese speaking male with end stage liver, stenosed TIPS.\n recuurent encephalopathy presents with leukocytosis, abd pain, and new\n renal failure with lactic acidosis and hyerkalemia. Tx to MICU for\n acute HD (new HD for him)\n Para in the ED - 33 wbc, 25% PMN, bloody- 6300 RBC\n INR reversed with FFP- right IJ and HD catheter.\n Initiated acute HD - took off 1 liter.\n About 11 days ago - he had a 5 liter tap.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Lactulose\n Insulin\n Octreotide\n Midodrine\n Past medical history:\n Family history:\n Social History:\n ESLD\n Portal vein thormbosis\n DM\n mother with stroke\n Occupation:\n Drugs:\n Tobacco:\n Alcohol: not currrent\n Other:\n Review of systems:\n Constitutional: Fatigue\n Gastrointestinal: Abdominal pain\n Genitourinary: Foley\n Flowsheet Data as of 08:40 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 71 (61 - 77) bpm\n BP: 115/62(75) {66/43(49) - 125/67(82)} mmHg\n RR: 22 (15 - 23) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Bladder pressure: 24 (24 - 24) mmHg\n Total In:\n 2,033 mL\n 207 mL\n PO:\n 150 mL\n TF:\n IVF:\n 275 mL\n 57 mL\n Blood products:\n 1,758 mL\n Total out:\n 91 mL\n 329 mL\n Urine:\n 91 mL\n 129 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,942 mL\n -122 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ////\n Physical Examination\n Gen: lying in bed, complains of abd pain\n HEENT: op clear\n CV: RR\n Ches: scattrered rales with ext wheezest\n Abd: massive distension, absent bowel sounds, tense ascites\n Ex: trace edemat\n Neuro: alert and answering questions\n Labs / Radiology\n 135 K/uL\n 24.5 %\n 8.4 g/dL\n 99 mg/dL\n 7.5 mg/dL\n 87 mg/dL\n 5.6 mEq/L\n 9.8 K/uL\n [image002.jpg]\n 11:47 PM\n 06:08 AM\n WBC\n 9.8\n Hct\n 24.5\n Plt\n 135\n Cr\n 7.5\n Glucose\n 99\n Other labs: PT / PTT / INR:23.3/73.8/2.2, Lactic Acid:8.7 mmol/L,\n Mg++:3.4 mg/dL\n Assessment and Plan\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O ASCITES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n .H/O HEPATIC ENCEPHALOPATHY\n .H/O RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O HYPOGLYCEMIA\n 1. Acute Renal Failure: DDX pre renal versus evolving hepatorenal\n he also has a bladder pressure of 24- a repeat tap is as likely to\n drop his BP as it is to improve it and the effect that will have on his\n HRS is difficult to predict. Fpr now we will rediscuss with liver and\n transplant . Increase midodirne and octreotide\n 2. ESLD: MELD is high at 41 with HRS concerning, liver team\n following. Consult transplant surgery and clarify role of listing for\n transplant, repeat abd US to evaluate for TIPS, send all TX labs,\n possible SW consult. Hold bblockers,\n 3. Acidosis: lactic- DDX is poor forward flow versus metformin\n induced in setting of liver failure with poor clearance. Need to trend\n after HD, hold metformin, jeep MAPS at 60, watch uop and mental status.\n 4. Leukocytosis: pan culture, will maintain on Zosyn as we await\n data\n 5. DM: continue to check FS closely since was so hypoglycemic on\n arrival\n Remaining issues as per Housestaff.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 06:48 PM\n Dialysis Catheter - 11:27 PM\n Comments:\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: pt and wife\n status: Full code\n Disposition: ICU\n Total time spent: 50\n" }, { "category": "Physician ", "chartdate": "2119-08-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 590002, "text": "Chief Complaint:\n 24 Hour Events:\n DIALYSIS CATHETER - START 11:27 PM\n right IJ dialysis cath placed\n with VIP port\n o/n events: R IJ HD catheter placed and HD started for lactic\n acidosis/hyperkalemia.\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 07:03 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: 36.7\nC (98.1\n HR: 73 (61 - 77) bpm\n BP: 66/43(49) {66/43(49) - 125/67(82)} mmHg\n RR: 16 (15 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,033 mL\n 147 mL\n PO:\n 90 mL\n TF:\n IVF:\n 275 mL\n 57 mL\n Blood products:\n 1,758 mL\n Total out:\n 91 mL\n 309 mL\n Urine:\n 91 mL\n 109 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,942 mL\n -162 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ////\n Physical Examination\n Gen- Alert to voice, unable to ascertain MS due to language barrier,\n but appears to be understanding and conversant\n HEENT- NCAT, no JVD\n Pulm- B/L end-expiratory wheeze posteriorly\n CV- S1/S2 w/o MGR\n Abd- Soft, Severely distended, not tight. +BS. No percussive\n tenderness.\n Ext- 1+ LE edema b/l, 2+ DP pulses.\n Labs / Radiology\n 248\n 11.8\n 99 mg/dL\n 7.5 mg/dL\n 10\n 5.6 mEq/L\n 87 mg/dL\n 95\n 133\n 34.7\n 21.3\n [image002.jpg]\n 11:47 PM\n Cr\n 7.5\n Glucose\n 99\n Other labs: Lactic Acid:8.7 mmol/L, Mg++:3.4 mg/dL INR 2.2\n Peritoneal fluid: WBC 33, PMN 25.\n Imaging: CXR- R IJ in place, atelectesis\n CT abd/pelvis prelim- large ascites, ? gastric outlet obstruction, and\n no evidence of bowel ischemia.\n KUB - pending read\n Microbiology: Bcx pending\n Ucx pending\n Ascites analysis pending, gram stain negative\n Assessment and Plan\n This is a 63 year old Portuguese-speaking man with end-stage liver\n disease and stenosed TIPS, recurrent admissions for hepatic\n encephalopathy, now here with abdominal pain and a WBC of 21.3 with a\n neutrophil predominance.\n ASCITES\n Likely related to massive ascites likely hepatorenal syndrome. No\n evidence of SBP given low WBC on diagnostic tap; tap appears bloody;\n most likely coagulopathy, though consistent appearance of this\n finding might suggest hemoperitoneum from another process rather than\n from trauma from tap; CT apparently offers no obvious suspect. No sign\n of perf on CT scan. Surgery evaluating per ED request. Possible gastric\n outlet obstruction seen on CT scan; may improve w decrease in ascitic\n fluid.\n - appreciate surgery recs; tplant service will follow\n - will give albumin per liver recs p HD per renal recs; albumin will\n also be provided by FFP needed for HD line placement\n - talk to renal and liver service about Tap vs no tap since bladder\n pressure 24 in the setting of hypotension.\n - NGT if not tolerating clears, emesis, etc\n - clear liquid diet for now\n Leukocytosis\n Unclear source. Concern for abdominal source but as above this is not\n clear after dx tap and CT abd/pelvis. I am underwhelmed by CXR but do\n make note of RLL opacity; hard to account for this degree of WBC with\n this small PNA though relative immune suppression of liver/renal\n failure may diminish inflammatory response. High WBC out of proportion\n to symptoms, with abd pain, in pt w multiple hospitalizations, raises\n special concern for c. diff though obvious colitis not seen on CT.\n - covering gram-negatives w zosyn; add vanco and flagyl if worsening\n - Bcx, Ucx pending\n - send c. diff given mult recent hospitalizations\n LIVER CIRRHOSIS, ETOH, w/ encephalopathy\n Hepatorenal syndrome worsens prognosis. Could have been precipitated by\n large volume tap on prior admission, though pt has tolerated similar\n (~5L) in the past. (Note: I initially believed this to have been 10L,\n this was in fact ~5L). Pt has been on transplant list. MELD on\n admission = 41.\n - abd U/S w doppler to eval TIPS stenosis, eval portal circulation\n - daily MELD labs\n - transplant surgery and liver services following, appreciate recs\n - octreotide and midodrine\n - regular lactulose at home dose\n - continue home rifaximin\n - PPI\n - will restart pt's outpt propranolol after completion of HD and\n stabilization of BP\n - hold pt's home diuretics\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely hepatorenal syndrome, perhaps large volume tap on last\n admission; vs change in hemodynamics infection. FeNa on admission\n 0.6.\n -Zosyn empirically for possible infectious contribution to ARF.\n - HD tonight per renal, appreciate renal involvement and placement of\n HD line w VIP port\n - holding metformin\n - continue midodrine, Octreotide\n - f/u Bcx, Ucx as above\nHYPOTENSION\n Possibly due to decreased venous return due to abdominal pressure vs\n infection/sepsis vs hypovolemia due to fluid sequestration as ascites.\n -start levophed for SBP <80 titrate to MAPs > 65.\n -consider TAP for decrease intraabdominal pressure\n -zosyn empirically for infection, consider adding flagyl/vanco if\n appears more toxic.\nHyperkalemia\n Likely in the setting of ESRD at admission, has resolved from 6.5 to\n 5.6.\n -Recheck lytes q12\n -Check EKG if K+ increases\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Per family report, patient currently appears to have intact MS,\n however, appears confused at times, with mumbling and groaning on.\n Possibly due to hepatic encephalopathy (NH3 = 66 on admission) vs\n infection, UTI vs SBP, vs acidemia. Remains afebrile\n - Be alert for harmful behavior, use soft restraints if pt begins to\n pull on lines\n - lactulose 30mg PO TID\n - await fluid results from paracentesis, including gram stain, WBC, and\n cx\n - UA\n - holding metforming for lactic acidosis\n - trend lactate\n LACTIC ACIDOSIS\n Most likely liver failure itself, though metformin toxicity in\n setting of new renal failure may also be responsible. Mesenteric\n ischemia could be culprit; no positive evidence for this at this point,\n but should follow closely.\n - Abd U/S w doppler as above\n - holding metformin and follow lactate as above.\n - follow lactate\n - guaiac stool\n DIABETES\n Holding oral antihyperglycemics based on low blood sugar in ED today.\n ISS alone for now. Has had more issues with high blood sugar than low\n in the past.\n - cont. ISS\n - check FSBG\n COAGULOPATHY\n Assoc w liver failure. Got 6U FFP for HD line placement. Holding\n coumadin for now.\n - continue to trend coags\n - give vit K for goal INR <2.\n - consider FFP for procedures\nACCESS\n Consider adding triple lumen since adding pressor\n -place L IJ triple lumen\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:48 PM\n Dialysis Catheter - 11:27 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Family speaks Portuguese, communication with\n family.\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2119-08-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591652, "text": "Hypernatremia (high sodium)\n Assessment:\n Pt with Na 152\n Action:\n Received with\n NS infusing and was switched over to D5W at 100cc/hr\n x3L, received 1L this shift.\n Response:\n Repeat Na 149.\n Plan:\n Continue with D5W for 2 more liters. Next set of labs at 2200.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt with history of diabetes was transferred to MICU 6 for management of\n high sugars with insulin gtt. Finger sticks ranging 127-250.\n Action:\n Pt\ns insulin gtt titrated\n Response:\n Plan:\n Cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2119-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591992, "text": "Synopsis per prior nursing note:\n Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Hypernatremia (high sodium)\n Assessment:\n Na 144, k 3.9.\n Action:\n NGT to IWS. Given lactulose enema.\n Response:\n Repeat Na 146. Repeat K 3.2. Very large, liquid stool after enema.\n Continues to put out small amt bilious fluid from NGT.\n Plan:\n Monitor electrolytes. Monitor stool/NGT output.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 156.\n Action:\n Took moderate amt of PO intake. Given evening dose of lantus. FS\n treated with humalog per new ISS.\n Response:\n 0400 FS 118.\n Plan:\n Monitor FS. Encourage PO intake.\n Cirrhosis of liver, alcoholic\n Assessment:\n Alert, oriented. Moving all extremities weakly. Follows commands. Able\n to let basic needs be known. Helps move self in bed. Jaundice,\n +Ascites.\n Action:\n Held PO lactulose d/t multiple loose, stools. NGT in place through\n night while monitoring mental status.\n Response:\n No change in mental status. Had multiple loose, brown stools.\n Plan:\n Lactulose for 3BM/day. Monitor change in mental status. ? remove NGT\n today.\n" }, { "category": "Physician ", "chartdate": "2119-08-05 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 590009, "text": "Chief Complaint: renal failure, liver 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 63 yr old Porteguese speaking male with end stage liver, stenosed TIPS.\n recurrent encephalopathy presents with leukocytosis, abd pain, and new\n renal failure with lactic acidosis and hyerkalemia. Tx to MICU for\n acute HD (new HD for him)\n Diagnostic Para in the ED - 33 wbc, 25% PMN, bloody- 6300 RBC\n INR reversed with FFP- right IJ and HD catheter placed\n Initiated acute HD - took off 1 liter but hemodynamics have been\n unstable since then.\n About 11 days ago - he had a 5 liter tap and ? dropped preload could\n have inciting event for ARF but unclear\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Lactulose\n Insulin\n Octreotide\n Midodrine\n Past medical history:\n Family history:\n Social History:\n ESLD\n Portal vein thrombosis\n DM\n Hypothyroid\n mother with stroke\n Occupation: retired\n Drugs:\n Tobacco:\n Alcohol: not currrent\n Other: loives with wife\n Review of systems:\n Constitutional: Fatigue\n Gastrointestinal: Abdominal pain\n Genitourinary: Foley\n No fevers chills no seizures, no headache or visual changes no rash,\n + anemia\n Flowsheet Data as of 08:40 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 71 (61 - 77) bpm\n BP: 115/62(75) {66/43(49) - 125/67(82)} mmHg\n RR: 22 (15 - 23) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Bladder pressure: 24 (24 - 24) mmHg\n Total In:\n 2,033 mL\n 207 mL\n PO:\n 150 mL\n TF:\n IVF:\n 275 mL\n 57 mL\n Blood products:\n 1,758 mL\n Total out:\n 91 mL\n 329 mL\n Urine:\n 91 mL\n 129 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,942 mL\n -122 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ////\n Physical Examination\n Gen: lying in bed, complains of abd pain\n HEENT: op clear\n CV: RR\n Ches: scattrered rales with ext wheezes\n Abd: massive distension, absent bowel sounds, tense ascites\n Ex: trace edema\n Neuro: alert and answering questions\n Labs / Radiology\n 135 K/uL\n 24.5 %\n 8.4 g/dL\n 99 mg/dL\n 7.5 mg/dL\n 87 mg/dL\n 5.6 mEq/L\n 9.8 K/uL\n [image002.jpg]\n 11:47 PM\n 06:08 AM\n WBC\n 9.8\n Hct\n 24.5\n Plt\n 135\n Cr\n 7.5\n Glucose\n 99\n Other labs: PT / PTT / INR:23.3/73.8/2.2, Lactic Acid:8.7 mmol/L,\n Mg++:3.4 mg/dL\n Assessment and Plan\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O ASCITES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n .H/O HEPATIC ENCEPHALOPATHY\n .H/O RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O HYPOGLYCEMIA\n 1. Acute Renal Failure: DDX pre renal versus evolving hepatorenal\n he also has a bladder pressure of 24- a repeat tap is as likely to\n drop his BP as it is to improve it and the effect that will have on his\n HRS is difficult to predict. For now we will rediscuss with liver and\n transplant . Increase midodirne and octreotide. Trend bladder\n pressure and urine oupt\n 2. Hypotension: in setting of known liver disease and volume\n shofts from HD and possible evolving abd complartment syndrome. At\n this point, I would not further give volume. Check CVP on VIP port.\n Support thorugh HD with pressors if needed for electrolyte or acidosis.\n Keep MAP 60-65 even if we need pressors to do so in light of dense ARF\n and lactic acidosis.\n 3. ESLD: MELD is high at 41 with HRS concerning, liver team\n following. Consult transplant surgery and clarify role of listing for\n transplant, repeat abd US to evaluate for TIPS, send all TX labs,\n possible SW consult. Hold bblockers. Rifaximin. Follow up cx of ascetic\n fluid\n 4. Acidosis: lactic- DDX is poor forward flow versus metformin\n induced in setting of liver failure with poor clearance. Need to trend\n after HD, hold metformin, keep MAPS at 60, watch uop and mental status.\n 5. Leukocytosis: pan culture, will maintain on Zosyn as we await\n data\n 6. DM: continue to check FS closely since was so hypoglycemic on\n arrival\n Remaining issues as per Housestaff.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 06:48 PM\n Dialysis Catheter - 11:27 PM\n Comments:\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: pt and wife\n status: Full code\n Disposition: ICU\n Total time spent: 50\n" }, { "category": "Nursing", "chartdate": "2119-08-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590086, "text": "63 yr old Porteguese speaking male with end stage liver, stenosed TIPS.\n recurrent encephalopathy presents with leukocytosis, abd pain, and new\n renal failure with lactic acidosis and hyerkalemia. Tx to MICU for\n acute HD (new HD for him)\n Diagnostic Para in the ED - 33 wbc, 25% PMN, bloody- 6300 RBC\n INR reversed with FFP- right IJ and HD catheter placed\n Initiated acute HD - took off 1 liter but hemodynamics have been\n unstable since then.\n About 11 days ago - he had a 5 liter tap and ? dropped preload could\n have inciting event for ARF but unclear\n .H/O ascites\n Assessment:\n Action:\n Response:\n Plan:\n .H/O altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hypoglycemia\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hepatic encephalopathy\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2119-08-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591520, "text": "Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. He is on liver transplant list. Has HD line Lt\n SC last HD . Over several days he has become increasingly agitated\n with mental status changes. He was transferred to MICU secondary to\n increase agitation and aggressive behavior toward staff requiring 4\n point restraints with persistant tachycardia, hypertension and blood\n sugar of 450. PMH alcoholic cirrhosis known varices, portal vein\n thrombosis, s/p TIPS, DM 2, hypothyroidism, pituitary mass, h/o\n nephrolithiasis, h/o +PPD\n Acute Confusion\n Assessment:\n Patiient moaning not engaging, moving all extremities, not following\n commands, tachycardic when awake to 130\ns. Pupils equal and reactive\n recent head CT neg\n Action:\n Given haldol .5mg IV x 2, given lactulose enema x1\n Response:\n Patient moaning, HR 90\ns nsr when given haldol then increases up to\n 137 ST when awake and agitated, he did open his eyes and engage briefly\n Plan:\n Unclear if agitation is from pain or encephalopathy,\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Bun 47 cr 2.9 incontinent of urine Na 152\n Action:\n On .45NS at 100cc qhr. Patient will continue midodrine and albumin\n Response:\n Plan:\n Monitor bun and cr, if he continues to be unresponsive may need foley\n placed for more accurate I +O, follow lytes\n Sepsis without organ dysfunction\n Assessment:\n Temp 96.9 wbc\n Action:\n Given vanco and zoysn\n Response:\n Wbc 7.1 blood cultures pnding\n Plan:\n Vanco, zoysn and cipro IV, monitor lactate, temp, wbc, await cx results\n Diabetes Mellitus (DM), Type II\n Assessment:\n First arrived in micu blood sugar 415 anion gap 28\n Action:\n He was given 10u regular insulin sq and started on a insulin gtt\n Response:\n Blood sugar slowly coming down, anion gap down to 25\n Plan:\n Continue insulin gtt monitor anion gag, blood sugars q 1hr titrate prn\n Cirrhosis of liver, alcoholic\n Assessment:\n Abdomen distended and firm, bowel sounds present. Patient has a\n puncture wound from previous paracentesis draining yellow fluid\n nonodorous, site is without erythema. Patient moaning rubbing abdomen.\n Patient has known left portal vein thrombosis\n Action:\n Given .5mg IV morphine. He continues on coumadin.\n Response:\n Heart rate came down to 95 and patient fell asleep unclear if moaning\n pain or encephalopathy. INR 2.0\n Plan:\n Monitor , patient has agreed to start pretransplant work up, follow\n lft, ? need for paracentesis, monitor pain, medicate prn. Lactulose tid\n po\n Hypernatremia (high sodium)\n Assessment:\n Sodium 152\n Action:\n Placed on .45%NS at 100cc qhr\n Response:\n unchanged\n Plan:\n Continue IVF, monitor bun and cr, renal following, monitor NA and\n electrolytes\n" }, { "category": "Physician ", "chartdate": "2119-08-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 591533, "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 Mr. was previously known to the MICU team when he was\n admitted on with right sided abdominal pain, ascites, lactic\n acidosis thought to be perhaps secondary to metformin toxicity, and\n renal failure requiring emergent dialysis. Then (and since then)\n diagnostic paracenteses did not show evidence for SBP (para done\n earlier today shows WBC 300 but in setting of RBC ). In MICU\n stay, dialysis was initiated. Since he has been on the floor, he\n has been able to stop dialysis for a time, with last session on 8.21\n per housestaff notes. He has had urine output of 600 as of the morning\n of . A diabetic who has been on insulin only during this admission,\n he has had difficult-to-control glucose, remaining in the 300s-400s for\n much of the last day despite an aggressive sliding scale. He triggered\n on the floor both the night of transfer and the night prior for\n agitation and altered mental status. The evening prior to transfer, the\n MICU resident was notified by the liver-kidney resident that Mr.\n \ns status was troubling and that a transfer might be necessary;\n on the second trigger overnight, nightfloat and MICU residents agreed\n to transfer Mr. to the MICU for insulin drip and closer\n monitoring in the setting of ongoing encephalopathy, intermittent\n agitation, and difficult to control blood sugar. The liver attending\n was contact by the nightfloat covering team, and reportedly\n recommended insulin drip and suggested the possibility of infection.\n At time of transfer, Mr. was tachycardic and hypertensive. He\n was alternating between periods of sleep and periods of agitated\n moaning, consistent with the mournful moans of the encephalopathic\n periods of his prior MICU stay.\n 24 Hour Events:\n Mr. was previously known to the MICU team when he was\n admitted on with right sided abdominal pain, ascites, lactic\n acidosis thought to be perhaps secondary to metformin toxicity, and\n renal failure requiring emergent dialysis. Then (and since then)\n diagnostic paracenteses did not show evidence for SBP (para done\n earlier today shows WBC 300 but in setting of RBC ). In MICU\n stay, dialysis was initiated. Since he has been on the floor, he\n has been able to stop dialysis for a time, with last session on 8.21\n per housestaff notes. He has had urine output of 600 as of the morning\n of . A diabetic who has been on insulin only during this admission,\n he has had difficult-to-control glucose, remaining in the 300s-400s for\n much of the last day despite an aggressive sliding scale. He triggered\n on the floor both the night of transfer and the night prior for\n agitation and altered mental status. The evening prior to transfer, the\n MICU resident was notified by the liver-kidney resident that Mr.\n \ns status was troubling and that a transfer might be necessary;\n on the second trigger overnight, nightfloat and MICU residents agreed\n to transfer Mr. to the MICU for insulin drip and closer\n monitoring in the setting of ongoing encephalopathy, intermittent\n agitation, and difficult to control blood sugar. The liver attending\n was contact by the nightfloat covering team, and reportedly\n recommended insulin drip and suggested the possibility of infection.\n At time of transfer, Mr. was tachycardic and hypertensive. He\n was alternating between periods of sleep and periods of agitated\n moaning, consistent with the mournful moans of the encephalopathic\n periods of his prior MICU stay.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Piperacillin - 02:46 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Other ICU medications:\n Haloperidol (Haldol) - 03:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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, 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 06:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 36\nC (96.8\n HR: 79 (79 - 134) bpm\n BP: 120/62(76) {120/62(76) - 169/95(113)} mmHg\n RR: 18 (17 - 23) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1 mL\n 796 mL\n PO:\n TF:\n IVF:\n 1 mL\n 796 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1 mL\n 796 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///18/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\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, 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, Distended, No(t)\n Tender: , No(t) Obese, Markedly distended, +fluid wave; umbilical\n hernia, easily reducible\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Tactile stimuli, No(t) Oriented (to): , Movement: Purposeful,\n Sedated, No(t) Paralyzed, Tone: Normal, Somnulant, moans to tactile\n stimuli\n Labs / Radiology\n 9.6 g/dL\n 102 K/uL\n 191 mg/dL\n 2.9 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 47 mg/dL\n 113 mEq/L\n 152 mEq/L\n 30.0 %\n 7.1 K/uL\n [image002.jpg]\n 02:56 AM\n WBC\n 7.1\n Hct\n 30.0\n Plt\n 102\n Cr\n 2.9\n Glucose\n 191\n Other labs: PT / PTT / INR:21.8/36.8/2.0, Alk Phos / T Bili:/1.0\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 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: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2119-08-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591535, "text": "Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. He is on liver transplant list. Has HD line Lt\n SC last HD . Over several days he has become increasingly agitated\n with mental status changes. He was transferred to MICU secondary to\n increase agitation and aggressive behavior toward staff requiring 4\n point restraints with persistant tachycardia, hypertension and blood\n sugar of 450. PMH alcoholic cirrhosis known varices, portal vein\n thrombosis, s/p TIPS, DM 2, hypothyroidism, pituitary mass, h/o\n nephrolithiasis, h/o +PPD\n Acute Confusion\n Assessment:\n Patiient moaning not engaging, moving all extremities, not following\n commands, tachycardic when awake to 130\ns. Pupils equal and reactive\n recent head CT neg\n Action:\n Given haldol .5mg IV x 2, given lactulose enema x1\n Response:\n Patient moaning, HR 90\ns nsr when given haldol then increases up to\n 137 ST when awake and agitated, he did open his eyes and engage briefly\n Plan:\n Unclear if agitation is from pain or encephalopathy,\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Bun 47 cr 2.9 incontinent of urine Na 152\n Action:\n On .45NS at 100cc qhr. Patient will continue midodrine and albumin\n Response:\n Plan:\n Monitor bun and cr, if he continues to be unresponsive may need foley\n placed for more accurate I +O, follow lytes, continue IVF\n Sepsis without organ dysfunction\n Assessment:\n Temp 96.9 wbc\n Action:\n Given vanco and zoysn\n Response:\n Wbc 7.1 blood cultures pnding\n Plan:\n Vanco, zoysn and cipro IV, monitor lactate, temp, wbc, await cx results\n Diabetes Mellitus (DM), Type II\n Assessment:\n First arrived in micu blood sugar 415 anion gap 28\n Action:\n He was given 10u regular insulin sq and started on a insulin gtt\n Response:\n Blood sugar slowly coming down, anion gap down to 25\n Plan:\n Continue insulin gtt monitor anion gag, blood sugars q 1hr titrate prn\n Cirrhosis of liver, alcoholic\n Assessment:\n Abdomen distended and firm, bowel sounds present. Patient has a\n puncture wound from previous paracentesis draining yellow fluid\n nonodorous, site is without erythema. Patient moaning rubbing abdomen.\n Patient has known left portal vein thrombosis\n Action:\n Given .5mg IV morphine. He continues on coumadin.\n Response:\n Heart rate came down to 95 and patient fell asleep unclear if moaning\n pain or encephalopathy. INR 2.0\n Plan:\n Monitor , patient has agreed to start pretransplant work up, follow\n lft, ? need for paracentesis, monitor pain, medicate prn. Lactulose tid\n po\n Hypernatremia (high sodium)\n Assessment:\n Sodium 152\n Action:\n Placed on .45%NS at 100cc qhr\n Response:\n unchanged\n Plan:\n Continue IVF, monitor bun and cr, renal following, monitor NA and\n electrolytes\n" }, { "category": "Physician ", "chartdate": "2119-08-17 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 591536, "text": "Chief Complaint: altered mental status\n HPI:\n Mr. was previously known to the MICU team when he was\n admitted on with right sided abdominal pain, ascites, lactic\n acidosis thought to be perhaps secondary to metformin toxicity, and\n renal failure requiring emergent dialysis. Then (and since then)\n diagnostic paracenteses did not show evidence for SBP (para done\n earlier today shows WBC 300 but in setting of RBC ). In MICU\n stay, dialysis was initiated. Since he has been on the floor, he\n has been able to stop dialysis for a time, with last session on 8.21\n per housestaff notes. He has had urine output of 600 as of the morning\n of . A diabetic who has been on insulin only during this admission,\n he has had difficult-to-control glucose, remaining in the 300s-400s for\n much of the last day despite an aggressive sliding scale. He triggered\n on the floor both the night of transfer and the night prior for\n agitation and altered mental status. The evening prior to transfer, the\n MICU resident was notified by the liver-kidney resident that Mr.\n \ns status was troubling and that a transfer might be necessary;\n on the second trigger overnight, nightfloat and MICU residents agreed\n to transfer Mr. to the MICU for insulin drip and closer\n monitoring in the setting of ongoing encephalopathy, intermittent\n agitation, and difficult to control blood sugar. The liver attending\n was contact by the nightfloat covering team, and reportedly\n recommended insulin drip and suggested the possibility of infection.\n At time of transfer, Mr. was tachycardic and hypertensive. He\n was alternating between periods of sleep and periods of agitated\n moaning, consistent with the mournful moans of the encephalopathic\n periods of his prior MICU stay.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Infusions:\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Haloperidol (Haldol) - 01:50 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n EtOH cirrhosis, c/b ascites and varices, s/p banding\n s/p TIPS ()-->redo for narrowing --> failure of TIPS\n noted in past admissions w d/c summaries noting decision not to redo\n TIPS further given diminished returns\n recent prior admission including 5L paracentesis\n portal vein thrombosis, on coumadin goal INR \n diabetes mellitus\n hypothyroidism\n pituitary mass\n h/o nephrolithiasis\n h/o +PPD\n Mother deceased at age 50, CVA. Father deceased, age 62, \"stomach\n problems\". One brother and two sisters, all living and in good health.\n Occupation: retired\n Drugs: no\n Tobacco: non\n Alcohol: quit \n Other:\n Review of systems:\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Emesis\n Endocrine: History of thyroid disease\n Pain: Unable to answer\n Flowsheet Data as of 03:08 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.9\nC (96.7\n HR: 105 (105 - 122) bpm\n BP: 149/87(101) {141/87(101) - 169/95(113)} mmHg\n RR: 18 (17 - 18) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1 mL\n 315 mL\n PO:\n TF:\n IVF:\n 1 mL\n 315 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1 mL\n 315 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL, staring into space, not clearly registering\n his examiners(s)\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 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 Altered mental status:\n Head CT negative. Abd u/s unchanged. Diagnostic para not revealing.\n Hypernatremic. Hyperglycemia and enceph suggests possibility of\n infection. Pt originally presented with abdominal pain that was not\n notable on exam but uncomfortable to patient, even in setting of no\n encephalopathy; pt currently moaning mournfully consistent with past\n presentation.\n - covering w vanc/zosyn\n - gently correcting hypernatremia though doubt this is major\n contributor\n - has had haldol on the floor, continuing this as prn; not clear\n whether this will be helpful other than as sedative, and will consider\n very low dose morphine as trial of pain relief; Tylenol at low dose\n also.\n - likely to need to hold POs currently, pt not w mental status to\n cooperate w POs; consider NG tube for nutrition and meds if not\n clearing by mid-morning.\n - lactulose enema\n - f/u micro data, cultures pending\n Liver failure\n Not yet listed for transplant. Transplant committee asking for\n colonoscopy and outpatient relapse therapy. Specific interventions:\n midodrine, albumin; lactulose.\n Hyperglycemia\n Likely secondary to infection given change over last several days\n coinciding w worsening encephalopathy.\n Hypernatremia\n Likely 2.2 poor intake. Giving gentle\n NS. Avoiding D5W in setting of\n hyperglycemia.\n Renal failure\n Continue midodrine, albumin as per floor team. Follow Cr and urine\n output closely. No urgent indication for HD.\n Diabetes\n Insulin drip for now. Will d/ in AM\nthey are following. Likely\n that hyperglycemia is infection as above.\n Hypothyroidism\n Continue synthroid\n Coagulopathy/anticoagulation\n Continuing warfarin for portal vein thrombosis which has been a problem\n for pt in the past.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 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": "2119-08-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 591539, "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 Pt. known to the MICU service from recent ICU admission for\n acute renal failure and lactic acidosis, attributed to metformin\n toxicity, and required dialysis. Transferred to medical .\n 24 Hour Events:\n Since transfer to medical , dialysis not required. Mental status\n remains abnormal, with periods of agitation and somnulance. Continues\n to require management of hyperglycemia. Tonight, progressive\n encephalopathy prompted transfer back to MICU for further evaluation\n and management.\n Upon transfer to MICU, notably somnulant (received iv morphine dose).\n Pt unable to provide history due to encephalopathy.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Piperacillin - 02:46 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Other ICU medications:\n Haloperidol (Haldol) - 03:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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, 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 06:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 36\nC (96.8\n HR: 79 (79 - 134) bpm\n BP: 120/62(76) {120/62(76) - 169/95(113)} mmHg\n RR: 18 (17 - 23) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1 mL\n 796 mL\n PO:\n TF:\n IVF:\n 1 mL\n 796 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1 mL\n 796 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///18/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\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, 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, Distended, No(t)\n Tender: , No(t) Obese, Markedly distended, +fluid wave; umbilical\n hernia, easily reducible\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Tactile stimuli, No(t) Oriented (to): , Movement: Purposeful,\n Sedated, No(t) Paralyzed, Tone: Normal, Somnulant, moans to tactile\n stimuli\n Labs / Radiology\n 9.6 g/dL\n 102 K/uL\n 191 mg/dL\n 2.9 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 47 mg/dL\n 113 mEq/L\n 152 mEq/L\n 30.0 %\n 7.1 K/uL\n [image002.jpg]\n 02:56 AM\n WBC\n 7.1\n Hct\n 30.0\n Plt\n 102\n Cr\n 2.9\n Glucose\n 191\n Other labs: PT / PTT / INR:21.8/36.8/2.0, Alk Phos / T Bili:/1.0\n Assessment and Plan\n Hepatic encephalopathy.\n ALTERED MENTAL STATUS\n attributable to hepatic encephalopathy.\n Precipitants likely multifactorial, including hypernatremia,\n hypokalemia, and contribution of renal failure, on background of prior\n TIPS (increased incidence of encephalopathy). No evidence for GI bleed\n or protein load in gut. Medication effect possible. Also need to\n consider possibility of infection, but no localizing signs or symptoms\n or line infection or SBP (no evidence for SBP by recent paracentesis).\n Plan provide free water, replete K, avoid sedating medications.\n Monitor for infection, await cultures (including C. Diff)\n empirical\n antimicrobials. Monitor airway, with low threshold for intubation to\n protect airway. Lactulose per NGT and enema to manage encephalopathy.\n LACTIC ACIDOSIS\n unclear etiology, variable levels. No obvious signs\n of infection. Consider thiamine repletion. Monitor.\n RENAL FAILURE\n Recovering ATN. No longer requiring renal replacement\n therapy. Monitor uo, BUN, creatinine. Check urine lytes, UA.\n Continue midodrine, albumin as per Renal consultation.\n HYPERNATREMIA\n requires free water repletion. Monitor Na.\n HYPERGLYCEMIA\n poorly controlled diabetes. Unclear precipitant, but\n concern for infection. No evidence for DKA. Plan monitor glucose,\n resume insulin continuous infusion, maintain glucose <150. \n Consultation.\n ELEVATED TSH\n unclear whether this represents hypothyroidism or\n consequences of critical illness. Monitor closely on synthroid or\n consider discontinuing.\n PORTAL VEIN THROMBOSIS\n continue anticoagulation. PT/INR.\n NUTRITIONAL SUPPORT\n NPO while encephalopathic, high aspiration risk.\n CIRRHOSIS\n not transplant candidate. Continue supportive care.\n Plans otherwise as outlined per Resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 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: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2119-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591828, "text": "Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2119-08-19 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 591921, "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 63 yo man with ETOH cirrhosis. Admitted for encephalopathy to floor.\n Tranferred to ICU for hyperglycemia and worsening agitation. Has had\n significant ileus limiting lactulosis.\n Has had hypernatremia.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Piperacillin - 02:46 AM\n Ciprofloxacin - 10:19 AM\n Piperacillin/Tazobactam (Zosyn) - 08:14 AM\n Infusions:\n Other ICU medications:\n Dextrose 50% - 06:00 AM\n Pantoprazole (Protonix) - 08:14 AM\n Heparin Sodium (Prophylaxis) - 08:14 AM\n Other medications:\n rifaxamin\n SSI\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 Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Integumentary (skin): No(t) Rash\n Flowsheet Data as of 11:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.6\nC (96\n HR: 76 (68 - 119) bpm\n BP: 126/69(84) {109/55(69) - 169/107(121)} mmHg\n RR: 14 (13 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.2 kg (admission): 90.6 kg\n Height: 67 Inch\n Total In:\n 2,742 mL\n 978 mL\n PO:\n TF:\n IVF:\n 2,542 mL\n 928 mL\n Blood products:\n 200 mL\n Total out:\n 1,850 mL\n 210 mL\n Urine:\n 500 mL\n 210 mL\n NG:\n 1,350 mL\n Stool:\n Drains:\n Balance:\n 892 mL\n 768 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///20/\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: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: No(t) Bowel sounds present, Distended, firm\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Purposeful, Tone: Normal, answers some questions\n Labs / Radiology\n 9.9 g/dL\n 170 K/uL\n 40 mg/dL\n 3.1 mg/dL\n 20 mEq/L\n 3.2 mEq/L\n 43 mg/dL\n 109 mEq/L\n 146 mEq/L\n 30.3 %\n 11.6 K/uL\n [image002.jpg]\n 02:56 AM\n 09:58 AM\n 02:35 PM\n 10:00 PM\n 03:09 AM\n 04:45 AM\n 12:16 PM\n 07:30 PM\n 03:54 AM\n WBC\n 7.1\n 9.4\n 13.0\n 11.6\n Hct\n 30.0\n 30.6\n 32.6\n 30.3\n Plt\n 102\n 108\n 147\n 170\n Cr\n 2.9\n 2.9\n 2.8\n 3.0\n 2.8\n 3.1\n 3.1\n 3.1\n 3.1\n Glucose\n 191\n 195\n 188\n 183\n 1\n 40\n Other labs: PT / PTT / INR:37.5/44.7/3.9, ALT / AST:, Alk Phos / T\n Bili:118/1.9, Differential-Neuts:84.7 %, Lymph:8.5 %, Mono:2.9 %,\n Eos:3.6 %, Lactic Acid:2.8 mmol/L, Albumin:4.8 g/dL, LDH:248 IU/L,\n Ca++:10.3 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPERNATREMIA (HIGH SODIUM)\n LIVER FUNCTION ABNORMALITIES\n CIRRHOSIS OF LIVER, ALCOHOLIC\n DIABETES MELLITUS (DM), TYPE II\n ACUTE CONFUSION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Cirrhosis: Will remove 4L of ascites fluid today.\n MS: might be little better as answering some questions in both english\n and portuguese\n acute renal failure: could be partially due to ascites, will check\n bladder pressure.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n 18 Gauge - 01:31 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2119-08-19 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 591922, "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 63 yo man with ETOH cirrhosis. Admitted for encephalopathy to floor.\n Tranferred to ICU for hyperglycemia and worsening agitation. Has had\n significant ileus limiting lactulosis.\n Has had hypernatremia.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Piperacillin - 02:46 AM\n Ciprofloxacin - 10:19 AM\n Piperacillin/Tazobactam (Zosyn) - 08:14 AM\n Infusions:\n Other ICU medications:\n Dextrose 50% - 06:00 AM\n Pantoprazole (Protonix) - 08:14 AM\n Heparin Sodium (Prophylaxis) - 08:14 AM\n Other medications:\n rifaxamin\n SSI\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 Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Integumentary (skin): No(t) Rash\n Flowsheet Data as of 11:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.6\nC (96\n HR: 76 (68 - 119) bpm\n BP: 126/69(84) {109/55(69) - 169/107(121)} mmHg\n RR: 14 (13 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.2 kg (admission): 90.6 kg\n Height: 67 Inch\n Total In:\n 2,742 mL\n 978 mL\n PO:\n TF:\n IVF:\n 2,542 mL\n 928 mL\n Blood products:\n 200 mL\n Total out:\n 1,850 mL\n 210 mL\n Urine:\n 500 mL\n 210 mL\n NG:\n 1,350 mL\n Stool:\n Drains:\n Balance:\n 892 mL\n 768 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///20/\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: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: No(t) Bowel sounds present, Distended, firm\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Purposeful, Tone: Normal, answers some questions\n Labs / Radiology\n 9.9 g/dL\n 170 K/uL\n 40 mg/dL\n 3.1 mg/dL\n 20 mEq/L\n 3.2 mEq/L\n 43 mg/dL\n 109 mEq/L\n 146 mEq/L\n 30.3 %\n 11.6 K/uL\n [image002.jpg]\n 02:56 AM\n 09:58 AM\n 02:35 PM\n 10:00 PM\n 03:09 AM\n 04:45 AM\n 12:16 PM\n 07:30 PM\n 03:54 AM\n WBC\n 7.1\n 9.4\n 13.0\n 11.6\n Hct\n 30.0\n 30.6\n 32.6\n 30.3\n Plt\n 102\n 108\n 147\n 170\n Cr\n 2.9\n 2.9\n 2.8\n 3.0\n 2.8\n 3.1\n 3.1\n 3.1\n 3.1\n Glucose\n 191\n 195\n 188\n 183\n 1\n 40\n Other labs: PT / PTT / INR:37.5/44.7/3.9, ALT / AST:, Alk Phos / T\n Bili:118/1.9, Differential-Neuts:84.7 %, Lymph:8.5 %, Mono:2.9 %,\n Eos:3.6 %, Lactic Acid:2.8 mmol/L, Albumin:4.8 g/dL, LDH:248 IU/L,\n Ca++:10.3 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPERNATREMIA (HIGH SODIUM)\n LIVER FUNCTION ABNORMALITIES\n CIRRHOSIS OF LIVER, ALCOHOLIC\n DIABETES MELLITUS (DM), TYPE II\n ACUTE CONFUSION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Cirrhosis: Will remove 4L of ascites fluid today.\n MS: might be little better as answering some questions in both english\n and portuguese\n acute renal failure: could be partially due to ascites, will check\n bladder pressure.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n 18 Gauge - 01:31 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n ------ Protected Section ------\n 35 minutes spent.\n Full Code.\n Stays in ICU\n ------ Protected Section Addendum Entered By: , MD\n on: 11:31 ------\n" }, { "category": "Nursing", "chartdate": "2119-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 589987, "text": "This is a 63 year old Portuguese-speaking man with extensive history of\n alcoholic cirrhosis, frequent admissions at , (9 since )\n now here with right-sided abdominal pain, and increased ascites.\n Starting on Wednesday () he began having right-sided abdominal\n pain. His wife reported that he had increased fatigue, abdominal pain,\n abdominal girth, and one episode of non-bloody emesis. His wife and\n cousin denied that he had any episodes of confusion.\n In the ED, he was guaiaic negative; and his labs were notable for a\n lactate 9.1, WBC 21.3, Cr 7.6, Glu 15. With low glucose of 15, a D5W\n drip was initiated. With consideration of ischemic colitis, the ED\n sent him for CT scan, ordered without contrast given his renal\n function; this did not show any signs of ischemia. Additionally, he\n received: 4.5 gm IV zosyn, octreotide 50 mcg IV and octreotide 25\n mcg/hr gtt; as well as 1 amp of calcium gluconate. Liver and kidney\n services were consulted in the ED; renal fellow planned for HD in the\n unit. A diagnostic paracentesis was performed in the ED; the liver\n service recommended against therapeutic tap for now. He was admitted to\n the MICU service for further management.\n Received a total of 6 units FFP prior to hemodialysis catheter\n placement. Line confirmed via CXR and hemodialysis initiated ~0030.\n Tolerated well, with the removal of 200 cc\n .H/O altered mental status (not Delirium)\n Assessment:\n Primary language is Portugese. Pt appears to have a fair understanding\n when spoken to, but doesn\nt speak English well. When wife was here\n earlier, she stated that pt was oriented but tired, and didn\nt want to\n speak much. Has been cooperative with care thus far.\n Action:\n Current care plan explained to pt prior to wife going home\n Response:\n Appeared comfortable with plan of care.\n Plan:\n Con\nt to provide explanations of POC, have interpreter or wife assist\n with translation.\n .H/O ascites\n Assessment:\n Abdomen firm and distended. Abdomen causing quite a bit of discomfort\n for patient when moving\n Action:\n Provide 2 person assist when moving pt.\n Response:\n Frequent postioning as needed\n Plan:\n 2 person assist with movements, f/u with team re: a possible\n paracentesis\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Newly elevated BUN/Cr\n Action:\n Dialysis catheter placed and pt dialyzed\n Response:\n Stable without hypotension\n Plan:\n f/u with lab results, drawn ~3 hrs post dialysis\n .H/O hypoglycemia\n Assessment:\n Glusose of 15 in ED, received D5W with correction of glucose\n Action:\n D5W with frequent BS checks\n Response:\n Glucose correcting\n Plan:\n FS checks, close monitoring\n" }, { "category": "Nursing", "chartdate": "2119-08-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590089, "text": "63 yr old Porteguese speaking male with end stage liver, stenosed TIPS.\n recurrent encephalopathy presents with leukocytosis, abd pain, and new\n renal failure with lactic acidosis and hyerkalemia. Tx to MICU for\n acute HD (new HD for him)\n Diagnostic Para in the ED - 33 wbc, 25% PMN, bloody- 6300 RBC\n INR reversed with FFP- right IJ and HD catheter placed\n .H/O ascites\n Assessment:\n Abdomen con\nts distended, causing pt discomfort with movements.\n Bladder pressure ~20\n Action:\n Frequent position changes\n Response:\n Pt resting better than previous shift\n Plan:\n Con\nt to assess, assist with postion changes as needed\n .H/O altered mental status (not Delirium)\n Assessment:\n Receiving lactulose qd for goal of 3 BM\ns per day\n Action:\n lactulose held\n Response:\n Large BM last eve\n Plan:\n Begin lactulose in am once again in order to reach projected goal of 3\n stools/day\n .H/O hypoglycemia\n Assessment:\n FS stable\n Action:\n QID FS with ss coverage as needed\n Response:\n No hypoglycemic episodes, required insulin coverage for glucose over\n 200 times two\n Plan:\n SS coverage per parameters\n .H/O hepatic encephalopathy\n Assessment:\n Per pt\ns wife, who remained at pt\ns bedside until ~2130, pt con\n alert and oriented with no disorientation\n Action:\n Pt answers when spoken to, difficult to assess full orientation. Per\n co-worker, who speaks , pt stated he was at the . He\n also stated he wanted to go home..\n Response:\n Pt was reoriented as appropriate. Postion changed frequently and he\n did well with this. Able to doze in small for short periods of time.\n Plan:\n Assess MS, reoriented as needed\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Dialysis on \n Action:\n Response:\n Urine output diminishing ~5-10 cc\ns per hr\n Plan:\n Con\nt to monitor lab results, assess u/o\n" }, { "category": "Physician ", "chartdate": "2119-08-17 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 591504, "text": "Chief Complaint: altered mental status\n HPI:\n Mr. was previously known to the MICU team when he was\n admitted on with right sided abdominal pain, ascites, lactic\n acidosis thought to be perhaps secondary to metformin toxicity, and\n renal failure requiring emergent dialysis. Then (and since then)\n diagnostic paracenteses did not show evidence for SBP (para done\n earlier today shows WBC 300 but in setting of RBC ). In MICU\n stay, dialysis was initiated. Since he has been on the floor, he\n has been able to stop dialysis for a time, with last session on 8.21\n per housestaff notes. He has had urine output of 600 as of the morning\n of . A diabetic who has been on insulin only during this admission,\n he has had difficult-to-control glucose, remaining in the 300s-400s for\n much of the last day despite an aggressive sliding scale. He triggered\n on the floor both the night of transfer and the night prior for\n agitation and altered mental status. The evening prior to transfer, the\n MICU resident was notified by the liver-kidney resident that Mr.\n \ns status was troubling and that a transfer might be necessary;\n on the second trigger overnight, nightfloat and MICU residents agreed\n to transfer Mr. to the MICU for insulin drip and closer\n monitoring in the setting of ongoing encephalopathy, intermittent\n agitation, and difficult to control blood sugar. The liver attending\n was contact by the nightfloat covering team, and reportedly\n recommended insulin drip and suggested the possibility of infection.\n At time of transfer, Mr. was tachycardic and hypertensive. He\n was alternating between periods of sleep and periods of agitated\n moaning, consistent with the mournful moans of the encephalopathic\n periods of his prior MICU stay.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Infusions:\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Haloperidol (Haldol) - 01:50 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n EtOH cirrhosis, c/b ascites and varices, s/p banding\n s/p TIPS ()-->redo for narrowing --> failure of TIPS\n noted in past admissions w d/c summaries noting decision not to redo\n TIPS further given diminished returns\n recent prior admission including 5L paracentesis\n portal vein thrombosis, on coumadin goal INR \n diabetes mellitus\n hypothyroidism\n pituitary mass\n h/o nephrolithiasis\n h/o +PPD\n Mother deceased at age 50, CVA. Father deceased, age 62, \"stomach\n problems\". One brother and two sisters, all living and in good health.\n Occupation: retired\n Drugs: no\n Tobacco: non\n Alcohol: quit \n Other:\n Review of systems:\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Emesis\n Endocrine: History of thyroid disease\n Pain: Unable to answer\n Flowsheet Data as of 03:08 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.9\nC (96.7\n HR: 105 (105 - 122) bpm\n BP: 149/87(101) {141/87(101) - 169/95(113)} mmHg\n RR: 18 (17 - 18) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1 mL\n 315 mL\n PO:\n TF:\n IVF:\n 1 mL\n 315 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1 mL\n 315 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL, staring into space, not clearly registering\n his examiners(s)\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 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 Altered mental status:\n Head CT negative. Abd u/s unchanged. Diagnostic para not revealing.\n Hypernatremic. Hyperglycemia and enceph suggests possibility of\n infection.\n - covering w vanc/zosyn\n - gently correcting hypernatremia though doubt this is major\n contributor\n -\n Hypernatremia\n Likely 2.2 poor intake. Giving gentle\n NS. Avoiding D5W in setting of\n hyperglycemia.\n Renal failure\n Continue midodrine, albumin as per floor team. Follow Cr and urine\n output closely. No urgent indication for HD.\n Diabetes\n Insulin drip for now. Will d/ in AM\nthey are following. Likely\n that hyperglycemia is infection as above.\n Hypothyroidism\n Continue synthroid\n Coagulopathy/anticoagulation\n Continuing warfarin for portal vein thrombosis which has been a problem\n for pt in the past.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 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": "2119-08-17 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 591507, "text": "Chief Complaint: altered mental status\n HPI:\n Mr. was previously known to the MICU team when he was\n admitted on with right sided abdominal pain, ascites, lactic\n acidosis thought to be perhaps secondary to metformin toxicity, and\n renal failure requiring emergent dialysis. Then (and since then)\n diagnostic paracenteses did not show evidence for SBP (para done\n earlier today shows WBC 300 but in setting of RBC ). In MICU\n stay, dialysis was initiated. Since he has been on the floor, he\n has been able to stop dialysis for a time, with last session on 8.21\n per housestaff notes. He has had urine output of 600 as of the morning\n of . A diabetic who has been on insulin only during this admission,\n he has had difficult-to-control glucose, remaining in the 300s-400s for\n much of the last day despite an aggressive sliding scale. He triggered\n on the floor both the night of transfer and the night prior for\n agitation and altered mental status. The evening prior to transfer, the\n MICU resident was notified by the liver-kidney resident that Mr.\n \ns status was troubling and that a transfer might be necessary;\n on the second trigger overnight, nightfloat and MICU residents agreed\n to transfer Mr. to the MICU for insulin drip and closer\n monitoring in the setting of ongoing encephalopathy, intermittent\n agitation, and difficult to control blood sugar. The liver attending\n was contact by the nightfloat covering team, and reportedly\n recommended insulin drip and suggested the possibility of infection.\n At time of transfer, Mr. was tachycardic and hypertensive. He\n was alternating between periods of sleep and periods of agitated\n moaning, consistent with the mournful moans of the encephalopathic\n periods of his prior MICU stay.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Infusions:\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Haloperidol (Haldol) - 01:50 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n EtOH cirrhosis, c/b ascites and varices, s/p banding\n s/p TIPS ()-->redo for narrowing --> failure of TIPS\n noted in past admissions w d/c summaries noting decision not to redo\n TIPS further given diminished returns\n recent prior admission including 5L paracentesis\n portal vein thrombosis, on coumadin goal INR \n diabetes mellitus\n hypothyroidism\n pituitary mass\n h/o nephrolithiasis\n h/o +PPD\n Mother deceased at age 50, CVA. Father deceased, age 62, \"stomach\n problems\". One brother and two sisters, all living and in good health.\n Occupation: retired\n Drugs: no\n Tobacco: non\n Alcohol: quit \n Other:\n Review of systems:\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Emesis\n Endocrine: History of thyroid disease\n Pain: Unable to answer\n Flowsheet Data as of 03:08 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.9\nC (96.7\n HR: 105 (105 - 122) bpm\n BP: 149/87(101) {141/87(101) - 169/95(113)} mmHg\n RR: 18 (17 - 18) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1 mL\n 315 mL\n PO:\n TF:\n IVF:\n 1 mL\n 315 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1 mL\n 315 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL, staring into space, not clearly registering\n his examiners(s)\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 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 Altered mental status:\n Head CT negative. Abd u/s unchanged. Diagnostic para not revealing.\n Hypernatremic. Hyperglycemia and enceph suggests possibility of\n infection. Pt originally presented with abdominal pain that was not\n notable on exam but uncomfortable to patient, even in setting of no\n encephalopathy; pt currently moaning mournfully consistent with past\n presentation.\n - covering w vanc/zosyn\n - gently correcting hypernatremia though doubt this is major\n contributor\n - has had haldol on the floor, continuing this as prn; not clear\n whether this will be helpful other than as sedative, and will consider\n very low dose morphine as trial of pain relief; Tylenol at low dose\n also.\n - likely to need to hold POs currently, pt not w mental status to\n cooperate w POs; consider NG tube for nutrition and meds if not\n clearing by mid-morning.\n - lactulose enema\n - f/u micro data, cultures pending\n Hyperglycemia\n Likely secondary to infection given change over last several days\n coinciding w worsening encephalopathy.\n Hypernatremia\n Likely 2.2 poor intake. Giving gentle\n NS. Avoiding D5W in setting of\n hyperglycemia.\n Renal failure\n Continue midodrine, albumin as per floor team. Follow Cr and urine\n output closely. No urgent indication for HD.\n Diabetes\n Insulin drip for now. Will d/ in AM\nthey are following. Likely\n that hyperglycemia is infection as above.\n Hypothyroidism\n Continue synthroid\n Coagulopathy/anticoagulation\n Continuing warfarin for portal vein thrombosis which has been a problem\n for pt in the past.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 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": "2119-08-17 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 591508, "text": "Chief Complaint: altered mental status\n HPI:\n Mr. was previously known to the MICU team when he was\n admitted on with right sided abdominal pain, ascites, lactic\n acidosis thought to be perhaps secondary to metformin toxicity, and\n renal failure requiring emergent dialysis. Then (and since then)\n diagnostic paracenteses did not show evidence for SBP (para done\n earlier today shows WBC 300 but in setting of RBC ). In MICU\n stay, dialysis was initiated. Since he has been on the floor, he\n has been able to stop dialysis for a time, with last session on 8.21\n per housestaff notes. He has had urine output of 600 as of the morning\n of . A diabetic who has been on insulin only during this admission,\n he has had difficult-to-control glucose, remaining in the 300s-400s for\n much of the last day despite an aggressive sliding scale. He triggered\n on the floor both the night of transfer and the night prior for\n agitation and altered mental status. The evening prior to transfer, the\n MICU resident was notified by the liver-kidney resident that Mr.\n \ns status was troubling and that a transfer might be necessary;\n on the second trigger overnight, nightfloat and MICU residents agreed\n to transfer Mr. to the MICU for insulin drip and closer\n monitoring in the setting of ongoing encephalopathy, intermittent\n agitation, and difficult to control blood sugar. The liver attending\n was contact by the nightfloat covering team, and reportedly\n recommended insulin drip and suggested the possibility of infection.\n At time of transfer, Mr. was tachycardic and hypertensive. He\n was alternating between periods of sleep and periods of agitated\n moaning, consistent with the mournful moans of the encephalopathic\n periods of his prior MICU stay.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Infusions:\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Haloperidol (Haldol) - 01:50 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n EtOH cirrhosis, c/b ascites and varices, s/p banding\n s/p TIPS ()-->redo for narrowing --> failure of TIPS\n noted in past admissions w d/c summaries noting decision not to redo\n TIPS further given diminished returns\n recent prior admission including 5L paracentesis\n portal vein thrombosis, on coumadin goal INR \n diabetes mellitus\n hypothyroidism\n pituitary mass\n h/o nephrolithiasis\n h/o +PPD\n Mother deceased at age 50, CVA. Father deceased, age 62, \"stomach\n problems\". One brother and two sisters, all living and in good health.\n Occupation: retired\n Drugs: no\n Tobacco: non\n Alcohol: quit \n Other:\n Review of systems:\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Emesis\n Endocrine: History of thyroid disease\n Pain: Unable to answer\n Flowsheet Data as of 03:08 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.9\nC (96.7\n HR: 105 (105 - 122) bpm\n BP: 149/87(101) {141/87(101) - 169/95(113)} mmHg\n RR: 18 (17 - 18) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1 mL\n 315 mL\n PO:\n TF:\n IVF:\n 1 mL\n 315 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1 mL\n 315 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL, staring into space, not clearly registering\n his examiners(s)\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 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 Altered mental status:\n Head CT negative. Abd u/s unchanged. Diagnostic para not revealing.\n Hypernatremic. Hyperglycemia and enceph suggests possibility of\n infection. Pt originally presented with abdominal pain that was not\n notable on exam but uncomfortable to patient, even in setting of no\n encephalopathy; pt currently moaning mournfully consistent with past\n presentation.\n - covering w vanc/zosyn\n - gently correcting hypernatremia though doubt this is major\n contributor\n - has had haldol on the floor, continuing this as prn; not clear\n whether this will be helpful other than as sedative, and will consider\n very low dose morphine as trial of pain relief; Tylenol at low dose\n also.\n - likely to need to hold POs currently, pt not w mental status to\n cooperate w POs; consider NG tube for nutrition and meds if not\n clearing by mid-morning.\n - lactulose enema\n - f/u micro data, cultures pending\n Hyperglycemia\n Likely secondary to infection given change over last several days\n coinciding w worsening encephalopathy.\n Hypernatremia\n Likely 2.2 poor intake. Giving gentle\n NS. Avoiding D5W in setting of\n hyperglycemia.\n Renal failure\n Continue midodrine, albumin as per floor team. Follow Cr and urine\n output closely. No urgent indication for HD.\n Diabetes\n Insulin drip for now. Will d/ in AM\nthey are following. Likely\n that hyperglycemia is infection as above.\n Hypothyroidism\n Continue synthroid\n Coagulopathy/anticoagulation\n Continuing warfarin for portal vein thrombosis which has been a problem\n for pt in the past.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 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": "Nursing", "chartdate": "2119-08-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591509, "text": "Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline. He has had frequent admissions for increased confusion and\n presented with right sided abdominal pain and increased ascites In\n ED his lactate 9.1 wbc 21.3 cr 7.6 and a glucose of 15. He is on liver\n transplant list. He has been receiving HD. Over several days he has\n become increasingly agitated with mental status changes. He was\n transferred to MICU secondary to increase agitation and aggressive\n behavior toward staff requiring 4 point restraints with persistant\n tachycardia, hypertension and blood sugar of 450. PMH alcoholic\n cirrhosis known varices, portal vein thrombosis, s/p TIOS, DM 2,\n hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD\n Acute Confusion\n Assessment:\n Patiient moaning not engaging, moving all extremities, not following\n commands, tachycardic when awake to 130\n Action:\n Given haldol .5mg IV x 2, given lactulose enema x1\n Response:\n Patient moaning, HR 90\ns nsr when given haldol then increases up to\n 137 ST when awake and agitated, he did open his eyes and engage briefly\n Plan:\n Unclear if agitation is from pain or encephalopathy,\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Temp 96.9 wbc\n Action:\n Given vanco and zoysn\n Response:\n Plan:\n Vanco, zoysn and cipro IV, monitor lactate, temp, wbc, await cx results\n Diabetes Mellitus (DM), Type II\n Assessment:\n First arrived in micu blood sugar 415\n Action:\n He was given 10u regular insulin sq and started on a insulin gtt\n Response:\n Blood sugar slowly coming down\n Plan:\n Continue insulin gtt monitor anion gag, blood sugars q 1hr titrate prbn\n Cirrhosis of liver, alcoholic\n Assessment:\n Abdomen distended and firm, bowel sounds present. Patient has a\n puncture wound from previous paracentesis draining yellow fluid\n nonodorous, site is without erythema. Patient moaning rubbing abdomen.\n Patient has known left portal vein thrombosis\n Action:\n Given .5mg IV morphine. He continues on coumadin.\n Response:\n Heart rate came down to 95 and patient fell asleep unclear if moaning\n pain or encephalopathy\n Plan:\n Monitor , patient has agreed to start pretransplant wourk up, follow\n lft, ? need for paracentesis, monitor pain, medicate prn. Lactulose tid\n po\n" }, { "category": "Physician ", "chartdate": "2119-08-17 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 591510, "text": "Chief Complaint: altered mental status\n HPI:\n Mr. was previously known to the MICU team when he was\n admitted on with right sided abdominal pain, ascites, lactic\n acidosis thought to be perhaps secondary to metformin toxicity, and\n renal failure requiring emergent dialysis. Then (and since then)\n diagnostic paracenteses did not show evidence for SBP (para done\n earlier today shows WBC 300 but in setting of RBC ). In MICU\n stay, dialysis was initiated. Since he has been on the floor, he\n has been able to stop dialysis for a time, with last session on 8.21\n per housestaff notes. He has had urine output of 600 as of the morning\n of . A diabetic who has been on insulin only during this admission,\n he has had difficult-to-control glucose, remaining in the 300s-400s for\n much of the last day despite an aggressive sliding scale. He triggered\n on the floor both the night of transfer and the night prior for\n agitation and altered mental status. The evening prior to transfer, the\n MICU resident was notified by the liver-kidney resident that Mr.\n \ns status was troubling and that a transfer might be necessary;\n on the second trigger overnight, nightfloat and MICU residents agreed\n to transfer Mr. to the MICU for insulin drip and closer\n monitoring in the setting of ongoing encephalopathy, intermittent\n agitation, and difficult to control blood sugar. The liver attending\n was contact by the nightfloat covering team, and reportedly\n recommended insulin drip and suggested the possibility of infection.\n At time of transfer, Mr. was tachycardic and hypertensive. He\n was alternating between periods of sleep and periods of agitated\n moaning, consistent with the mournful moans of the encephalopathic\n periods of his prior MICU stay.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Infusions:\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Haloperidol (Haldol) - 01:50 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n EtOH cirrhosis, c/b ascites and varices, s/p banding\n s/p TIPS ()-->redo for narrowing --> failure of TIPS\n noted in past admissions w d/c summaries noting decision not to redo\n TIPS further given diminished returns\n recent prior admission including 5L paracentesis\n portal vein thrombosis, on coumadin goal INR \n diabetes mellitus\n hypothyroidism\n pituitary mass\n h/o nephrolithiasis\n h/o +PPD\n Mother deceased at age 50, CVA. Father deceased, age 62, \"stomach\n problems\". One brother and two sisters, all living and in good health.\n Occupation: retired\n Drugs: no\n Tobacco: non\n Alcohol: quit \n Other:\n Review of systems:\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Emesis\n Endocrine: History of thyroid disease\n Pain: Unable to answer\n Flowsheet Data as of 03:08 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.9\nC (96.7\n HR: 105 (105 - 122) bpm\n BP: 149/87(101) {141/87(101) - 169/95(113)} mmHg\n RR: 18 (17 - 18) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1 mL\n 315 mL\n PO:\n TF:\n IVF:\n 1 mL\n 315 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1 mL\n 315 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL, staring into space, not clearly registering\n his examiners(s)\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 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 Altered mental status:\n Head CT negative. Abd u/s unchanged. Diagnostic para not revealing.\n Hypernatremic. Hyperglycemia and enceph suggests possibility of\n infection. Pt originally presented with abdominal pain that was not\n notable on exam but uncomfortable to patient, even in setting of no\n encephalopathy; pt currently moaning mournfully consistent with past\n presentation.\n - covering w vanc/zosyn\n - gently correcting hypernatremia though doubt this is major\n contributor\n - has had haldol on the floor, continuing this as prn; not clear\n whether this will be helpful other than as sedative, and will consider\n very low dose morphine as trial of pain relief; Tylenol at low dose\n also.\n - likely to need to hold POs currently, pt not w mental status to\n cooperate w POs; consider NG tube for nutrition and meds if not\n clearing by mid-morning.\n - lactulose enema\n - f/u micro data, cultures pending\n Hyperglycemia\n Likely secondary to infection given change over last several days\n coinciding w worsening encephalopathy.\n Hypernatremia\n Likely 2.2 poor intake. Giving gentle\n NS. Avoiding D5W in setting of\n hyperglycemia.\n Renal failure\n Continue midodrine, albumin as per floor team. Follow Cr and urine\n output closely. No urgent indication for HD.\n Diabetes\n Insulin drip for now. Will d/ in AM\nthey are following. Likely\n that hyperglycemia is infection as above.\n Hypothyroidism\n Continue synthroid\n Coagulopathy/anticoagulation\n Continuing warfarin for portal vein thrombosis which has been a problem\n for pt in the past.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 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": "Nursing", "chartdate": "2119-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591690, "text": "Synopsis per prior nursing note:\n Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Hypernatremia (high sodium)\n Assessment:\n Na 146, k 3.6.\n Action:\n Received 2^nd L of D5W @ 100cc/hr. Started 1L of D5W with 40mEq\n potassium @ 100cc/hr. NGT with residuals of 600cc x2. NGT placed on\n intermittent suction. Given lactulose enema.\n Response:\n Repeat Na . Stool output ~2L, liquid stool. Continues to put out\n bilious fluid from NGT.\n Plan:\n Monitor electrolytes.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 97-153 while on insulin gtt.\n Action:\n NPO. FS monitored q1hr while on insulin gtt. Given evening dose of\n lantus. Insulin gtt turned off @ 0100, FS 153 and given 7units(half\n dose) of humalog.\n Response:\n FS 170, covered w/ humalog.\n Plan:\n Monitor FS q4hrs.\n Cirrhosis of liver, alcoholic\n Assessment:\n Confused, garbled speech, not following commands, purposeful movements\n of extremities, occasionally combative, +ascites.\n Action:\n Attempted to reorient. Soft wrist restraints continued d/t patient\n attempting to pull out lines. Given PR lactulose.\n Response:\n No change in mental status.\n Plan:\n Lactulose PR .\n" }, { "category": "Nursing", "chartdate": "2119-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591829, "text": "Hypernatremia (high sodium)\n Assessment:\n Today\ns NA+ 147 after 1 L free water iv last PM\n Action:\n D5W @ 125/hr x 1 L today\n Response:\n Will repeat NA+ with am labs\n Plan:\n Repeat NA+ with am labs, tx as ordered if hypernatremic\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt with massive ascites, mental status change d/t hepatic\n encephalopathy, pt somnulant, deos not follow any commands, perl,\n moving all extremities, moaning @ times, tries to pull out ngt & put\n feet over side rails, not tolerating po meds via ngt, ? ileus\n Action:\n Neuro assessment q 2-4 hrs, lactulose enema, ngt placed to continous\n low wall sux, kub done, no meds via ngt\n Response:\n Lg liquid stool after enema, mental status with slight improvement\n after lactulose\n Plan:\n Lactulose enema , continue to assess MS, ? of abd tap\n" }, { "category": "Nursing", "chartdate": "2119-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591988, "text": "Synopsis per prior nursing note:\n Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Hypernatremia (high sodium)\n Assessment:\n Na 144, k 3.9.\n Action:\n NGT to IWS. Given lactulose enema.\n Response:\n Repeat Na 146. Repeat K 3.2. Very large, liquid stool after enema.\n Continues to put out small amt bilious fluid from NGT.\n Plan:\n Monitor electrolytes. Monitor stool/NGT output.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 156.\n Action:\n Took moderate amt of PO intake. Given evening dose of lantus. FS\n treated with humalog per new ISS.\n Response:\n 0400 FS 118.\n Plan:\n Monitor FS. Encourage PO intake.\n Cirrhosis of liver, alcoholic\n Assessment:\n Alert, oriented. Moving all extremities weakly. Follows commands. Able\n to let basic needs be known. Helps move self in bed. Jaundice,\n +Ascites.\n Action:\n Held PO lactulose d/t multiple loose, stools. NGT in place through\n night while monitoring mental status.\n Response:\n No change in mental status. Had multiple loose, brown stools.\n Plan:\n Lactulose for 3BM/day. Monitor change in mental status. ? remove NGT\n today.\n" }, { "category": "Nursing", "chartdate": "2119-08-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590174, "text": "Hypotension (not Shock)\n Assessment:\n Action:\n Bp 80\ns-115/, Bp dips down to 80\ns/ while asleep, plan to not treat\n unless SBP <80/\n Aline positional, hand placed on board\n CVp transduced via vip port in HD line, \n Response:\n Labile bp\n Plan:\n Levophed gtt as ordered\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Paracentesis\n Action:\n Abd remains distended and tense, bladder pressure 20\n Paracentesis done, ~5l removed, ascetic fluid turbid\n Albumen 100gm IV ordered for during paracentesis\n Receiving lactulosr, titrating to 3 stools per day, pt had 500 ml brown\n ob pos liquid stool after am lactulose\n Wife in to visit, translating for pt, states he is not confused and is\n oriented\n Wife at times when speaking to pt, states he is talking about\n dying\n Response:\n Paracentesis\n Plan:\n Social work consult in am for family support\n Lactulose as ordered\n Albumen as ordered\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Min u/o\n Action:\n Pt with <10ml urine out per hour\n Plans for HD \n Response:\n Oliguric\n Plan:\n Pm lytes and lactate\n HD in am\n .H/O hypoglycemia\n Assessment:\n Receiving SS coverage\n Action:\n Fs elevated, receiving SS humalog as ordered\n Po po intake, poor appetite\n Response:\n Elevated FS\n Plan:\n Insulin as ordered\n Fs qid\n" }, { "category": "Nursing", "chartdate": "2119-08-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591515, "text": "Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline. He has had frequent admissions for increased confusion and\n presented with right sided abdominal pain and increased ascites In\n ED his lactate 9.1 wbc 21.3 cr 7.6 and a glucose of 15. He is on liver\n transplant list. He has been receiving HD. Over several days he has\n become increasingly agitated with mental status changes. He was\n transferred to MICU secondary to increase agitation and aggressive\n behavior toward staff requiring 4 point restraints with persistant\n tachycardia, hypertension and blood sugar of 450. PMH alcoholic\n cirrhosis known varices, portal vein thrombosis, s/p TIOS, DM 2,\n hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD\n Acute Confusion\n Assessment:\n Patiient moaning not engaging, moving all extremities, not following\n commands, tachycardic when awake to 130\n Action:\n Given haldol .5mg IV x 2, given lactulose enema x1\n Response:\n Patient moaning, HR 90\ns nsr when given haldol then increases up to\n 137 ST when awake and agitated, he did open his eyes and engage briefly\n Plan:\n Unclear if agitation is from pain or encephalopathy,\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Bun 47 cr 2.9\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Temp 96.9 wbc\n Action:\n Given vanco and zoysn\n Response:\n Wbc 7.1 blood cultures pnding\n Plan:\n Vanco, zoysn and cipro IV, monitor lactate, temp, wbc, await cx results\n Diabetes Mellitus (DM), Type II\n Assessment:\n First arrived in micu blood sugar 415 anion gap 28\n Action:\n He was given 10u regular insulin sq and started on a insulin gtt\n Response:\n Blood sugar slowly coming down, anion gap down to 25\n Plan:\n Continue insulin gtt monitor anion gag, blood sugars q 1hr titrate prbn\n Cirrhosis of liver, alcoholic\n Assessment:\n Abdomen distended and firm, bowel sounds present. Patient has a\n puncture wound from previous paracentesis draining yellow fluid\n nonodorous, site is without erythema. Patient moaning rubbing abdomen.\n Patient has known left portal vein thrombosis\n Action:\n Given .5mg IV morphine. He continues on coumadin.\n Response:\n Heart rate came down to 95 and patient fell asleep unclear if moaning\n pain or encephalopathy\n Plan:\n Monitor , patient has agreed to start pretransplant wourk up, follow\n lft, ? need for paracentesis, monitor pain, medicate prn. Lactulose tid\n po\n Hypernatremia (high sodium)\n Assessment:\n Sodium 152\n Action:\n Placed on .45%NS at 100cc qhr\n Response:\n unchanged\n Plan:\n Continue IVF, monitor bun and cr, renal following, monitor NA and\n electrolytes\n" }, { "category": "Nursing", "chartdate": "2119-08-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591518, "text": "Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline. He has had frequent admissions for increased confusion and\n presented with right sided abdominal pain and increased ascites In\n ED his lactate 9.1 wbc 21.3 cr 7.6 and a glucose of 15. He is on liver\n transplant list. He has been receiving HD. Over several days he has\n become increasingly agitated with mental status changes. He was\n transferred to MICU secondary to increase agitation and aggressive\n behavior toward staff requiring 4 point restraints with persistant\n tachycardia, hypertension and blood sugar of 450. PMH alcoholic\n cirrhosis known varices, portal vein thrombosis, s/p TIOS, DM 2,\n hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD\n Acute Confusion\n Assessment:\n Patiient moaning not engaging, moving all extremities, not following\n commands, tachycardic when awake to 130\n Action:\n Given haldol .5mg IV x 2, given lactulose enema x1\n Response:\n Patient moaning, HR 90\ns nsr when given haldol then increases up to\n 137 ST when awake and agitated, he did open his eyes and engage briefly\n Plan:\n Unclear if agitation is from pain or encephalopathy,\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Bun 47 cr 2.9 incontinent of urine Na 152\n Action:\n On .45NS at 100cc qhr\n Response:\n Plan:\n Monitor bun and cr, if he continues to be unresponsive may need foley\n placed\n Sepsis without organ dysfunction\n Assessment:\n Temp 96.9 wbc\n Action:\n Given vanco and zoysn\n Response:\n Wbc 7.1 blood cultures pnding\n Plan:\n Vanco, zoysn and cipro IV, monitor lactate, temp, wbc, await cx results\n Diabetes Mellitus (DM), Type II\n Assessment:\n First arrived in micu blood sugar 415 anion gap 28\n Action:\n He was given 10u regular insulin sq and started on a insulin gtt\n Response:\n Blood sugar slowly coming down, anion gap down to 25\n Plan:\n Continue insulin gtt monitor anion gag, blood sugars q 1hr titrate prbn\n Cirrhosis of liver, alcoholic\n Assessment:\n Abdomen distended and firm, bowel sounds present. Patient has a\n puncture wound from previous paracentesis draining yellow fluid\n nonodorous, site is without erythema. Patient moaning rubbing abdomen.\n Patient has known left portal vein thrombosis\n Action:\n Given .5mg IV morphine. He continues on coumadin.\n Response:\n Heart rate came down to 95 and patient fell asleep unclear if moaning\n pain or encephalopathy\n Plan:\n Monitor , patient has agreed to start pretransplant wourk up, follow\n lft, ? need for paracentesis, monitor pain, medicate prn. Lactulose tid\n po\n Hypernatremia (high sodium)\n Assessment:\n Sodium 152\n Action:\n Placed on .45%NS at 100cc qhr\n Response:\n unchanged\n Plan:\n Continue IVF, monitor bun and cr, renal following, monitor NA and\n electrolytes\n" }, { "category": "Physician ", "chartdate": "2119-08-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 591898, "text": "Chief Complaint:\n 24 Hour Events:\n C.diff sent. recommended changing insulin from q4 to Q6 HISS\n since insulin stacks in renal disease and lantus to 30 from 26.\n Ciprofloxacin dc'd.\n am labs showed increase Na, K+ low, thus started on D5W in 40meq KCl.\n Therapeutic tap deferred.\n CXR showed stable bilateral lower lobe atelectasis associated with low\n lung volumes. No new consolidation or pneumothorax.\n Toxo pos/neg result\n Blood/urine cultures pending\n u cx growing yeast\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:48 AM\n Piperacillin - 02:46 AM\n Ciprofloxacin - 10:19 AM\n Piperacillin/Tazobactam (Zosyn) - 08:07 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:08 AM\n Dextrose 50% - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.2\nC (97.1\n HR: 76 (76 - 119) bpm\n BP: 133/80(91) {109/55(69) - 169/107(121)} mmHg\n RR: 13 (13 - 19) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.2 kg (admission): 90.6 kg\n Height: 67 Inch\n Total In:\n 2,742 mL\n 253 mL\n PO:\n TF:\n IVF:\n 2,542 mL\n 203 mL\n Blood products:\n 200 mL\n Total out:\n 1,850 mL\n 150 mL\n Urine:\n 500 mL\n 150 mL\n NG:\n 1,350 mL\n Stool:\n Drains:\n Balance:\n 892 mL\n 103 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///20/\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 170 K/uL\n 9.9 g/dL\n 40 mg/dL\n 3.1 mg/dL\n 20 mEq/L\n 3.2 mEq/L\n 43 mg/dL\n 109 mEq/L\n 146 mEq/L\n 30.3 %\n 11.6 K/uL\n [image002.jpg]\n 02:56 AM\n 09:58 AM\n 02:35 PM\n 10:00 PM\n 03:09 AM\n 04:45 AM\n 12:16 PM\n 07:30 PM\n 03:54 AM\n WBC\n 7.1\n 9.4\n 13.0\n 11.6\n Hct\n 30.0\n 30.6\n 32.6\n 30.3\n Plt\n 102\n 108\n 147\n 170\n Cr\n 2.9\n 2.9\n 2.8\n 3.0\n 2.8\n 3.1\n 3.1\n 3.1\n 3.1\n Glucose\n 191\n 195\n 188\n 183\n 1\n 40\n Other labs: PT / PTT / INR:37.5/44.7/3.9, ALT / AST:, Alk Phos / T\n Bili:118/1.9, Differential-Neuts:84.7 %, Lymph:8.5 %, Mono:2.9 %,\n Eos:3.6 %, Lactic Acid:2.8 mmol/L, Albumin:4.8 g/dL, LDH:248 IU/L,\n Ca++:10.3 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPERNATREMIA (HIGH SODIUM)\n LIVER FUNCTION ABNORMALITIES\n CIRRHOSIS OF LIVER, ALCOHOLIC\n DIABETES MELLITUS (DM), TYPE II\n ACUTE CONFUSION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Leukocytosis: From 9.0 this am to 13.-0 without fever. Pt admitted with\n suspected infection given hyperglycemia, and treated empirically, only\n now developing infection. Regarding source, SBP v.unlikely since just\n had unremarkable diagnostic tap and on cipro prophylaxis, UTI possible\n given new hematuria on exam today (however INR3.8), line infection, PNA\n to be considered. Difficult to invoke CNS infection given MS \nted to hepatic encephalopathy, continue to consider. On multiple\n abx, consider c.diff.\n - cipro discontinued\n - Stool Cx pending\n -Sputum Cx pending\n -CXR\n -cont zosyn, vanc. Consider flagyll\n Altered mental status:\n Head CT negative. Abd u/s unchanged. Diagnostic para not revealing.\n Hypernatremic. Hyperglycemia and enceph suggests possibility of\n infection. Pt originally presented with abdominal pain that was not\n notable on exam but uncomfortable to patient, even in setting of no\n encephalopathy; pt currently moaning mournfully consistent with past\n presentation.\n has had haldol on the floor, continuing this as prn; not clear whether\n this will be helpful other than as sedative, and will consider very low\n dose morphine as trial of pain relief; Tylenol at low dose also.\n - covering w vanc/zosyn\n - gently correcting hypernatremia though doubt this is major\n contributor, with D5W for free water deficit.\n -Continue lactulose enema\n - f/u 4 blood cx pending, Ucx pending, peritoneal fluid gram stain\n negative, no growth preliminary.\n Liver failure\n Not yet listed for transplant. Transplant committee asking for\n colonoscopy and outpatient relapse therapy. Liver today indicated\n continue on this course. DC\nd midodrine given HTN. Specific\n interventions: albumin; lactulose.\n Tense/ obese ascetic abdomen with compartment syndrome possibly\n contributing to ileus and renal failure however unable to remove large\n volumes given risk rapid fluid shifts. Planned to remove 1.5 liters\n yesterday, deferred due to time contraints.\n Hyperglycemia / diabetes\n Likely secondary to infection given change over last several days\n coinciding w worsening encephalopathy. GFS ranged 49-153 on insulin\n drip, 170s when drip dc\n - recs yesterday\n insuline regimen adjusted.\n Hypernatremia\n D5W with potassium yesterday\n labs this morning still with low sodium,\n high potassium. Will continue D5W with K for repletion.\n Renal failure: 2.8 today from 3.0 y/d.\n ?Abdominal compartment syndrome vs s/p drug toxicity, unclear etiology.\n Liver failure likely contributing to some degree of pre-renal failure\n although the degree of resolution suggests against HRS. Continue\n albumin as per floor team. Follow Cr and urine output closely. No\n urgent indication for HD. Renal following, will follow up recs.\n Hematuria likely related to supratherapeutic INR however in setting\n leukocytosis without source, check UA, U Cx.\n Hypothyroidism\n Mild hypothyroidism from tests from . Team discontinued prior\n synthroid, not clear why from notes; will discuss with them in AM.\n Coagulopathy/anticoagulation\n Hold warfarin given supratherapeutic INR 3.9\n Check daily INR.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:36 PM\n 20 Gauge - 11:36 PM\n 18 Gauge - 01:31 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2119-08-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 589972, "text": "Chief Complaint: abdominal discomfort\n HPI:\n This is a 63 year old Portuguese-speaking man with extensive history of\n alcoholic cirrhosis, frequent admissions at , now here with\n right-sided abdominal pain, and increased ascites. Starting on\n Wednesday () he began having right-sided abdominal pain. His wife\n reported that he had increased fatigue, abdominal pain, abdominal\n girth, and one episode of non-bloody emesis. His wife and cousin denied\n that he had any episodes of confusion. They explained that he had \"pain\n where they took the water out\" on the right. They explained and he\n affirmed that he has been urinating less. I confirmed the essentials of\n this history with him during a brief Portuguese interpreter phone\n interview.\n .\n In the emergency department his initial vitals were: 97.9, 111/63, 18,\n 98% on room air. He was found to be guaiaic negative; and he had labs\n notable for lactate 9.1, WBC 21.3, Cr 7.6, Glu 15. With low glucose, a\n D5 drip was started. With consideration of ischemic colitis, the ED\n sent him for CT scan, ordered without contrast given his renal\n function; this did not show any signs of ischemia. Additionally, he\n received: 4.5 gm IV zosyn, octreotide 50 mcg IV and octreotide 25\n mcg/hr gtt; as well as 1 amp of calcium gluconate. Liver and kidney\n services were consulted in the ED; liver fellow left recs in the ED\n chart and renal fellow planned for HD in the unit. A diagnostic\n paracentesis was performed in the ED; the liver service recommended\n against therapeutic tap for now. He was admitted to the MICU service\n for further management.\n Patient admitted from: ER\n History obtained from Interpreter\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Octreotide - 25 mcg/hour\n Other ICU medications:\n Other medications:\n HOME MEDICATIONS\n Calcium Carbonate 500 mg tid\n Vitamin D3 800 units daily\n Glipizide 10 mg daily.\n Lactulose 60 mL PO QID\n Levothyroxine 100 mcg Tablet DAILY\n Metformin 1,000 mg Tablet DAILY\n Omeprazole 20 mg DAILY\n Propranolol 40 mg TID\n Rifaximin 400 TID\n Warfarin 3 mg qHS\n Past medical history:\n Family history:\n Social History:\n - ETOH cirrhosis, complicated by ascites and varices, s/p banding\n * s/p TIPS () -> redo for narrowing -> failure of TIPS\n noted in past admissions w/ d/c summaries noting decision not to redo\n tips further given diminished returns\n * recent admission including 5L paracentesis (note: originally\n thought this was 10L, past records appear to confirm 5L)\n - Portal vein thrombosis: on coumadin goal INR \n - Diabetes mellitus\n - Hypothyroidism\n - Pituitary mass\n - h/o nephrolithiasis\n - h/o + PPD\n Mother deceased, age 50, CVA. Father deceased, age 62, stomach\n problems. One brother living and in good health. Two sisters, both\n living and in good health.\n .\n Occupation: retired\n Drugs: no\n Tobacco: none\n Alcohol: quit \n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema\n Respiratory: Tachypnea, Wheeze\n Gastrointestinal: Abdominal pain, Nausea, Emesis\n Integumentary (skin): No(t) Jaundice\n Endocrine: History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy\n Flowsheet Data as of 03:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 73 (61 - 74) bpm\n BP: 91/45(55) {91/45(55) - 125/67(82)} mmHg\n RR: 21 (15 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,300 mL\n 313 mL\n PO:\n TF:\n IVF:\n 542 mL\n 313 mL\n Blood products:\n 1,758 mL\n Total out:\n 91 mL\n 80 mL\n Urine:\n 91 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,209 mL\n 233 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: Anxious\n Eyes / Conjunctiva: Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal, Fixed)\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 scattered crackles at bases, Diminished: )\n Abdominal: Distended, massive distension assoc w hypoxia and bhperhapb\n producem.\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, No(t) Cyanosis\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Oriented (to): , Movement: Not assessed, Tone: Normal\n Labs / Radiology\n 99 mg/dL\n 7.5 mg/dL\n 87 mg/dL\n 5.6 mEq/L\n [image002.jpg]\n \n 5:00p\n PERITONEAL RT SIDE PARACENTESIS FLUID\n Other Body Fluid Hematology:\n WBC: 33\n RBC: 6340\n Polys: 25\n Lymphs: 14\n Monos: 18\n Mesothe: 11\n Macro: 32\n \n 3:42p\n _______________________________________________________________________\n Lactate:9.1\n \n 2:55p\n _______________________________________________________________________\n Lactate:9.1\n \n 2:33 A8/14/ 11:47 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 Cr\n 7.5\n Glucose\n 99\n Other labs: Lactic Acid:8.7 mmol/L, Mg++:3.4 mg/dL\n Other Blood Chemistry:\n Ammonia: 66\n 133\n [image004.gif]\n 95\n [image004.gif]\n 86\n [image006.gif]\n 15\n AGap=35\n [image007.gif]\n 6.5\n [image004.gif]\n 10\n [image004.gif]\n 7.6\n [image009.gif]\n CK: 40\n MB: Notdone\n Ca: 11.9 Mg: 3.9 P: 8.7\n ALT: 28\n AP: 391\n Tbili: 0.7\n Alb: 3.9\n AST: 44\n LDH:\n Dbili:\n TProt:\n :\n Lip: 94\n 90\n 21.3\n [image009.gif]\n 11.8\n [image006.gif]\n 248\n [image010.gif]\n [image006.gif]\n 34.7\n [image009.gif]\n N:90.0 L:5.9 M:3.6 E:0.3 Bas:0.2\n PT: 40.6\n PTT: 39.9\n INR: 4.3\n STUDIES:\n .\n CT ABD/PELVIS *WET READ*\n Limited ascites and lack of contrast.\n Marked distention of the stomach and prox duodenum. ? gastric outlet\n obstruction of unclear etiology, new since .\n Large ascites, Cirrhosis\n left 2-3 mm nonobstructive renal calc\n No definite wall thickening or pneumatosis or portal venous gas to\n suggest bowel ischemia.\n appendix partially seen\n .\n CT ABD/PELVIS\n 1. Findings compatible with cirrhosis and portal hypertension without\n evidence of focal mass lesion in the liver.\n 2. Conventional hepatic vascular anatomy without evidence of occlusion.\n 3. Liver volume 1233 cm3.\n .\n CARDIAC PERFUSION PERSANTINE\n 1. Normal myocardial perfusion, estimated LVEF of 57%.\n .\n Stress\n 1. No anginal symptoms or ischemic ST segment changes. Nuclear\n report sent separately.\n .\n LIVER OR GALLBLADDER US (SINGLE ORGAN)\n 1. TIPS with elevated velocities at the mid and distal portion\n concerning for stenosis.\n 2. Ascites is similar to the previous study and is large in amount.\n 3. Unchanged appearance of the right anterior portal vein with\n hepatopetal flow. Non-visualized left portal vein\n .\n ECHO\n The left atrium is mildly dilated. There is mild symmetric left\n ventricular hypertrophy with normal cavity size and global systolic\n function (LVEF>55%). Due to suboptimal technical quality, a focal wall\n motion abnormality cannot be fully excluded. Right ventricular chamber\n size and free wall motion are normal. The diameters of aorta at the\n sinus, ascending and arch levels are normal. The aortic valve leaflets\n (3) appear structurally normal with good leaflet excursion and no\n aortic regurgitation. The mitral valve leaflets are structurally\n normal. There is no mitral valve prolapse. Very mild (1+) mitral\n regurgitation is seen. There is borderline pulmonary artery systolic\n hypertension. There is no pericardial effusion.\n Assessment and Plan\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O ASCITES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n .H/O HEPATIC ENCEPHALOPATHY\n .H/O RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O HYPOGLYCEMIA\n ASSESSMENT AND PLAN\n This is a 63 year old Portuguese-speaking man with end-stage liver\n disease and stenosed TIPS, recurrent admissions for hepatic\n encephalopathy, now here with abdominal pain and a WBC of 21.3 with a\n neutrophil predominance.\n .\n ABDOMINAL PAIN\n Likely related to massive ascites likely hepatorenal syndrome. No\n evidence of SBP given low WBC on diagnostic tap; tap appears bloody;\n most likely coagulopathy, though consistent appearance of this\n finding might suggest hemoperitoneum from another process rather than\n from trauma from tap; CT apparently offers no obvious suspect. No sign\n of perf on CT scan. Surgery evaluating per ED request. Possible gastric\n outlet obstruction seen on CT scan; may improve w decrease in ascitic\n fluid.\n - appreciate surgery recs; tplant service will follow\n - will give albumin per liver recs p HD per renal recs; albumin will\n also be provided by FFP needed for HD line placement\n - consider tx tap if renal function improves\n - NGT if not tolerating clears, emesis, etc\n - clear liquid diet for now\n .\n LEUKOCYTOSIS\n Unclear source. Concern for abdominal source but as above this is not\n clear after dx tap and CT abd/pelvis. I am underwhelmed by CXR but do\n make note of RLL opacity; hard to account for this degree of WBC with\n this small PNA though relative immune suppression of liver/renal\n failure may diminish inflammatory response. High WBC out of proportion\n to symptoms, with abd pain, in pt w multiple hospitalizations, raises\n special concern for c. diff though obvious colitis not seen on CT.\n - covering gram-negatives w zosyn; add vanco and flagyl if worsening\n - cxs pending; additionally send c. diff given mult recent\n hospitalizations\n .\n LIVER FAILURE\n Hepatorenal syndrome worsens prognosis. Could have been precipitated by\n large volume tap on prior admission, though pt has tolerated similar\n (~5L) in the past. (Note: I initially believed this to have been 10L,\n this was in fact ~5L). Pt has been on transplant list.\n - abd U/S w doppler to eval TIPS stenosis, eval portal circulation\n - daily MELD labs\n - transplant surgery and liver services following, appreciate recs\n - octreotide and midodrine\n - regular lactulose at home dose\n - PPI\n - will restart pt's outpt propranolol after completion of HD and\n stabilization of BP\n - continue home rifaximin\n - continuing to hold pt's past diuretics\n .\n RENAL FAILURE\n Likely hepatorenal syndrome, perhaps large volume tap on last\n admission; vs change in hemodynamics infection.\n - HD tonight per renal, appreciate renal involvement and placement of\n HD line w VIP port\n - holding metformin\n .\n LACTIC ACIDOSIS\n Most likely liver failure itself, though metformin toxicity in\n setting of new renal failure may also be responsible. Mesenteric\n ischemia could be culprit; no positive evidence for this at this point,\n but should follow closely.\n - Abd U/S w doppler as above\n - holding metformin\n - follow lactate\n .\n DIABETES\n Holding oral antihyperglycemics based on low blood sugar in ED today.\n ISS alone for now. Has had more issues with high blood sugar than low\n in the past.\n .\n COAGULOPATHY\n Assoc w liver failure. Got FFP for HD line placement. Holding coumadin\n for now.\n ICU Care\n Nutrition: Clears, consistent carbs; clears until para\n Glycemic Control:\n Lines:\n 18 Gauge - 06:48 PM\n Dialysis Catheter - 11:27 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held Comments: cousin and wife present\n status: Full code\n Disposition: ICU overnight ; if stable, to liver-kidney floor for\n further management\n -- MD\n / PGY3 / MICU \n" }, { "category": "Physician ", "chartdate": "2119-08-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 590249, "text": "Chief Complaint: This is a 63 year old Portuguese-speaking man with\n end-stage liver disease and stenosed TIPS, recurrent admissions for\n hepatic encephalopathy, now here with abdominal pain and a WBC of 21.3\n with a neutrophil predominance, lactic acidosis, hypotension and\n hepatorenal disease.\n 24 Hour Events:\n PARACENTESIS - At 04:00 PM\n 1. Acute Renal Failure: DDX pre renal versus evolving hepatorenal\n he also has a bladder pressure of 24- held off on repeat tap\n yesterday but will tap today. Plan for HD tomorrow. Watch lytes and\n renally dose all meds. Try a 1 mg/kg albumin challenge today\n 2. Hypotension: has been more stable\n Aline 20 pts higher. When\n sleeps drops MAP to 55-60 but otherwise OK. Check CVP. Anticipate\n potential fluid shifts and hypotension with tap and will support with\n pressors as needed\n 3. ESLD: MELD is high at 41 with HRS concerning, liver team\n following. Consult transplant surgery following and onogin work up for\n listing.\n 4. Acidosis: lactic- DDX is poor forward flow versus metformin\n induced in setting of liver failure with poor clearance. Resolving.\n Holding metformin, had HD, we will continue to follow\n 5. Leukocytosis: pan culture, will maintain on Zosyn as we await\n data\n 6. DM: continue to check FS closely since was so hypoglycemic on\n arrival\n but now hyperglycemic\n Got paracentesis of 5L fluid with albumin given, maintaining MAPs\n 100-120s systolic with gram stain, culture pending.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 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 (97.9\n HR: 49 (49 - 67) bpm\n BP: 127/51(72) {83/36(50) - 173/75(109)} mmHg\n RR: 15 (13 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.5 kg (admission): 87.2 kg\n CVP: 7 (7 - 212)mmHg\n Total In:\n 1,055 mL\n 450 mL\n PO:\n 320 mL\n 400 mL\n TF:\n IVF:\n 235 mL\n 50 mL\n Blood products:\n 500 mL\n Total out:\n 5,838 mL\n 215 mL\n Urine:\n 338 mL\n 215 mL\n NG:\n Stool:\n 500 mL\n Drains:\n 5,000 mL\n Balance:\n -4,783 mL\n 235 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.41/39/104/24/0\n Physical Examination\n Cardiovascular: comfortable, oriented to person, place, disoriented to\n time\n Abd less tense, distended\n Bladder pressure 18.\n PE: comfortable, continues to moan periodically, denies abdominal pain\n Neuro: A0x3, asterixis\n CV: RRR\n LUNG: scattered rales with expiratory wheeze\n abd: +ve bs, less tense/distended compared to y/d, paracentesis site\n c/d/i, no hematoma\n EXT: trace 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 99 K/uL\n 8.7 g/dL\n 182 mg/dL\n 4.2 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 38 mg/dL\n 103 mEq/L\n 138 mEq/L\n 25.3 %\n 5.2 K/uL\n [image002.jpg]\n 11:47 PM\n 06:08 AM\n 09:12 AM\n 07:00 PM\n 11:28 PM\n 04:10 AM\n 03:06 PM\n 03:07 PM\n 03:17 PM\n 04:09 AM\n WBC\n 9.8\n 10.2\n 7.6\n 7.4\n 6.5\n 5.2\n Hct\n 24.5\n 24.7\n 24.8\n 26.0\n 26.2\n 27.8\n 25.3\n Plt\n 135\n 110\n 104\n 115\n 105\n 99\n Cr\n 7.5\n 4.8\n 5.2\n 2.1\n 3.5\n 3.8\n 4.2\n TCO2\n 26\n Glucose\n 99\n 59\n 74\n 175\n 206\n 256\n 182\n Other labs: PT / PTT / INR:16.5/33.1/1.5, ALT / AST:18/28, Alk Phos / T\n Bili:184/1.8, Differential-Neuts:79.0 %, Lymph:11.9 %, Mono:6.1 %,\n Eos:2.8 %, D-dimer:1656 ng/mL, Fibrinogen:504 mg/dL, Lactic Acid:2.4\n mmol/L, Albumin:3.1 g/dL, LDH:130 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.9 mg/dL\n Imaging: no new imaging\n ASCITES Likely related to massive ascites likely hepatorenal\n syndrome.\n Tapped 5L with relief of discomfort, albumin given. Fluid analysis\n showed 175 WBC, 36 polys,gram stain + cx pending.\n Microbiology: Diagnostic tap of 14th, no growth\n Therapeutic tap y/d: gram stain, cx pending, blood cx x2 pending, urine\n cx showed yeast (10,000-100,000).\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O ASCITES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n .H/O HEPATIC ENCEPHALOPATHY\n .H/O RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O HYPOGLYCEMIA\n No evidence of SBP given low WBC on diagnostic tap; tap appears\n bloody; most likely coagulopathy, though consistent appearance of\n this finding might suggest hemoperitoneum from another process rather\n than from trauma from tap; CT apparently offers no obvious suspect. No\n sign of perf on CT scan. Surgery evaluating per ED request. Possible\n gastric outlet obstruction seen on CT scan; may improve w decrease in\n ascitic fluid. U/S done, shows partial stenosis of the portal vein. No\n tap at this time due to risk of worsening hepatorenal syndrome,\n however, if worsening hypotension/renal failure, may need to tap due to\n compartment syndrome. Bladder pressure of 24 yesterday.\n .\n LIVER CIRRHOSIS, ETOH, w/ encephalopathy Hepatorenal syndrome worsens\n prognosis. Could have been precipitated by large volume tap on prior\n admission, though pt has tolerated similar (~5L) in the past. Pt has\n been on transplant list. MELD on admission = 41. U/S shows some\n stenosis from TIPS in protal circulation.\n * bowel movements *\n -MS improved.\n - Being worked up for liver/renal transplant, f/u workup with\n transplant surgery team. Liver following, appreciate recs.\n .\n Continue octreotide and midrodrine\n - home lactulose dose\n - continue home rifaximin.\n .\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) Likely hepatorenal\n syndrome, perhaps large volume tap on last admission; vs change in\n hemodynamics infection; vs compartment syndrome from ascites\n causing pre-renal picture. FeNa on admission 0.6.\n .\n Bladder pressure pre tap 20, post tap: *\n Improved hyperkalemia, acidosis w lactate of *\n HD today.\n - NGT if not tolerating clears, emesis, etc\n - clear liquid diet for now\n - Cont zosyn\n d/c when cultures negative\n - holding metformin - contributing to lactic acidosis\n - renal following, appreciate recs.\n .\n HYPOTENSION Possibly due to decreased venous return due to abdominal\n pressure vs infection/sepsis vs hypovolemia due to fluid sequestration\n as ascites.\n Hypotension: related to HRS\n holding diuretics, propranolol.\n -levophed for SBP <80 titrate to MAPs > 65.\n - zosyn empirically for infection, consider adding flagyl/vanco if\n appears more toxic.\n .\n ALTERED MENTAL STATUS (NOT DELIRIUM) Per family report, patient\n currently appears to have intact mental status, however, appears\n confused at times, with mumbling and groaning on. Possibly due to\n hepatic encephalopathy (NH3 = 66 on admission) vs infection, UTI vs\n SBP, vs acidemia. Remains afebrile.\n Clinically improved, not trending albumin\n - Lactulose - titrate to 3 BM per day\n - follow culture results\n - holding metformin\n - trend lactate\n - restraints if needed\n .\n COAGULOPATHY Assoc w liver failure. Got 6U FFP for HD line placement.\n Holding coumadin for now. PT: 17.2 PTT: 32.7 INR: 1.5 Sunday pm*\n - continue to trend coags\n - give vit K for goal INR <2.\n - consider FFP for procedures\n .\n LACTIC ACIDOSIS Most likely liver failure itself, though metformin\n toxicity in setting of new renal failure may also be responsible.\n Mesenteric ischemia could be culprit; no positive evidence for this at\n this point, but should follow closely.\n Lactate 2.4 (Sunday pm) from peak 9.\n - trend lactate\n - hold metformin\n - guaiac stool\n - follow AG\n .\n Leukocytosis Unclear source. Concern for abdominal source but as above\n this is not clear after dx tap and CT abd/pelvis, RLL opacity; hard to\n account for this degree of WBC with this small PNA though relative\n immune suppression of liver/renal failure may diminish inflammatory\n response. High WBC out of proportion to symptoms, with abd pain, in pt\n w multiple hospitalizations, raises special concern for c. diff though\n obvious colitis not seen on CT. Resolved since admission.\n resolved: WBC today 6.5 from 10.2\n - f/u urine, blood and ascites cultures, c.diff toxin negative.\n - continue empiric gram negative coverage with zosyn per liver's\n request *\n Zosyn day: 3.\n - consider adding vanco and flagyl if clinical status is worsening\n - trend with CBC with diff\n Hyperkalemia Likely in the setting of renal disease at admission, has\n resolved from 6.5 to 5.6. Currently stable at 4.3*\n - Check lytes q12h\n - Check EKG if K+ increases\n .\n DIABETES Holding oral antihyperglycemics based on low blood sugar in ED\n . Now hyperglycemic on floor to 250s, currently 136 after 16 U insulin.\n Glipizide 10 mg DAILY\n Metformin 1,000 mg \n Hold metformin. Lactate yd p, . Repeat today.\n ISS alone for now. Has had more issues with high blood sugar than low\n in the past.\n Blood sugars during day *\n - cont. ISS\n ACCESS\n - if requires further pressors place central line - IJ with ultrasound.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 11:27 PM\n Arterial Line - 12:15 PM\n 18 Gauge - 12:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: omeprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Consider floor\n" }, { "category": "Physician ", "chartdate": "2119-08-07 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 590254, "text": "Chief Complaint: liver failure ARF\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PARACENTESIS - At 04:00 PM - 5 liters tolerated well\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:47 AM\n Other medications:\n Rifaximin, PPI, Octreotide, Midrodrine, 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 Flowsheet Data as of 09:26 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 (97.1\n HR: 49 (49 - 67) bpm\n BP: 110/44(63) {90/36(52) - 173/75(109)} mmHg\n RR: 14 (13 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 85.5 kg (admission): 87.2 kg\n CVP: 9 (7 - 212)mmHg\n Total In:\n 1,055 mL\n 650 mL\n PO:\n 320 mL\n 600 mL\n TF:\n IVF:\n 235 mL\n 50 mL\n Blood products:\n 500 mL\n Total out:\n 5,838 mL\n 265 mL\n Urine:\n 338 mL\n 265 mL\n NG:\n Stool:\n 500 mL\n Drains:\n 5,000 mL\n Balance:\n -4,783 mL\n 385 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.41/39/104/24/0\n Physical Examination\n Labs / Radiology\n 8.7 g/dL\n 99 K/uL\n 182 mg/dL\n 4.2 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 38 mg/dL\n 103 mEq/L\n 138 mEq/L\n 25.3 %\n 5.2 K/uL\n [image002.jpg]\n 11:47 PM\n 06:08 AM\n 09:12 AM\n 07:00 PM\n 11:28 PM\n 04:10 AM\n 03:06 PM\n 03:07 PM\n 03:17 PM\n 04:09 AM\n WBC\n 9.8\n 10.2\n 7.6\n 7.4\n 6.5\n 5.2\n Hct\n 24.5\n 24.7\n 24.8\n 26.0\n 26.2\n 27.8\n 25.3\n Plt\n 135\n 110\n 104\n 115\n 105\n 99\n Cr\n 7.5\n 4.8\n 5.2\n 2.1\n 3.5\n 3.8\n 4.2\n TCO2\n 26\n Glucose\n 99\n 59\n 74\n 175\n 206\n 256\n 182\n Other labs: PT / PTT / INR:16.5/33.1/1.5, ALT / AST:18/28, Alk Phos / T\n Bili:184/1.8, Differential-Neuts:79.0 %, Lymph:11.9 %, Mono:6.1 %,\n Eos:2.8 %, D-dimer:1656 ng/mL, Fibrinogen:504 mg/dL, Lactic Acid:2.4\n mmol/L, Albumin:3.1 g/dL, LDH:130 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O ASCITES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n .H/O HEPATIC ENCEPHALOPATHY\n .H/O RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O HYPOGLYCEMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:27 PM\n Arterial Line - 12:15 PM\n 18 Gauge - 12:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2119-08-07 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 590255, "text": "Chief Complaint: liver failure ARF\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PARACENTESIS - At 04:00 PM - 5 liters tolerated well\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:47 AM\n Other medications:\n Rifaximin, PPI, Octreotide, Midrodrine, 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 Flowsheet Data as of 09:26 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 (97.1\n HR: 49 (49 - 67) bpm\n BP: 110/44(63) {90/36(52) - 173/75(109)} mmHg\n RR: 14 (13 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 85.5 kg (admission): 87.2 kg\n CVP: 9 (7 - 212)mmHg\n Total In:\n 1,055 mL\n 650 mL\n PO:\n 320 mL\n 600 mL\n TF:\n IVF:\n 235 mL\n 50 mL\n Blood products:\n 500 mL\n Total out:\n 5,838 mL\n 265 mL\n Urine:\n 338 mL\n 265 mL\n NG:\n Stool:\n 500 mL\n Drains:\n 5,000 mL\n Balance:\n -4,783 mL\n 385 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.41/39/104/24/0\n Physical Examination\n Labs / Radiology\n 8.7 g/dL\n 99 K/uL\n 182 mg/dL\n 4.2 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 38 mg/dL\n 103 mEq/L\n 138 mEq/L\n 25.3 %\n 5.2 K/uL\n [image002.jpg]\n 11:47 PM\n 06:08 AM\n 09:12 AM\n 07:00 PM\n 11:28 PM\n 04:10 AM\n 03:06 PM\n 03:07 PM\n 03:17 PM\n 04:09 AM\n WBC\n 9.8\n 10.2\n 7.6\n 7.4\n 6.5\n 5.2\n Hct\n 24.5\n 24.7\n 24.8\n 26.0\n 26.2\n 27.8\n 25.3\n Plt\n 135\n 110\n 104\n 115\n 105\n 99\n Cr\n 7.5\n 4.8\n 5.2\n 2.1\n 3.5\n 3.8\n 4.2\n TCO2\n 26\n Glucose\n 99\n 59\n 74\n 175\n 206\n 256\n 182\n Other labs: PT / PTT / INR:16.5/33.1/1.5, ALT / AST:18/28, Alk Phos / T\n Bili:184/1.8, Differential-Neuts:79.0 %, Lymph:11.9 %, Mono:6.1 %,\n Eos:2.8 %, D-dimer:1656 ng/mL, Fibrinogen:504 mg/dL, Lactic Acid:2.4\n mmol/L, Albumin:3.1 g/dL, LDH:130 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O ASCITES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n .H/O HEPATIC ENCEPHALOPATHY\n .H/O RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O HYPOGLYCEMIA\n 1. Acute Renal Failure: DDX pre renal versus evolving hepatorenal\n he also has a bladder pressure of 24- Plan for HD today. Watch lytes\n and renally dose all meds. repeat 1 mg/kg albumin challenge today\n 2. Hypotension: resolved now HTN\n 3. ESLD: MELD is high at 41 with HRS concerning, liver team\n following. Consult transplant surgery following and ongoing work up for\n listing.\n 4. Acidosis: lactic- DDX is poor forward flow versus metformin\n induced in setting of liver failure with poor clearance. Resolving.\n Holding metformin, had HD, we will continue to follow\n Remaining issues as per Housestaff\n ICU Care\n Nutrition: advance\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:27 PM\n Arterial Line - 12:15 PM\n 18 Gauge - 12:30 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: with family\n Code status: Full code\n Disposition : tx to 10\n" }, { "category": "Physician ", "chartdate": "2119-08-07 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 590257, "text": "Chief Complaint: liver failure ARF\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PARACENTESIS - At 04:00 PM - 5 liters tolerated well\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:47 AM\n Other medications:\n Rifaximin, PPI, Octreotide, Midrodrine, 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 Flowsheet Data as of 09:26 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 (97.1\n HR: 49 (49 - 67) bpm\n BP: 110/44(63) {90/36(52) - 173/75(109)} mmHg\n RR: 14 (13 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 85.5 kg (admission): 87.2 kg\n CVP: 9 (7 - 212)mmHg\n Total In:\n 1,055 mL\n 650 mL\n PO:\n 320 mL\n 600 mL\n TF:\n IVF:\n 235 mL\n 50 mL\n Blood products:\n 500 mL\n Total out:\n 5,838 mL\n 265 mL\n Urine:\n 338 mL\n 265 mL\n NG:\n Stool:\n 500 mL\n Drains:\n 5,000 mL\n Balance:\n -4,783 mL\n 385 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.41/39/104/24/0\n Physical Examination\n Gen: lying in bed, complains of abd pain and foley pain\n HEENT: op clear\n CV: RR\n Ches: scattered rales with ext wheezes\n Abd: massive distension, absent bowel sounds, tense ascites\n Ex: trace edema\n Neuro: alert and answering questions\n asking to have foley out\n Labs / Radiology\n 8.7 g/dL\n 99 K/uL\n 182 mg/dL\n 4.2 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 38 mg/dL\n 103 mEq/L\n 138 mEq/L\n 25.3 %\n 5.2 K/uL\n [image002.jpg]\n 11:47 PM\n 06:08 AM\n 09:12 AM\n 07:00 PM\n 11:28 PM\n 04:10 AM\n 03:06 PM\n 03:07 PM\n 03:17 PM\n 04:09 AM\n WBC\n 9.8\n 10.2\n 7.6\n 7.4\n 6.5\n 5.2\n Hct\n 24.5\n 24.7\n 24.8\n 26.0\n 26.2\n 27.8\n 25.3\n Plt\n 135\n 110\n 104\n 115\n 105\n 99\n Cr\n 7.5\n 4.8\n 5.2\n 2.1\n 3.5\n 3.8\n 4.2\n TCO2\n 26\n Glucose\n 99\n 59\n 74\n 175\n 206\n 256\n 182\n Other labs: PT / PTT / INR:16.5/33.1/1.5, ALT / AST:18/28, Alk Phos / T\n Bili:184/1.8, Differential-Neuts:79.0 %, Lymph:11.9 %, Mono:6.1 %,\n Eos:2.8 %, D-dimer:1656 ng/mL, Fibrinogen:504 mg/dL, Lactic Acid:2.4\n mmol/L, Albumin:3.1 g/dL, LDH:130 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O ASCITES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n .H/O HEPATIC ENCEPHALOPATHY\n .H/O RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O HYPOGLYCEMIA\n 1. Acute Renal Failure: DDX pre renal versus evolving hepatorenal\n he also has a bladder pressure of 24- Plan for HD today. Watch lytes\n and renally dose all meds. repeat 1 mg/kg albumin challenge today\n 2. Hypotension: resolved now HTN\n 3. ESLD: MELD is high at 41 with HRS concerning, liver team\n following. Consult transplant surgery following and ongoing work up for\n listing.\n 4. Acidosis: lactic- DDX is poor forward flow versus metformin\n induced in setting of liver failure with poor clearance. Resolving.\n Holding metformin, had HD, we will continue to follow\n Remaining issues as per Housestaff\n ICU Care\n Nutrition: advance\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:27 PM\n Arterial Line - 12:15 PM\n 18 Gauge - 12:30 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: with family\n Code status: Full code\n Disposition : tx to 10\n" }, { "category": "Physician ", "chartdate": "2119-08-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 590260, "text": "Chief Complaint: This is a 63 year old Portuguese-speaking man with\n end-stage liver disease and stenosed TIPS, recurrent admissions for\n hepatic encephalopathy, now here with abdominal pain and a WBC of 21.3\n with a neutrophil predominance, lactic acidosis, hypotension and\n hepatorenal disease.\n 24 Hour Events:\n Got paracentesis of 5L fluid with albumin given, maintaining MAPs\n 100-120s systolic with gram stain, culture pending.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 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 (97.9\n HR: 49 (49 - 67) bpm\n BP: 127/51(72) {83/36(50) - 173/75(109)} mmHg\n RR: 15 (13 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.5 kg (admission): 87.2 kg\n CVP: 7 (7 - 212)mmHg\n Total In:\n 1,055 mL\n 450 mL\n PO:\n 320 mL\n 400 mL\n TF:\n IVF:\n 235 mL\n 50 mL\n Blood products:\n 500 mL\n Total out:\n 5,838 mL\n 215 mL\n Urine:\n 338 mL\n 215 mL\n NG:\n Stool:\n 500 mL\n Drains:\n 5,000 mL\n Balance:\n -4,783 mL\n 235 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.41/39/104/24/0\n Physical Examination\n Cardiovascular: comfortable, oriented to person, place, disoriented to\n time\n Abd less tense, distended\n Bladder pressure 18.\n PE: comfortable, continues to moan periodically, denies abdominal pain\n Neuro: A0x3, asterixis\n CV: RRR\n LUNG: scattered rales with expiratory wheeze\n abd: +ve bs, less tense/distended compared to y/d, paracentesis site\n c/d/i, no hematoma\n EXT: trace edema\n Labs / Radiology\n 99 K/uL\n 8.7 g/dL\n 182 mg/dL\n 4.2 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 38 mg/dL\n 103 mEq/L\n 138 mEq/L\n 25.3 %\n 5.2 K/uL\n [image002.jpg]\n 11:47 PM\n 06:08 AM\n 09:12 AM\n 07:00 PM\n 11:28 PM\n 04:10 AM\n 03:06 PM\n 03:07 PM\n 03:17 PM\n 04:09 AM\n WBC\n 9.8\n 10.2\n 7.6\n 7.4\n 6.5\n 5.2\n Hct\n 24.5\n 24.7\n 24.8\n 26.0\n 26.2\n 27.8\n 25.3\n Plt\n 135\n 110\n 104\n 115\n 105\n 99\n Cr\n 7.5\n 4.8\n 5.2\n 2.1\n 3.5\n 3.8\n 4.2\n TCO2\n 26\n Glucose\n 99\n 59\n 74\n 175\n 206\n 256\n 182\n Other labs: PT / PTT / INR:16.5/33.1/1.5, ALT / AST:18/28, Alk Phos / T\n Bili:184/1.8, Differential-Neuts:79.0 %, Lymph:11.9 %, Mono:6.1 %,\n Eos:2.8 %, D-dimer:1656 ng/mL, Fibrinogen:504 mg/dL, Lactic Acid:2.4\n mmol/L, Albumin:3.1 g/dL, LDH:130 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.9 mg/dL\n Imaging: no new imaging\n Microbiology: Diagnostic tap of 14th, no growth\n Therapeutic tap y/d: gram stain, cx pending, blood cx x2 pending, urine\n cx showed yeast (10,000-100,000).\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O ASCITES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n .H/O HEPATIC ENCEPHALOPATHY\n .H/O RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O HYPOGLYCEMIA\n .\n LIVER CIRRHOSIS, ETOH, w/ encephalopathy Hepatorenal syndrome worsens\n prognosis. Could have been precipitated by large volume tap on prior\n admission, though pt has tolerated similar (~5L) in the past. Pt has\n been on transplant list. MELD on admission = 41. U/S shows some\n stenosis from TIPS in protal circulation.\n * bowel movements *\n -MS improved.\n - Being worked up for liver/renal transplant, f/u workup with\n transplant surgery team. Liver following, appreciate recs.\n .\n Continue octreotide and midrodrine\n - home lactulose dose\n - continue home rifaximin.\n .\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) Likely hepatorenal\n syndrome, perhaps large volume tap on last admission; vs change in\n hemodynamics infection; vs compartment syndrome from ascites\n causing pre-renal picture. FeNa on admission 0.6.\n .\n Bladder pressure pre tap 20, post tap 18, with improved urine output\n suggesting compartment syndrome contributing.\n HD today.\n - Cont zosyn\n d/c when cultures negative\n - holding metformin - contributing to lactic acidosis\n - renal following, appreciate recs.\n .\n HYPOTENSION Possibly due to decreased venous return due to abdominal\n pressure vs infection/sepsis vs hypovolemia due to fluid sequestration\n as ascites.\n holding diuretics, propranolol.\n -levophed for SBP <80 titrate to MAPs > 65.\n - zosyn empirically for infection, consider adding flagyl/vanco if\n appears more toxic.\n .\n ALTERED MENTAL STATUS (NOT DELIRIUM) Per family report, patient\n currently appears to have intact mental status, however, appears\n confused at times, with mumbling and groaning on. Possibly due to\n hepatic encephalopathy (NH3 = 66 on admission) vs infection, UTI vs\n SBP, vs acidemia. Remains afebrile.\n Clinically improved, not trending albumin\n - Lactulose - titrate to 3 BM per day\n - follow culture results\n - holding metformin\n - trend lactate\n - restraints if needed\n .\n COAGULOPATHY Assoc w liver failure. Got 6U FFP for HD line placement.\n Holding coumadin for now. PT: 17.2 PTT: 32.7 INR: 1.5 Sunday pm*\n - continue to trend coags\n - give vit K for goal INR <2.\n - consider FFP for procedures\n .\n LACTIC ACIDOSIS Most likely liver failure itself, though metformin\n toxicity in setting of new renal failure may also be responsible.\n Mesenteric ischemia could be culprit; no positive evidence for this at\n this point, but should follow closely.\n Lactate 2.4 (Sunday pm) from peak 9.\n - trend lactate\n - hold metformin\n - guaiac stool\n - follow AG\n .\n Leukocytosis Unclear source. Concern for abdominal source but as above\n this is not clear after dx tap and CT abd/pelvis, RLL opacity; hard to\n account for this degree of WBC with this small PNA though relative\n immune suppression of liver/renal failure may diminish inflammatory\n response. High WBC out of proportion to symptoms, with abd pain, in pt\n w multiple hospitalizations, raises special concern for c. diff though\n obvious colitis not seen on CT. Resolved since admission.\n resolved: WBC today 6.5 from 10.2\n - f/u urine, blood and ascites cultures, c.diff toxin negative.\n - continue empiric gram negative coverage with zosyn per liver's\n request *\n Zosyn day: 3.\n - consider adding vanco and flagyl if clinical status is worsening\n - trend with CBC with diff\n Hyperkalemia Likely in the setting of renal disease at admission, has\n resolved from 6.5 to 5.6. Currently stable at 4.3*\n - Check lytes q12h\n - Check EKG if K+ increases\n DIABETES Holding oral antihyperglycemics based on low blood sugar in ED\n . Now hyperglycemic on floor to 250s, currently 136 after 16 U insulin.\n Glipizide 10 mg DAILY\n Metformin 1,000 mg \n Hold metformin, glipizide. GFS 400y/d iimproved with 16 U insulin.\n Consider NPH vs uptitrate SS.\n Cont to check GFS.\n ACCESS\n - if requires further pressors place central line - IJ with ultrasound.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 11:27 PM\n Arterial Line - 12:15 PM\n 18 Gauge - 12:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: omeprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Dispositon : Called out\n" }, { "category": "Physician ", "chartdate": "2119-08-07 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 590275, "text": "Chief Complaint: liver failure ARF\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PARACENTESIS - At 04:00 PM - 5 liters tolerated well\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:47 AM\n Other medications:\n Rifaximin, PPI, Octreotide, Midrodrine, 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 Flowsheet Data as of 09:26 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 (97.1\n HR: 49 (49 - 67) bpm\n BP: 110/44(63) {90/36(52) - 173/75(109)} mmHg\n RR: 14 (13 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 85.5 kg (admission): 87.2 kg\n CVP: 9 (7 - 212)mmHg\n Total In:\n 1,055 mL\n 650 mL\n PO:\n 320 mL\n 600 mL\n TF:\n IVF:\n 235 mL\n 50 mL\n Blood products:\n 500 mL\n Total out:\n 5,838 mL\n 265 mL\n Urine:\n 338 mL\n 265 mL\n NG:\n Stool:\n 500 mL\n Drains:\n 5,000 mL\n Balance:\n -4,783 mL\n 385 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.41/39/104/24/0\n Physical Examination\n Gen: lying in bed, complains of abd pain and foley pain\n HEENT: op clear\n CV: RR\n Ches: scattered rales with ext wheezes\n Abd: decreased distension, hypoactive bowel sounds\n Ex: trace edema\n Neuro: alert and answering questions\n asking to have foley out and\n getting agitated\n Labs / Radiology\n 8.7 g/dL\n 99 K/uL\n 182 mg/dL\n 4.2 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 38 mg/dL\n 103 mEq/L\n 138 mEq/L\n 25.3 %\n 5.2 K/uL\n [image002.jpg]\n 11:47 PM\n 06:08 AM\n 09:12 AM\n 07:00 PM\n 11:28 PM\n 04:10 AM\n 03:06 PM\n 03:07 PM\n 03:17 PM\n 04:09 AM\n WBC\n 9.8\n 10.2\n 7.6\n 7.4\n 6.5\n 5.2\n Hct\n 24.5\n 24.7\n 24.8\n 26.0\n 26.2\n 27.8\n 25.3\n Plt\n 135\n 110\n 104\n 115\n 105\n 99\n Cr\n 7.5\n 4.8\n 5.2\n 2.1\n 3.5\n 3.8\n 4.2\n TCO2\n 26\n Glucose\n 99\n 59\n 74\n 175\n 206\n 256\n 182\n Other labs: PT / PTT / INR:16.5/33.1/1.5, ALT / AST:18/28, Alk Phos / T\n Bili:184/1.8, Differential-Neuts:79.0 %, Lymph:11.9 %, Mono:6.1 %,\n Eos:2.8 %, D-dimer:1656 ng/mL, Fibrinogen:504 mg/dL, Lactic Acid:2.4\n mmol/L, Albumin:3.1 g/dL, LDH:130 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O ASCITES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n .H/O HEPATIC ENCEPHALOPATHY\n .H/O RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O HYPOGLYCEMIA\n 1. Acute Renal Failure: DDX pre renal versus evolving hepatorenal\n he also had a bladder pressure of 24- rasigin ? of abd hypertension.\n He is making some ruine but per renal plan for HD today. Watch lytes\n and renally dose all meds. repeat 1 mg/kg albumin challenge today\n as part of ongoing HRX plan but we will discuss further with renal and\n hepatology teams.\n 2. ESLD: MELD is high and with HRS concerning, liver team\n following. Consulted transplant surgery following and ongoing work up\n for listing.\n 3. Acidosis: lactic- DDX is poor forward flow versus metformin\n induced in setting of liver failure with poor clearance. Resolving.\n Holding metformin, had HD, we will continue to follow\n Remaining issues as per Housestaff\n ICU Care\n Nutrition: advance\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:27 PM\n Arterial Line - 12:15 PM\n 18 Gauge - 12:30 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: with family\n Code status: Full code\n Disposition : tx to 10\n" }, { "category": "Nursing", "chartdate": "2119-08-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590284, "text": ".H/O cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2119-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591883, "text": "Synopsis per prior nursing note:\n Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Hypernatremia (high sodium)\n Assessment:\n Na 144, k 3.9.\n Action:\n NGT to IWS. Given lactulose enema.\n Response:\n Repeat Na 146. Repeat K 3.2. Very large, liquid stool after enema.\n Continues to put out small amt bilious fluid from NGT.\n Plan:\n Monitor electrolytes. Monitor stool/NGT output.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 125-130.\n Action:\n NPO. FS monitored q4hrs. Given evening dose of lantus. FS treated with\n humalog per ISS.\n Response:\n 0400 FS-47, given\n amp D50, repeat FS 92. FS monitored q30min to 1hr.\n Started 1L of D5W w/ 40mEq potassium at 150cc/hr.\n Plan:\n Monitor FS. ? change ISS if NPO and D5W not running.\n Cirrhosis of liver, alcoholic\n Assessment:\n Confused, garbled speech, not following commands, purposeful movements\n of extremities, occasionally combative, +ascites.\n Action:\n Attempted to reorient. Soft wrist restraints continued d/t patient\n attempting to pull out lines. Given PR lactulose.\n Response:\n No change in mental status.\n Plan:\n Lactulose PR . Monitor change in mental status.\n" }, { "category": "Nursing", "chartdate": "2119-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 589974, "text": "This is a 63 year old Portuguese-speaking man with extensive history of\n alcoholic cirrhosis, frequent admissions at , (9 since )\n now here with right-sided abdominal pain, and increased ascites.\n Starting on Wednesday () he began having right-sided abdominal\n pain. His wife reported that he had increased fatigue, abdominal pain,\n abdominal girth, and one episode of non-bloody emesis. His wife and\n cousin denied that he had any episodes of confusion. They explained\n that he had \"pain where they took the water out\" on the right. They\n explained and he affirmed that he has been urinating less.\n In the ED, he was guaiaic negative; and his labs were notable for a\n lactate 9.1, WBC 21.3, Cr 7.6, Glu 15. With low glucose of 1 a D5 drip\n was started. With consideration of ischemic colitis, the ED sent him\n for CT scan, ordered without contrast given his renal function; this\n did not show any signs of ischemia. Additionally, he received: 4.5 gm\n IV zosyn, octreotide 50 mcg IV and octreotide 25 mcg/hr gtt; as well as\n 1 amp of calcium gluconate. Liver and kidney services were consulted\n in the ED; liver fellow left recs in the ED chart and renal fellow\n planned for HD in the unit. A diagnostic paracentesis was performed in\n the ED; the liver service recommended against therapeutic tap for now.\n He was admitted to the MICU service for further management.\n Pt is a 63 year old male with ETOH cirrhosis s/p TIPs redo \n (originally done ). Recent admission -> for worsening\n encephalopathy and increased ascites..\n .H/O altered mental status (not Delirium)\n Assessment:\n Primary language is Portugese. Pt appears to have a fair understanding\n when spoken to, but doesn\nt speak English well. When wife was here\n earlier, she stated that pt was oriented but tired, and didn\nt want to\n speak much. Has been cooperative with care thus far.\n Action:\n Current care plan explained to pt prior to wife going home\n Response:\n Appeared comfortable with plan of care.\n Plan:\n Con\nt to provide explanations of POC, have interpreter or wife assist\n with translation.\n .H/O ascites\n Assessment:\n Abdomen firm and distended. Abdomen causing quite a bit of discomfort\n for patient when moving\n Action:\n Provide 2 person assist when moving pt.\n Response:\n Plan:\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hepatic encephalopathy\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hypoglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2119-08-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 589975, "text": "Chief Complaint: abdominal discomfort\n HPI:\n This is a 63 year old Portuguese-speaking man with extensive history of\n alcoholic cirrhosis, frequent admissions at , now here with\n right-sided abdominal pain, and increased ascites. Starting on\n Wednesday () he began having right-sided abdominal pain. His wife\n reported that he had increased fatigue, abdominal pain, abdominal\n girth, and one episode of non-bloody emesis. His wife and cousin denied\n that he had any episodes of confusion. They explained that he had \"pain\n where they took the water out\" on the right. They explained and he\n affirmed that he has been urinating less. I confirmed the essentials of\n this history with him during a brief Portuguese interpreter phone\n interview.\n .\n In the emergency department his initial vitals were: 97.9, 111/63, 18,\n 98% on room air. He was found to be guaiaic negative; and he had labs\n notable for lactate 9.1, WBC 21.3, Cr 7.6, Glu 15. With low glucose, a\n D5 drip was started. With consideration of ischemic colitis, the ED\n sent him for CT scan, ordered without contrast given his renal\n function; this did not show any signs of ischemia. Additionally, he\n received: 4.5 gm IV zosyn, octreotide 50 mcg IV and octreotide 25\n mcg/hr gtt; as well as 1 amp of calcium gluconate. Liver and kidney\n services were consulted in the ED; liver fellow left recs in the ED\n chart and renal fellow planned for HD in the unit. A diagnostic\n paracentesis was performed in the ED; the liver service recommended\n against therapeutic tap for now. He was admitted to the MICU service\n for further management.\n Patient admitted from: ER\n History obtained from Interpreter\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Octreotide - 25 mcg/hour\n Other ICU medications:\n Other medications:\n HOME MEDICATIONS\n Calcium Carbonate 500 mg tid\n Vitamin D3 800 units daily\n Glipizide 10 mg daily.\n Lactulose 60 mL PO QID\n Levothyroxine 100 mcg Tablet DAILY\n Metformin 1,000 mg Tablet DAILY\n Omeprazole 20 mg DAILY\n Propranolol 40 mg TID\n Rifaximin 400 TID\n Warfarin 3 mg qHS\n Past medical history:\n Family history:\n Social History:\n - ETOH cirrhosis, complicated by ascites and varices, s/p banding\n * s/p TIPS () -> redo for narrowing -> failure of TIPS\n noted in past admissions w/ d/c summaries noting decision not to redo\n tips further given diminished returns\n * recent admission including 5L paracentesis (note: originally\n thought this was 10L, past records appear to confirm 5L)\n - Portal vein thrombosis: on coumadin goal INR \n - Diabetes mellitus\n - Hypothyroidism\n - Pituitary mass\n - h/o nephrolithiasis\n - h/o + PPD\n Mother deceased, age 50, CVA. Father deceased, age 62, stomach\n problems. One brother living and in good health. Two sisters, both\n living and in good health.\n .\n Occupation: retired\n Drugs: no\n Tobacco: none\n Alcohol: quit \n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema\n Respiratory: Tachypnea, Wheeze\n Gastrointestinal: Abdominal pain, Nausea, Emesis\n Integumentary (skin): No(t) Jaundice\n Endocrine: History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy\n Flowsheet Data as of 03:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 73 (61 - 74) bpm\n BP: 91/45(55) {91/45(55) - 125/67(82)} mmHg\n RR: 21 (15 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,300 mL\n 313 mL\n PO:\n TF:\n IVF:\n 542 mL\n 313 mL\n Blood products:\n 1,758 mL\n Total out:\n 91 mL\n 80 mL\n Urine:\n 91 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,209 mL\n 233 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: Anxious\n Eyes / Conjunctiva: Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal, Fixed) SEM heard best at\n RUSB\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 scattered crackles at bases, Diminished: )\n Abdominal: Extremely istended; dull to percussion at bulging flanks;\n bulging umbilicus\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, No(t) Cyanosis\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Oriented (to): , Movement: Not assessed, Tone: Normal\n Labs / Radiology\n 99 mg/dL\n 7.5 mg/dL\n 87 mg/dL\n 5.6 mEq/L\n [image002.jpg]\n \n 5:00p\n PERITONEAL RT SIDE PARACENTESIS FLUID\n Other Body Fluid Hematology:\n WBC: 33\n RBC: 6340\n Polys: 25\n Lymphs: 14\n Monos: 18\n Mesothe: 11\n Macro: 32\n \n 3:42p\n _______________________________________________________________________\n Lactate:9.1\n \n 2:55p\n _______________________________________________________________________\n Lactate:9.1\n \n 2:33 A8/14/ 11:47 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 Cr\n 7.5\n Glucose\n 99\n Other labs: Lactic Acid:8.7 mmol/L, Mg++:3.4 mg/dL\n Other Blood Chemistry:\n Ammonia: 66\n 133\n [image004.gif]\n 95\n [image004.gif]\n 86\n [image006.gif]\n 15\n AGap=35\n [image007.gif]\n 6.5\n [image004.gif]\n 10\n [image004.gif]\n 7.6\n [image009.gif]\n CK: 40\n MB: Notdone\n Ca: 11.9 Mg: 3.9 P: 8.7\n ALT: 28\n AP: 391\n Tbili: 0.7\n Alb: 3.9\n AST: 44\n LDH:\n Dbili:\n TProt:\n :\n Lip: 94\n 90\n 21.3\n [image009.gif]\n 11.8\n [image006.gif]\n 248\n [image010.gif]\n [image006.gif]\n 34.7\n [image009.gif]\n N:90.0 L:5.9 M:3.6 E:0.3 Bas:0.2\n PT: 40.6\n PTT: 39.9\n INR: 4.3\n STUDIES:\n .\n CT ABD/PELVIS *WET READ*\n Limited ascites and lack of contrast.\n Marked distention of the stomach and prox duodenum. ? gastric outlet\n obstruction of unclear etiology, new since .\n Large ascites, Cirrhosis\n left 2-3 mm nonobstructive renal calc\n No definite wall thickening or pneumatosis or portal venous gas to\n suggest bowel ischemia.\n appendix partially seen\n .\n CT ABD/PELVIS\n 1. Findings compatible with cirrhosis and portal hypertension without\n evidence of focal mass lesion in the liver.\n 2. Conventional hepatic vascular anatomy without evidence of occlusion.\n 3. Liver volume 1233 cm3.\n .\n CARDIAC PERFUSION PERSANTINE\n 1. Normal myocardial perfusion, estimated LVEF of 57%.\n .\n Stress\n 1. No anginal symptoms or ischemic ST segment changes. Nuclear\n report sent separately.\n .\n LIVER OR GALLBLADDER US (SINGLE ORGAN)\n 1. TIPS with elevated velocities at the mid and distal portion\n concerning for stenosis.\n 2. Ascites is similar to the previous study and is large in amount.\n 3. Unchanged appearance of the right anterior portal vein with\n hepatopetal flow. Non-visualized left portal vein\n .\n ECHO\n The left atrium is mildly dilated. There is mild symmetric left\n ventricular hypertrophy with normal cavity size and global systolic\n function (LVEF>55%). Due to suboptimal technical quality, a focal wall\n motion abnormality cannot be fully excluded. Right ventricular chamber\n size and free wall motion are normal. The diameters of aorta at the\n sinus, ascending and arch levels are normal. The aortic valve leaflets\n (3) appear structurally normal with good leaflet excursion and no\n aortic regurgitation. The mitral valve leaflets are structurally\n normal. There is no mitral valve prolapse. Very mild (1+) mitral\n regurgitation is seen. There is borderline pulmonary artery systolic\n hypertension. There is no pericardial effusion.\n Assessment and Plan\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O ASCITES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n .H/O HEPATIC ENCEPHALOPATHY\n .H/O RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O HYPOGLYCEMIA\n ASSESSMENT AND PLAN\n This is a 63 year old Portuguese-speaking man with end-stage liver\n disease and stenosed TIPS, recurrent admissions for hepatic\n encephalopathy, now here with abdominal pain and a WBC of 21.3 with a\n neutrophil predominance.\n .\n ABDOMINAL PAIN\n Likely related to massive ascites likely hepatorenal syndrome. No\n evidence of SBP given low WBC on diagnostic tap; tap appears bloody;\n most likely coagulopathy, though consistent appearance of this\n finding might suggest hemoperitoneum from another process rather than\n from trauma from tap; CT apparently offers no obvious suspect. No sign\n of perf on CT scan. Surgery evaluating per ED request. Possible gastric\n outlet obstruction seen on CT scan; may improve w decrease in ascitic\n fluid.\n - appreciate surgery recs; tplant service will follow\n - will give albumin per liver recs p HD per renal recs; albumin will\n also be provided by FFP needed for HD line placement\n - consider tx tap if renal function improves\n - NGT if not tolerating clears, emesis, etc\n - clear liquid diet for now\n .\n LEUKOCYTOSIS\n Unclear source. Concern for abdominal source but as above this is not\n clear after dx tap and CT abd/pelvis. I am underwhelmed by CXR but do\n make note of RLL opacity; hard to account for this degree of WBC with\n this small PNA though relative immune suppression of liver/renal\n failure may diminish inflammatory response. High WBC out of proportion\n to symptoms, with abd pain, in pt w multiple hospitalizations, raises\n special concern for c. diff though obvious colitis not seen on CT.\n - covering gram-negatives w zosyn; add vanco and flagyl if worsening\n - cxs pending; additionally send c. diff given mult recent\n hospitalizations\n .\n LIVER FAILURE\n Hepatorenal syndrome worsens prognosis. Could have been precipitated by\n large volume tap on prior admission, though pt has tolerated similar\n (~5L) in the past. (Note: I initially believed this to have been 10L,\n this was in fact ~5L). Pt has been on transplant list.\n - abd U/S w doppler to eval TIPS stenosis, eval portal circulation\n - daily MELD labs\n - transplant surgery and liver services following, appreciate recs\n - octreotide and midodrine\n - regular lactulose at home dose\n - PPI\n - will restart pt's outpt propranolol after completion of HD and\n stabilization of BP\n - continue home rifaximin\n - continuing to hold pt's past diuretics\n .\n RENAL FAILURE\n Likely hepatorenal syndrome, perhaps large volume tap on last\n admission; vs change in hemodynamics infection.\n - HD tonight per renal, appreciate renal involvement and placement of\n HD line w VIP port\n - holding metformin\n .\n LACTIC ACIDOSIS\n Most likely liver failure itself, though metformin toxicity in\n setting of new renal failure may also be responsible. Mesenteric\n ischemia could be culprit; no positive evidence for this at this point,\n but should follow closely.\n - Abd U/S w doppler as above\n - holding metformin\n - follow lactate\n .\n DIABETES\n Holding oral antihyperglycemics based on low blood sugar in ED today.\n ISS alone for now. Has had more issues with high blood sugar than low\n in the past.\n .\n COAGULOPATHY\n Assoc w liver failure. Got FFP for HD line placement. Holding coumadin\n for now.\n ICU Care\n Nutrition: Clears, consistent carbs; clears until para\n Glycemic Control:\n Lines:\n 18 Gauge - 06:48 PM\n Dialysis Catheter - 11:27 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held Comments: cousin and wife present\n status: Full code\n Disposition: ICU overnight ; if stable, to liver-kidney floor for\n further management\n -- MD\n / PGY3 / MICU \n" }, { "category": "Nursing", "chartdate": "2119-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591875, "text": "Synopsis per prior nursing note:\n Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Hypernatremia (high sodium)\n Assessment:\n Na 144, k 3.9.\n Action:\n NGT to IWS. Given lactulose enema.\n Response:\n Repeat Na. Repeat K. Very large, liquid stool after enema. Continues\n to put out small amt bilious fluid from NGT.\n Plan:\n Monitor electrolytes. Monitor stool/NGT output.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 125-130.\n Action:\n NPO. FS monitored q4hrs. Given evening dose of lantus. FS treated with\n humalog per ISS.\n Response:\n 0400 FS-47, given\n amp D50, repeat FS 92. Started 1L of D5W w/ 40mEq\n potassium at 150cc/hr.\n Plan:\n Monitor FS.\n Cirrhosis of liver, alcoholic\n Assessment:\n Confused, garbled speech, not following commands, purposeful movements\n of extremities, occasionally combative, +ascites.\n Action:\n Attempted to reorient. Soft wrist restraints continued d/t patient\n attempting to pull out lines. Given PR lactulose.\n Response:\n No change in mental status.\n Plan:\n Lactulose PR . Monitor change in mental status.\n" }, { "category": "Nursing", "chartdate": "2119-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591979, "text": "Synopsis per prior nursing note:\n Mr is a 63 yo male with ESLD. He is alert and oriented x2 at\n baseline able to participate in ADLs. He has had frequent admissions\n recently for increased confusion and presented with right sided\n abdominal pain and increased ascites In ED his lactate 9.1 wbc 21.3 cr\n 7.6 and a glucose of 15. Has HD line Lt SC last HD . Over several\n days he has become increasingly agitated with mental status changes.\n He was transferred to MICU secondary to increase agitation and\n aggressive behavior toward staff requiring 4 point restraints with\n persistant tachycardia, hypertension and blood sugar of 450. PMH\n alcoholic cirrhosis known varices, portal vein thrombosis, s/p TIPS, DM\n 2, hypothyroidism, pituitary mass, h/o nephrolithiasis, h/o +PPD. Pt\n being worked up for liver transplant.\n Hypernatremia (high sodium)\n Assessment:\n Na 144, k 3.9.\n Action:\n NGT to IWS. Given lactulose enema.\n Response:\n Repeat Na 146. Repeat K 3.2. Very large, liquid stool after enema.\n Continues to put out small amt bilious fluid from NGT.\n Plan:\n Monitor electrolytes. Monitor stool/NGT output.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 156.\n Action:\n Took moderate amt of PO intake. Given evening dose of lantus. FS\n treated with humalog per new ISS.\n Response:\n 0400 FS\n Plan:\n Monitor FS. Encourage PO intake.\n Cirrhosis of liver, alcoholic\n Assessment:\n Alert, oriented. Moving all extremities weakly. Follows commands. Able\n to let basic needs be known. Helps move self in bed. Jaundice,\n +Ascites.\n Action:\n Held PO lactulose d/t multiple loose, stools. NGT in place through\n night while monitoring mental status.\n Response:\n No change in mental status. Had multiple loose, brown stools.\n Plan:\n Lactulose for 3BM/day. Monitor change in mental status. ? remove NGT\n today.\n" }, { "category": "Nursing", "chartdate": "2119-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 591965, "text": "Acute Confusion\n Assessment:\n Pt Portuguese speaking only. Understands some English. Following\n commands this AM. MAE. Per wife mental status currently at baseline\n Action:\n Wrist restraints D/C\nd, lactulose given as ordered\n Response:\n Pt not pulling at lines & tubes appropriate through this afternoon\n Plan:\n Continue to monitor mental status provide safe care environment\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 180-200\n Action:\n Given\n dose of HISS, DT NPO status\n Response:\n FS stable\n Plan:\n Lantus this evening, HISS per order\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt with ascites, slightly jaundice. Bladder pressure 17, hypoactive\n bowel sounds, minimal residuals from NGT.\n Action:\n Lactulose given as ordered, paracentesis done. 4 L removed.\n Response:\n Pt with 4 BM\ns this afternoon, mental status at baseline\n Plan:\n ADAT, ? D/C of NGT later this evening\n Hypernatremia (high sodium)\n Assessment:\n AM NA 146\n Action:\n Given D5W @ 150 for one liter\n Response:\n AM NA 143\n Plan:\n Serial Lytes\n" }, { "category": "Nursing", "chartdate": "2119-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590039, "text": ".H/O cirrhosis of liver, alcoholic\n Assessment:\n Paracentesis on hold\n Action:\n Paracentesis on hold this shift, abd large and distended due to ascites\n Bladder pressure done 24\n Received albumen 5% 500ml x1\n Hct 24, plans to transfuse during HD\n Stooling to lactulose, `12pm dose held, ob pos, team aware\n Started on zosyn for SBP prophylaxis\n Pt yelling out\nJesusChrist\n, speaks mainly , wife in to\n interpret, states pt is not confused, but uncomfortable, c/o discomfort\n from foley and from abd, team aware\n US of abd done to eval TIPS\n Pt remains off coumadin am INR 2.1\n Response:\n Paracentesis on hold\n Plan:\n Follow bladder pressure qd\n Iv abx as ordered\n Pm labs\n .H/O hypoglycemia\n Assessment:\n FS 90\n Action:\n Tolerating sips of clear liquids\n Fs qid\n Response:\n Fs wnl\n Plan:\n Fs qid\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n HD treatment\n Action:\n HD treatment doe this shift due to continued elevated lactate level and\n pt previously on metformin\n Pt oliguric\n Repeat k 4.6\n Due for lytes after HD\n Response:\n Oliguric\n HD\n Plan:\n Next HD on Monday\n Monitor u/o\n Renal dose meds\n Hypotension (not Shock)\n Assessment:\n Hypotensive\n Action:\n BP 70\ns/ this am, improved while awake and after albumen\n Briefly started on levophed gtt\n Aline placed, able to wean off levophed\n 20 point difference between bp cuff and aline pressures\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2119-08-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 589945, "text": "Pt is a 63y/o gentleman recently discharged from where he had\n been admitted for hypocalcemia, mental status changes, Did have TIPS\n for esophageal bleeding, paracentisis for ascites. Had been home with\n his wife when she noticed over the past two days and increase in\n lethargy and loss of appetite. She brought him to EW where he was found\n to have abnormal labs\n.Lacate 9.1, BUN 86 creat 7.6, wbc 21.3, glucose\n was 15, given amp of D50 and repeat fs was 13, placed on D5W infusion\n at 100cc/hr, Had abd.CT scan showing limited 2.2 ascites and lack of\n contrast\nmarked distention of the stomach, and prox duodenum ?gartric\n outlet obstruction of unclear etiology, new since , large\n ascites, Octreotide infusion started . Admit to MICU for closer\n monitoring.\n" }, { "category": "Nursing", "chartdate": "2119-08-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590203, "text": "63 yr old Porteguese speaking male with end stage liver, stenosed TIPS.\n recurrent encephalopathy presents with leukocytosis, abd pain, and new\n renal failure with lactic acidosis and hyerkalemia. Tx to MICU for\n acute HD (new HD for him)\n Paracentesis done on , ~5l removed, ascetic fluid turbid Albumen\n 100gm IV ordered for during paracentesis\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Paracentesis\n Action:\n Abd remains distended and tense, bladder pressure 18, Receiving\n lactulose, titrating to 3 stools per day, pt had 500 ml brown ob pos\n liquid stool after am lactulose Wife in to visit, translating for pt,\n states he is not confused and is oriented Wife at times when\n speaking to pt, states he is talking about dying\n Response:\n Paracentesis\n Plan:\n Social work consult in am for family support\n Lactulose as ordered, check bladder pressure twice daily.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output slightly improved in this shift 20-40cc/hr.\n Action:\n Monitoring, Plans for HD \n Response:\n Oliguric\n Plan:\n HD in am\n .H/O hypoglycemia\n Assessment:\n Receiving SS coverage\n Action:\n Fs elevated 404 @ midnight received 12 units humalog and monitored BS\n q2h.\n Response:\n Pending\n Plan:\n Insulin as ordered\n Fs qid\n" }, { "category": "Nursing", "chartdate": "2119-08-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 590328, "text": "Pt is a 63 year old male with ETOH cirrhosis c/b ascites and varices\n with banding in the past, TIPS () with redo (). Pt presented\n with leukocytosis, abd pain, and new renal failure with lactic acidosis\n and hyperkalemia. Pt transferred to MICU for acute HD.\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Pt with large ascitic abdomen, pos bowel sounds. Para site now open to\n air with no bleeding/oozing noted. Per translator and wife pt is\n oriented x3, conversation appropriate.\n Action:\n Pt given lactulose, octreotide midodrine, and rifaximin per order. Pt\n also on IV zosyn for SBP prophylaxis. Bladder pressure taken. Pt did\n have paracentesis yesterday with 5L removed.\n Response:\n Pt with 2^nd BM today, afebrile, WBC 5.2. Bladder pressure 14-15.\n Plan:\n Continue to assess abdomen and para site, admin meds per order, titrate\n lactulose to 3 BMs/day, trend temp, monitor mental status. Cultures\n pending.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with new onset renal failure requiring HD. Cr 4.2. Voiding small\n amounts of yellow urine with sediment.\n Action:\n Pt dialyzed today, UF 1000ml.\n Response:\n Pt tolerated HD well. Repeat Cr 2.3. Continues voiding 10-20cc/hr via\n foley.\n Plan:\n Continue to monitor UOP, renal following ?next dialysis, Monitor labs.\n Neuro: alert and oriented x3, OOB to commode w/ assistance.\n CV: HR 40s-90s NSR with no ectopy noted. BP stable. +2 pitting pedal\n edema.\n Resp: On room air sating >95%\n GI: Diet advanced to renal as he tolerates. BMx3 today is brown\n liquid on lactulose.\n Skin: c/d/i\n Social: Pt\ns wife at bedside all shift is teary at times and was\n unaware pt had a problem with his kidneys. Social work met with\n family, support and disease process information discussed with pt,\n wife, RN and MD.\n Access: Right subclavian HD catheter. #18 gauge x2.\n FULL CODE\n NKDA\n" }, { "category": "Nursing", "chartdate": "2119-08-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 590329, "text": "Pt is a 63 year old male with ETOH cirrhosis c/b ascites and varices\n with banding in the past, TIPS () with redo (). Pt presented\n with leukocytosis, abd pain, and new renal failure with lactic acidosis\n and hyperkalemia. Pt transferred to MICU for acute HD.\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Pt with large ascitic abdomen, pos bowel sounds. Para site now open to\n air with no bleeding/oozing noted. Per translator and wife pt is\n oriented x3, conversation appropriate.\n Action:\n Pt given lactulose, octreotide midodrine, and rifaximin per order. Pt\n also on IV zosyn for SBP prophylaxis. Bladder pressure taken. Pt did\n have paracentesis yesterday with 5L removed.\n Response:\n Pt with 2^nd BM today, afebrile, WBC 5.2. Bladder pressure 14-15.\n Plan:\n Continue to assess abdomen and para site, admin meds per order, titrate\n lactulose to 3 BMs/day, trend temp, monitor mental status. Cultures\n pending.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with new onset renal failure requiring HD. Cr 4.2. Voiding small\n amounts of yellow urine with sediment.\n Action:\n Pt dialyzed today, UF 1000ml.\n Response:\n Pt tolerated HD well. Repeat Cr 2.3. Continues voiding 10-20cc/hr via\n foley.\n Plan:\n Continue to monitor UOP, renal following ?next dialysis, Monitor labs.\n Neuro: alert and oriented x3\n CV: HR 40s-90s NSR with no ectopy noted. BP stable. +2 pitting pedal\n edema.\n Resp: Weaned to RA with RR 20s and sats 99%.\n GI: Pt tolerated renal diet. BMx3 today is brown liquid.\n Skin: c/d/i\n MS: Pt transferred to BSC with 2 assist, he is weak to stand but no\n SOB noted.\n Social: Pt\ns wife at bedside all shift is teary at times and was\n unaware pt had a problem with his kidneys. Social work met with\n family, support and disease process information discussed with pt,\n wife, RN and MD.\n Access: Right subclavian HD catheter. #18 gauge x2.\n FULL CODE\n NKDA\n" }, { "category": "Nursing", "chartdate": "2119-08-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590330, "text": "Pt is a 63 year old male with ETOH cirrhosis c/b ascites and varices\n with banding in the past, TIPS () with redo (). Pt presented\n with leukocytosis, abd pain, and new renal failure with lactic acidosis\n and hyperkalemia. Pt transferred to MICU for acute HD.\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Pt with large ascitic abdomen, pos bowel sounds. Para site now open to\n air with no bleeding/oozing noted. Per translator and wife pt is\n oriented x3, conversation appropriate.\n Action:\n Pt given lactulose, octreotide midodrine, and rifaximin per order. Pt\n also on IV zosyn for SBP prophylaxis. Bladder pressure taken. Pt did\n have paracentesis yesterday with 5L removed.\n Response:\n Pt with 2^nd BM today, afebrile, WBC 5.2. Bladder pressure 14-15.\n Plan:\n Continue to assess abdomen and para site, admin meds per order, titrate\n lactulose to 3 BMs/day, trend temp, monitor mental status. Cultures\n pending.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with new onset renal failure requiring HD. Cr 4.2. Voiding small\n amounts of yellow urine with sediment.\n Action:\n Pt dialyzed today, UF 1000ml.\n Response:\n Pt tolerated HD well. Repeat Cr 2.3. Continues voiding 10-20cc/hr via\n foley.\n Plan:\n Continue to monitor UOP, renal following ?next dialysis, Monitor labs.\n Neuro: alert and oriented x3\n CV: HR 40s-90s NSR with no ectopy noted. BP stable. +2 pitting pedal\n edema.\n Resp: Weaned to RA with RR 20s and sats 99%.\n GI: Pt tolerated renal diet. BMx3 today is brown liquid.\n Skin: c/d/i\n MS: Pt transferred to BSC with 2 assist, he is weak to stand but no\n SOB noted.\n Social: Pt\ns wife at bedside all shift is teary at times and was\n unaware pt had a problem with his kidneys. Social work met with\n family, support and disease process information discussed with pt,\n wife, RN and MD.\n Access: Right subclavian HD catheter. #18 gauge x2.\n FULL CODE\n NKDA\n" }, { "category": "Nursing", "chartdate": "2119-08-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 590331, "text": "Pt is a 63 year old male with ETOH cirrhosis c/b ascites and varices\n with banding in the past, TIPS () with redo (). Pt presented\n with leukocytosis, abd pain, and new renal failure with lactic acidosis\n and hyperkalemia. Pt transferred to MICU for acute HD.\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Pt with large ascitic abdomen, pos bowel sounds. Para site now open to\n air no bleeding/oozing noted. Per translator and wife pt is oriented\n x3, conversation appropriate.\n Action:\n Pt given lactulose, octreotide midodrine, and rifaximin per order. Pt\n also on IV zosyn . Bladder pressure taken. Pt did have paracentesis\n yesterday with 5L removed.\n Response:\n Pt with 3\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n ASCITES, HYPOGLYCEMIA\n Code status:\n Full code\n Height:\n Admission weight:\n 87.2 kg\n Daily weight:\n 85.5 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: GI Bleed, Liver Failure\n CV-PMH:\n Additional history: DM, hypothyriodism, pituitary mass, s/p TIPS, h/o\n +PPD, h/o nephrolithiasis, ascities, kidney stones, esophageal varies\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:60\n Temperature:\n 98.1\n Arterial BP:\n S:185\n D:76\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 60 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 24h total in:\n 950 mL\n 24h total out:\n 1,414 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:09 PM\n Potassium:\n 4.0 mEq/L\n 04:09 PM\n Chloride:\n 106 mEq/L\n 04:09 PM\n CO2:\n 24 mEq/L\n 04:09 PM\n BUN:\n 15 mg/dL\n 04:09 PM\n Creatinine:\n 2.3 mg/dL\n 04:09 PM\n Glucose:\n 245 mg/dL\n 04:09 PM\n Hematocrit:\n 27.5 %\n 04:09 PM\n Finger Stick Glucose:\n 236\n 01:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: 10- 14\n Date & time of Transfer: 12:00 AM\n BM today, afebrile, WBC 5.2. Bladder pressure 14-15.\n Plan:\n Continue to assess abdomen and para site, admin meds per order, titrate\n lactulose to 3 BMs/day, trend temp, monitor mental status. Cultures\n pending.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with new onset renal failure requiring HD. Cr 4.2. Voiding small\n amounts of yellow urine with sediment.\n Action:\n Pt dialyzed today, UF 1000ml.\n Response:\n Pt tolerated HD well. Repeat Cr 2.3. Continues voiding 10-20cc/hr via\n foley.\n Plan:\n Continue to monitor UOP, renal following ?next dialysis, Monitor labs.\n Neuro: alert and oriented x3, OOB to commode w/ assistance.\n CV: HR 40s-90s NSR with no ectopy noted. BP stable. +2 pitting pedal\n edema.\n Resp: On room air sating >95%\n GI: Diet advanced to renal and tolerated well. BMx3 today is brown\n liquid on lactulose.\n Skin: c/d/i\n Social: Pt\ns wife at bedside all shift is teary at times and was\n unaware pt had a problem with his kidneys. Social work met with\n family, support and disease process information discussed with pt,\n wife, RN and MD.\n Access: Right subclavian HD catheter. #18 gauge x2.\n FULL CODE\n NKDA\n" }, { "category": "Nursing", "chartdate": "2119-08-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590202, "text": ".H/O cirrhosis of liver, alcoholic\n Assessment:\n Paracentesis\n Action:\n Abd remains distended and tense, bladder pressure 18 Paracentesis done\n on , ~5l removed, ascetic fluid turbid Albumen 100gm IV ordered for\n during paracentesis. Receiving lactulosr, titrating to 3 stools per\n day, pt had 500 ml brown ob pos liquid stool after am lactulose Wife in\n to visit, translating for pt, states he is not confused and is oriented\n Wife at times when speaking to pt, states he is talking about\n dying\n Response:\n Paracentesis\n Plan:\n Social work consult in am for family support\n Lactulose as ordered, check bladder pressure twice daily.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output slightly improved in this shift 20-40cc/hr.\n Action:\n Monitoring, Plans for HD \n Response:\n Oliguric\n Plan:\n HD in am\n .H/O hypoglycemia\n Assessment:\n Receiving SS coverage\n Action:\n Fs elevated 404 @ midnight received 12 units humalog and monitored BS\n q2h.\n Response:\n Pending\n Plan:\n Insulin as ordered\n Fs qid\n" }, { "category": "Nursing", "chartdate": "2119-08-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 590314, "text": "Pt is a 63 year old male with ETOH cirrhosis c/b ascites and varices\n with banding in the past, TIPS () with redo (). Pt presented\n with leukocytosis, abd pain, and new renal failure with lactic acidosis\n and hyperkalemia. Pt transferred to MICU for acute HD.\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Pt with large ascitic abdomen, pos bowel sounds. Para site now open to\n air with no bleeding/oozing noted. Per translator and wife pt is\n oriented x3, conversation appropriate.\n Action:\n Pt given lactulose, octreotide midodrine, and rifaximin per order. Pt\n also on IV zosyn for SBP prophylaxis. Bladder pressure taken. Pt did\n have paracentesis yesterday with 5L removed.\n Response:\n Pt with 2^nd BM today, afebrile, WBC 5.2. Bladder pressure 14-15.\n Plan:\n Continue to assess abdomen and para site, admin meds per order, titrate\n lactulose to 3 BMs/day, trend temp, monitor mental status.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with new onset renal failure requiring HD. Cr 4.2. Voiding small\n amounts of yellow urine with sediment.\n Action:\n Pt dialyzed today, UF 1000ml.\n Response:\n Pt tolerated HD well. Repeat Cr 2.3. Continues voiding 10-20cc/hr via\n foley.\n Plan:\n Continue to monitor UOP, renal following ?next dialysis, Monitor labs.\n Neuro: alert and oriented x3\n CV: HR 40s-90s NSR with no ectopy noted. BP stable. +2 pitting pedal\n edema.\n Resp: Weaned to 1L NC with RR 20s and sats 99%.\n GI: Tolerated clear liquids and diet will be advanced to renal as he\n tolerates. BMx3 today is brown liquid.\n Skin: c/d/i\n MS: Pt transferred to BSC with 2 assist, he is weak to stand but no\n SOB noted.\n Social: Pt\ns wife at bedside all shift is teary at times and was\n unaware pt had a problem with his kidneys. Social work met with\n family, support and disease process information discussed with pt,\n wife, RN and MD.\n Access: Right subclavian HD catheter. #18 gauge x2.\n FULL CODE\n NKDA\n" }, { "category": "Nursing", "chartdate": "2119-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590025, "text": ".H/O cirrhosis of liver, alcoholic\n Assessment:\n Paracentesis on hold\n Action:\n Paracentesis on hold this shift, abd large and distended due to ascites\n Bladder pressure done 24\n Received albumen 5% 500ml x1\n Hct 24, plans to transfuse during HD\n Stooling to lactulose, `12pm dose held, ob pos, team aware\n Started on zosyn for SBP prophylaxis\n Pt yelling out\nJesusChrist\n, speaks mainly , wife in to\n interpret, states pt is not confused, but uncomfortable, c/o discomfort\n from foley and from abd, team aware\n US of abd done to eval TIPS\n Pt remains off coumadin am INR 2.1\n Response:\n Paracentesis on hold\n Plan:\n Follow bladder pressure qd\n Iv abx as ordered\n Pm labs\n .H/O hypoglycemia\n Assessment:\n FS 90\n Action:\n Tolerating sips of clear liquids\n Fs qid\n Response:\n Fs wnl\n Plan:\n Fs qid\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n HD treatment\n Action:\n HD treatment doe this shift due to continued elevated lactate level and\n pt previously on metformin\n Pt oliguric\n Repeat k 4.6\n Due for lytes after HD\n Response:\n Oliguric\n HD\n Plan:\n Next HD on Monday\n Monitor u/o\n Renal dose meds\n Hypotension (not Shock)\n Assessment:\n Hypotensive\n Action:\n BP 70\ns/ this am, improved while awake and after albumen\n Briefly started on levophed gtt\n Aline placed, able to wean off levophed\n 20 point difference between bp cuff and aline pressures\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2119-08-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590095, "text": "63 yr old Porteguese speaking male with end stage liver, stenosed TIPS.\n recurrent encephalopathy presents with leukocytosis, abd pain, and new\n renal failure with lactic acidosis and hyerkalemia. Tx to MICU for\n acute HD (new HD for him)\n Diagnostic Para in the ED - 33 wbc, 25% PMN, bloody- 6300 RBC\n INR reversed with FFP- right IJ and HD catheter placed\n Events overnight: Elevated PTT: 150. Rechecked-> 150. 10mg Vitamin K\n IV administered with PTT down to 35.6 by morning.\n Hct stable at 26.2 with no active bleeding noted.\n .H/O ascites\n Assessment:\n Abdomen con\nts distended, causing pt discomfort with movements.\n Bladder pressure ~20\n Action:\n Frequent position changes\n Response:\n Pt resting better than previous shift\n Plan:\n Con\nt to assess, assist with postion changes as needed\n .H/O altered mental status (not Delirium)\n Assessment:\n Receiving lactulose qd for goal of 3 BM\ns per day\n Action:\n lactulose held\n Response:\n Large BM last eve\n Plan:\n Begin lactulose in am once again in order to reach projected goal of 3\n stools/day\n .H/O hypoglycemia\n Assessment:\n FS stable\n Action:\n QID FS with ss coverage as needed\n Response:\n No hypoglycemic episodes, required insulin coverage for glucose over\n 200 times two\n Plan:\n SS coverage per parameters\n .H/O hepatic encephalopathy\n Assessment:\n Per pt\ns wife, who remained at pt\ns bedside until ~2130, pt con\n alert and oriented with no disorientation\n Action:\n Pt answers when spoken to, difficult to assess full orientation. Per\n co-worker, who speaks , pt stated he was at the . He\n also stated he wanted to go home..\n Response:\n Pt was reoriented as appropriate. Position changed frequently and he\n did well with this. Able to doze in small for short periods of time.\n Plan:\n Assess MS, reoriented as needed\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Tolerated Dialysis on . BUN/Cr 32/3.5 with K of 4.3\n Action:\n Con\nt to follow labs\n Response:\n Urine output diminishing ~5-10 cc\ns per hr\n Plan:\n Con\nt to monitor lab results, assess u/o\n" }, { "category": "Nursing", "chartdate": "2119-08-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 590316, "text": "Pt is a 63 year old male with ETOH cirrhosis c/b ascites and varices\n with banding in the past, TIPS () with redo (). Pt presented\n with leukocytosis, abd pain, and new renal failure with lactic acidosis\n and hyperkalemia. Pt transferred to MICU for acute HD.\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Pt with large ascitic abdomen, pos bowel sounds. Para site now open to\n air with no bleeding/oozing noted. Per translator and wife pt is\n oriented x3, conversation appropriate.\n Action:\n Pt given lactulose, octreotide midodrine, and rifaximin per order. Pt\n also on IV zosyn for SBP prophylaxis. Bladder pressure taken. Pt did\n have paracentesis yesterday with 5L removed.\n Response:\n Pt with 2^nd BM today, afebrile, WBC 5.2. Bladder pressure 14-15.\n Plan:\n Continue to assess abdomen and para site, admin meds per order, titrate\n lactulose to 3 BMs/day, trend temp, monitor mental status. Cultures\n pending.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with new onset renal failure requiring HD. Cr 4.2. Voiding small\n amounts of yellow urine with sediment.\n Action:\n Pt dialyzed today, UF 1000ml.\n Response:\n Pt tolerated HD well. Repeat Cr 2.3. Continues voiding 10-20cc/hr via\n foley.\n Plan:\n Continue to monitor UOP, renal following ?next dialysis, Monitor labs.\n Neuro: alert and oriented x3\n CV: HR 40s-90s NSR with no ectopy noted. BP stable. +2 pitting pedal\n edema.\n Resp: Weaned to 1L NC with RR 20s and sats 99%.\n GI: Tolerated clear liquids and diet will be advanced to renal as he\n tolerates. BMx3 today is brown liquid.\n Skin: c/d/i\n MS: Pt transferred to BSC with 2 assist, he is weak to stand but no\n SOB noted.\n Social: Pt\ns wife at bedside all shift is teary at times and was\n unaware pt had a problem with his kidneys. Social work met with\n family, support and disease process information discussed with pt,\n wife, RN and MD.\n Access: Right subclavian HD catheter. #18 gauge x2.\n FULL CODE\n NKDA\n" }, { "category": "Nursing", "chartdate": "2119-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590015, "text": ".H/O cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hypoglycemia\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2119-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590016, "text": ".H/O cirrhosis of liver, alcoholic\n Assessment:\n Paracentesis on hold\n Action:\n Paracentesis on hold this shift, abd large and distended due to ascites\n Bladder pressure done 24\n Received albumen 5% 500ml x1\n Hct 24, plans to transfuse during HD\n Stooling to lactulose, `12pm dose held, ob pos, team aware\n Started on zosyn for SBP prophylaxis\n Pt yelling out\nJesusChrist\n, speaks mainly , wife in to\n interpret, states pt is not confused, but uncomfortable, c/o discomfort\n from foley and from abd, team aware\n Response:\n Paracentesis on hold\n Plan:\n Follow bladder pressure qd\n Iv abx as ordered\n .H/O hypoglycemia\n Assessment:\n FS 90\n Action:\n Tolerating sips of clear liquids\n Fs qid\n Response:\n Fs wnl\n Plan:\n Fs qid\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2119-08-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 590307, "text": "Pt is a 63 year old male with ETOH cirrhosis c/b ascites and varices\n with banding in the past, TIPS () with redo (). Pt presented\n with leukocytosis, abd pain, and new renal failure with lactic acidosis\n and hyperkalemia. Pt transferred to MICU for acute HD.\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Pt with large ascitic abdomen, pos bowel sounds. Para site now open to\n air with no bleeding/oozing noted. Per translator and wife pt is\n oriented x3, conversation appropriate.\n Action:\n Pt given lactulose, octreotide midodrine, and rifaximin per order. Pt\n also on IV zosyn for SBP prophylaxis. Bladder pressure taken. Pt did\n have paracentesis yesterday with 5L removed.\n Response:\n Pt with 2^nd BM today, afebrile, WBC 5.2. Bladder pressure 14-15.\n Plan:\n Continue to assess abdomen and para site, admin meds per order, titrate\n lactulose to 3 BMs/day, trend temp, monitor mental status.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with new onset renal failure requiring HD. Cr 4.2. Voiding small\n amounts of yellow urine with sediment.\n Action:\n Pt dialyzed today, UF 1000ml.\n Response:\n Pt tolerated HD well. Repeat Cr 2.3. Continues voiding\n Plan:\n" }, { "category": "Physician ", "chartdate": "2119-08-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 589964, "text": "Chief Complaint: abdominal discomfort\n HPI:\n This is a 63 year old Portuguese-speaking man with extensive history of\n alcoholic cirrhosis, frequent admissions at , now here with\n right-sided abdominal pain, and increased ascites. Starting on\n Wednesday () he began having right-sided abdominal pain. His wife\n reported that he had increased fatigue, abdominal pain, abdominal\n girth, and one episode of non-bloody emesis. His wife and cousin denied\n that he had any episodes of confusion. They explained that he had \"pain\n where they took the water out\" on the right. They explained and he\n affirmed that he has been urinating less. I confirmed the essentials of\n this history with him during a brief Portuguese interpreter phone\n interview.\n .\n In the emergency department his initial vitals were: 97.9, 111/63, 18,\n 98% on room air. He was found to be guaiaic negative; and he had labs\n notable for lactate 9.1, WBC 21.3, Cr 7.6, Glu 15. With low glucose, a\n D5 drip was started. With consideration of ischemic colitis, the ED\n sent him for CT scan, ordered without contrast given his renal\n function; this did not show any signs of ischemia. Additionally, he\n received: 4.5 gm IV zosyn, octreotide 50 mcg IV and octreotide 25\n mcg/hr gtt; as well as 1 amp of calcium gluconate. Liver and kidney\n services were consulted in the ED; liver fellow left recs in the ED\n chart and renal fellow planned for HD in the unit. A diagnostic\n paracentesis was performed in the ED; the liver service recommended\n against therapeutic tap for now. He was admitted to the MICU service\n for further management.\n Patient admitted from: ER\n History obtained from Interpreter\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Octreotide - 25 mcg/hour\n Other ICU medications:\n Other medications:\n HOME MEDICATIONS\n Calcium Carbonate 500 mg tid\n Vitamin D3 800 units daily\n Glipizide 10 mg daily.\n Lactulose 60 mL PO QID\n Levothyroxine 100 mcg Tablet DAILY\n Metformin 1,000 mg Tablet DAILY\n Omeprazole 20 mg DAILY\n Propranolol 40 mg TID\n Rifaximin 400 TID\n Warfarin 3 mg qHS\n Past medical history:\n Family history:\n Social History:\n - ETOH cirrhosis, complicated by ascites and varices, s/p banding\n * s/p TIPS () -> redo for narrowing -> failure of TIPS\n noted in past admissions w/ d/c summaries noting decision not to redo\n tips further given diminished returns\n * recent admission including 5L paracentesis (note: originally\n thought this was 10L, past records appear to confirm 5L)\n - Portal vein thrombosis: on coumadin goal INR \n - Diabetes mellitus\n - Hypothyroidism\n - Pituitary mass\n - h/o nephrolithiasis\n - h/o + PPD\n Mother deceased, age 50, CVA. Father deceased, age 62, stomach\n problems. One brother living and in good health. Two sisters, both\n living and in good health.\n .\n Occupation: retired\n Drugs: no\n Tobacco: none\n Alcohol: quit \n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema\n Respiratory: Tachypnea, Wheeze\n Gastrointestinal: Abdominal pain, Nausea, Emesis\n Integumentary (skin): No(t) Jaundice\n Endocrine: History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy\n Flowsheet Data as of 03:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 73 (61 - 74) bpm\n BP: 91/45(55) {91/45(55) - 125/67(82)} mmHg\n RR: 21 (15 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,300 mL\n 313 mL\n PO:\n TF:\n IVF:\n 542 mL\n 313 mL\n Blood products:\n 1,758 mL\n Total out:\n 91 mL\n 80 mL\n Urine:\n 91 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,209 mL\n 233 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: Anxious\n Eyes / Conjunctiva: Pupils dilated\n Cardiovascular: (S1: Normal), (S2: Normal, Fixed)\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 scattered crackles at bases, Diminished: )\n Abdominal: Distended, massive distension assoc w hypoxia and bhperhapb\n producem.\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, No(t) Cyanosis\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Oriented (to): , Movement: Not assessed, Tone: Normal\n Labs / Radiology\n 99 mg/dL\n 7.5 mg/dL\n 87 mg/dL\n 5.6 mEq/L\n [image002.jpg]\n \n 5:00p\n PERITONEAL RT SIDE PARACENTESIS FLUID\n Other Body Fluid Hematology:\n WBC: 33\n RBC: 6340\n Polys: 25\n Lymphs: 14\n Monos: 18\n Mesothe: 11\n Macro: 32\n \n 3:42p\n _______________________________________________________________________\n Lactate:9.1\n \n 2:55p\n _______________________________________________________________________\n Lactate:9.1\n \n 2:33 A8/14/ 11:47 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 Cr\n 7.5\n Glucose\n 99\n Other labs: Lactic Acid:8.7 mmol/L, Mg++:3.4 mg/dL\n Other Blood Chemistry:\n Ammonia: 66\n 133\n [image004.gif]\n 95\n [image004.gif]\n 86\n [image006.gif]\n 15\n AGap=35\n [image007.gif]\n 6.5\n [image004.gif]\n 10\n [image004.gif]\n 7.6\n [image009.gif]\n CK: 40\n MB: Notdone\n Ca: 11.9 Mg: 3.9 P: 8.7\n ALT: 28\n AP: 391\n Tbili: 0.7\n Alb: 3.9\n AST: 44\n LDH:\n Dbili:\n TProt:\n :\n Lip: 94\n 90\n 21.3\n [image009.gif]\n 11.8\n [image006.gif]\n 248\n [image010.gif]\n [image006.gif]\n 34.7\n [image009.gif]\n N:90.0 L:5.9 M:3.6 E:0.3 Bas:0.2\n PT: 40.6\n PTT: 39.9\n INR: 4.3\n STUDIES:\n .\n CT ABD/PELVIS *WET READ*\n Limited ascites and lack of contrast.\n Marked distention of the stomach and prox duodenum. ? gastric outlet\n obstruction of unclear etiology, new since .\n Large ascites, Cirrhosis\n left 2-3 mm nonobstructive renal calc\n No definite wall thickening or pneumatosis or portal venous gas to\n suggest bowel ischemia.\n appendix partially seen\n .\n CT ABD/PELVIS\n 1. Findings compatible with cirrhosis and portal hypertension without\n evidence of focal mass lesion in the liver.\n 2. Conventional hepatic vascular anatomy without evidence of occlusion.\n 3. Liver volume 1233 cm3.\n .\n CARDIAC PERFUSION PERSANTINE\n 1. Normal myocardial perfusion, estimated LVEF of 57%.\n .\n Stress\n 1. No anginal symptoms or ischemic ST segment changes. Nuclear\n report sent separately.\n .\n LIVER OR GALLBLADDER US (SINGLE ORGAN)\n 1. TIPS with elevated velocities at the mid and distal portion\n concerning for stenosis.\n 2. Ascites is similar to the previous study and is large in amount.\n 3. Unchanged appearance of the right anterior portal vein with\n hepatopetal flow. Non-visualized left portal vein\n .\n ECHO\n The left atrium is mildly dilated. There is mild symmetric left\n ventricular hypertrophy with normal cavity size and global systolic\n function (LVEF>55%). Due to suboptimal technical quality, a focal wall\n motion abnormality cannot be fully excluded. Right ventricular chamber\n size and free wall motion are normal. The diameters of aorta at the\n sinus, ascending and arch levels are normal. The aortic valve leaflets\n (3) appear structurally normal with good leaflet excursion and no\n aortic regurgitation. The mitral valve leaflets are structurally\n normal. There is no mitral valve prolapse. Very mild (1+) mitral\n regurgitation is seen. There is borderline pulmonary artery systolic\n hypertension. There is no pericardial effusion.\n Assessment and Plan\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O ASCITES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n .H/O HEPATIC ENCEPHALOPATHY\n .H/O RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O HYPOGLYCEMIA\n ASSESSMENT AND PLAN\n This is a 63 year old Portuguese-speaking man with end-stage liver\n disease and stenosed TIPS, recurrent admissions for hepatic\n encephalopathy, now here with abdominal pain and a WBC of 21.3 with a\n neutrophil predominance.\n .\n ABDOMINAL PAIN\n Likely related to massive ascites likely hepatorenal syndrome. No\n evidence of SBP given low WBC on diagnostic tap, although tap appears\n bloody. No sign of perf on CT scan. Surgery evaluating per ED request.\n Possible gastric outlet obstruction seen on CT scan; may improve w\n decrease in ascitic fluid.\n - appreciate surgery recs; tplant service will follow\n - will give albumin per liver recs p HD per renal recs; albumin will\n also be provided by FFP needed for HD line placement\n - consider tx tap if renal function improves\n - NGT if not tolerating clears, emesis, etc\n - clear liquid diet for now\n .\n LEUKOCYTOSIS\n Unclear source. Concern for abdominal source but as above this is not\n clear after dx tap and CT abd/pelvis. I am underwhelmed by CXR but do\n make note of RLL opacity; hard to account for this degree of WBC with\n this small PNA though relative immune suppression of liver/renal\n failure may diminish inflammatory response. High WBC out of proportion\n to symptoms, with abd pain, in pt w multiple hospitalizations, raises\n special concern for c. diff though obvious colitis not seen on CT.\n - covering gram-negatives w zosyn; add vanco and flagyl if worsening\n - cxs pending; additionally send c. diff given mult recent\n hospitalizations\n .\n LIVER FAILURE\n Hepatorenal syndrome worsens prognosis. Could have been precipitated by\n large volume tap on prior admission, though pt has tolerated similar\n (~5L) in the past. (Note: I initially believed this to have been 10L,\n this was in fact ~5L). Pt has been on transplant list.\n - abd U/S w doppler to eval TIPS stenosis, eval portal circulation\n - daily MELD labs\n - transplant surgery and liver services following, appreciate recs\n - octreotide and midodrine\n - regular lactulose at home dose\n - PPI\n - will restart pt's outpt propranolol after completion of HD and\n stabilization of BP\n - continue home rifaximin\n - continuing to hold pt's past diuretics\n .\n RENAL FAILURE\n Likely hepatorenal syndrome, perhaps large volume tap on last\n admission; vs change in hemodynamics infection.\n - HD tonight per renal, appreciate renal involvement and placement of\n HD line w VIP port\n - holding metformin\n .\n LACTIC ACIDOSIS\n Most likely liver failure itself, though metformin toxicity in\n setting of new renal failure may also be responsible. Mesenteric\n ischemia could be culprit; no positive evidence for this at this point,\n but should follow closely.\n - Abd U/S w doppler as above\n - holding metformin\n - follow lactate\n .\n DIABETES\n Holding oral antihyperglycemics based on low blood sugar in ED today.\n ISS alone for now. Has had more issues with high blood sugar than low\n in the past.\n .\n ICU Care\n Nutrition: Clears, consistent carbs; clears until para\n Glycemic Control:\n Lines:\n 18 Gauge - 06:48 PM\n Dialysis Catheter - 11:27 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held Comments: cousin and wife present\n status: Full code\n Disposition: ICU overnight ; if stable, to liver-kidney floor for\n further management\n -- MD\n / PGY3 / MICU \n" }, { "category": "Nursing", "chartdate": "2119-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 589961, "text": "Pt is a 63 year old male with ETOH cirrhosis s/p TIPs redo \n (originally done ). Recent admission -> for worsening\n encephalopathy and increased ascites..\n .H/O altered mental status (not Delirium)\n Assessment:\n Primary language is Portugese. Pt appears to have a fair understanding\n when spoken to, but doesn\nt speak English well. When wife was here\n earlier, she stated that pt was oriented but tired, and didn\nt want to\n speak much. Has been cooperative with care thus far.\n Action:\n Current care plan explained to pt prior to wife going home\n Response:\n Appeared comfortable with plan of care.\n Plan:\n Con\nt to provide explanations of POC, have interpreter or wife assist\n with translation.\n .H/O ascites\n Assessment:\n Abdomen firm and distended. Abdomen causing quite a bit of discomfort\n for patient when moving\n Action:\n Provide 2 person assist when moving pt.\n Response:\n Plan:\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hepatic encephalopathy\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hypoglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2119-08-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590141, "text": "Hypotension (not Shock)\n Assessment:\n Action:\n Bp 80\ns-115/, Bp dips down to 80\ns/ while asleep, plan to not treat\n unless SBP <80/\n Aline positional, hand placed on board\n CVp transduced via vip port in HD line, \n Response:\n Labile bp\n Plan:\n Levophed gtt as ordered\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Paracentesis\n Action:\n Abd remains distended and tense, bladder pressure 20\n Plans for paracentesis this shift\n Albumen 100gm IV ordered for during paracentesis\n Receiving lactulosr, titrating to 3 stools per day, pt had 500 ml brown\n ob pos liquid stool after am lactulose\n Wife in to visit, translating for pt, states he is not confused and is\n oriented\n Wife at times when speaking to pt, states he is talking about\n dying\n Response:\n Paracentesis\n Plan:\n Social work consult in am for family support\n Lactulose as ordered\n Albumen as ordered\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Min u/o\n Action:\n Pt with <10ml urine out per hour\n Plans for HD \n Response:\n Oliguric\n Plan:\n Pm lytes and lactate\n HD in am\n .H/O hypoglycemia\n Assessment:\n Receiving SS coverage\n Action:\n Fs elevated, receiving SS humalog as ordered\n Po po intake, poor appetite\n Response:\n Elevated FS\n Plan:\n Insulin as ordered\n Fs qid\n" }, { "category": "Nursing", "chartdate": "2119-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590048, "text": ".H/O cirrhosis of liver, alcoholic\n Assessment:\n Paracentesis on hold\n Action:\n Paracentesis on hold this shift, abd large and distended due to ascites\n Bladder pressure done 24\n Received albumen 5% 500ml x1\n Hct 24, plans to transfuse during HD\n Stooling to lactulose, `12pm dose held, ob pos, team aware\n Started on zosyn for SBP prophylaxis\n Pt yelling out\nJesusChrist\n and moaning, speaks mainly ,\n wife in to interpret, states pt is not confused, but uncomfortable, c/o\n discomfort from foley and from abd, team aware\n Pt not yelling out while wife in visiting\n US of abd done to eval TIPS\n Pt remains off coumadin am INR 2.1\n Lactulose changed to hold for >3stools per day\n Response:\n Paracentesis on hold\n Plan:\n Follow bladder pressure qd\n Iv abx as ordered\n Pm labs\n .H/O hypoglycemia\n Assessment:\n FS 90\n Action:\n Tolerating sips of clear liquids\n Fs qid\n Response:\n Fs wnl\n Plan:\n Fs qid\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n HD treatment\n Action:\n HD treatment doe this shift due to continued elevated lactate level and\n pt previously on metformin\n Pt oliguric\n Repeat k 4.6\n Due for lytes after HD\n Response:\n Oliguric\n HD\n Plan:\n Next HD on Monday\n Monitor u/o\n Renal dose meds\n PM lytes\n Hypotension (not Shock)\n Assessment:\n Hypotensive\n Action:\n BP 70\ns/ this am, improved while awake and after albumen\n Briefly started on levophed gtt\n Aline placed, able to wean off levophed\n 20 point difference between bp cuff and aline pressures\n Response:\n Briefly on levophed gtt\n Aline BP 20 (+) points higher than cuff\n Plan:\n Monitor bp via aline\n Levophed gtt for bp <90/\n" }, { "category": "Physician ", "chartdate": "2119-08-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 590121, "text": "Chief Complaint: liver failure, hepatorenal syndrome, 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 24 Hour Events:\n ARTERIAL LINE - START 12:15 PM\n ULTRASOUND - At 01:30 PM\n ULTRASOUND - At 04:00 PM\n Transient Levophed\n Higher dose Midorine and Octreotide\n HD tolerated - only 200 ml negative - given 1 u PRBCs\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Octreotide, Midodrine, 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 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: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.2\n HR: 62 (50 - 77) bpm\n BP: 83/38(50) {83/37(0) - 142/101(234)} mmHg\n RR: 17 (14 - 23) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.5 kg (admission): 87.2 kg\n Bladder pressure: 20 (20 - 20) mmHg\n Total In:\n 1,647 mL\n 265 mL\n PO:\n 390 mL\n 120 mL\n TF:\n IVF:\n 382 mL\n 145 mL\n Blood products:\n 875 mL\n Total out:\n 469 mL\n 43 mL\n Urine:\n 269 mL\n 43 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,178 mL\n 222 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///23/\n Physical Examination\n Gen: lying in bed, complains of abd pain\n HEENT: op clear\n CV: RR\n Ches: scattered rales with ext wheezes\n Abd: massive distension, absent bowel sounds, tense ascites\n Ex: trace edema\n Neuro: alert and answering questions\n Labs / Radiology\n 8.7 g/dL\n 105 K/uL\n 206 mg/dL\n 3.5 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 32 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.2 %\n 6.5 K/uL\n [image002.jpg]\n 11:47 PM\n 06:08 AM\n 09:12 AM\n 07:00 PM\n 11:28 PM\n 04:10 AM\n WBC\n 9.8\n 10.2\n 7.6\n 7.4\n 6.5\n Hct\n 24.5\n 24.7\n 24.8\n 26.0\n 26.2\n Plt\n 135\n 110\n 104\n 115\n 105\n Cr\n 7.5\n 4.8\n 5.2\n 2.1\n 3.5\n Glucose\n 99\n 59\n 74\n 175\n 206\n Other labs: PT / PTT / INR:22.2/35.6/2.1, ALT / AST:18/28, Alk Phos / T\n Bili:184/1.8, Differential-Neuts:83.9 %, Lymph:8.7 %, Mono:5.9 %,\n Eos:1.2 %, D-dimer:1656 ng/mL, Fibrinogen:504 mg/dL, Lactic Acid:2.5\n mmol/L, Albumin:3.1 g/dL, LDH:130 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:2.8 mg/dL\n US: persistent TIPS stenosis, large ascites\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O ASCITES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n .H/O HEPATIC ENCEPHALOPATHY\n .H/O RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O HYPOGLYCEMIA\n 1. Acute Renal Failure: DDX pre renal versus evolving hepatorenal\n he also has a bladder pressure of 24- held off on repeat tap\n yesterday but will tap today. Plan for HD tomorrow. Watch lytes and\n renally dose all meds. Try a 1 mg/kg albumin challenge today\n 2. Hypotension: has been more stable\n Aline 20 pts higher. When\n sleeps drops MAP to 55-60 but otherwise OK. Check CVP\n 3. ESLD: MELD is high at 41 with HRS concerning, liver team\n following. Consult transplant surgery following and onogin work up for\n listing.\n 4. Acidosis: lactic- DDX is poor forward flow versus metformin\n induced in setting of liver failure with poor clearance. Resolving.\n Holding metformin, had HD, we will\n 5. Leukocytosis: pan culture, will maintain on Zosyn as we await\n data\n 6. DM: continue to check FS closely since was so hypoglycemic on\n arrival\n Remaining issues as per Housestaff.\n ICU Care\n Nutrition: clears\n Glycemic Control:\n Lines: Dialysis Catheter - 11:27 PM\n Arterial Line - 12:15 PM\n 18 Gauge - 12:30 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: with pt and wife\n status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2119-08-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 590123, "text": "Chief Complaint: This is a 63 year old Portuguese-speaking man with\n end-stage liver disease and stenosed TIPS, recurrent admissions for\n hepatic encephalopathy, now here with abdominal pain and a WBC of 21.3\n with a neutrophil predominance and hepatorenal syndrome.\n 24 Hour Events:\n Patient hypotensive, started on levophed, quickly weaned (duration 35\n minutes), pressures stable throughout day off pressor\n Arterial line placed\n HD without incidence, 200ml off\n Transfused 1 unit of pRBC without appropriate bump during dialysis\n ARTERIAL LINE - START 12:15 PM\n ULTRASOUND - At 01:30 PM\n ULTRASOUND - At 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:22 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: 36.8\nC (98.3\n HR: 63 (58 - 77) bpm\n BP: 104/44(60) {97/44(0) - 142/101(234)} mmHg\n RR: 16 (14 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.5 kg (admission): 87.2 kg\n Bladder pressure: 20 (20 - 24) mmHg\n Total In:\n 1,647 mL\n 128 mL\n PO:\n 390 mL\n TF:\n IVF:\n 382 mL\n 128 mL\n Blood products:\n 875 mL\n Total out:\n 469 mL\n 38 mL\n Urine:\n 269 mL\n 38 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,178 mL\n 90 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///23/\n Physical Examination\n Patient moaning, interactive despite language barrier\n Bradycardic to 50\ns, S1, S2 normal, II/VI systolic murmur\n Inspiratory crackles at lung bases, diminished breath sounds at bases,\n without wheeze or rub\n Distended abdomen, diffusely tender, prominent bulging umbilicus, no\n bowel sounds appreciated\n Lower ext edema, warm ext\n Positive for asterixis\n Labs / Radiology\n 105 K/uL\n 8.7 g/dL\n 206 mg/dL\n 3.5 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 32 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.2 %\n 6.5 K/uL\n [image002.jpg]\n 11:47 PM\n 06:08 AM\n 09:12 AM\n 07:00 PM\n 11:28 PM\n 04:10 AM\n WBC\n 9.8\n 10.2\n 7.6\n 7.4\n 6.5\n Hct\n 24.5\n 24.7\n 24.8\n 26.0\n 26.2\n Plt\n 135\n 110\n 104\n 115\n 105\n Cr\n 7.5\n 4.8\n 5.2\n 2.1\n 3.5\n Glucose\n 99\n 59\n 74\n 175\n 206\n Other labs: PT / PTT / INR:22.2/35.6/2.1, ALT / AST:18/28, Alk Phos / T\n Bili:184/1.8, Differential-Neuts:83.9 %, Lymph:8.7 %, Mono:5.9 %,\n Eos:1.2 %, D-dimer:1656 ng/mL, Fibrinogen:504 mg/dL, Lactic Acid:2.5\n mmol/L, Albumin:3.1 g/dL, LDH:130 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:2.8 mg/dL\n Fluid analysis / Other labs: FDP 0-10\n Fibrinogen 504\n Haptoglobin 98\n Imaging: Liver ultrasound with doppler\n IMPRESSION:\n 1. Large amount of ascites as in prior study.\n 2. No improvement in elevated velocities of TIPS, and possibly\n increased in the mid portion, concerning for stenosis, although patent.\n Please note that the main portal vein and its other major branches are\n not assessed in any\n detail on this study.\n 3. Coarsened architecture liver without evidence of focal lesion.\n Microbiology: C.Diff pending\n Blood culture pending\n Urine culture pending\n Gram stain of ascites - no bacteria\n Ascites culture - prelim no growth\n Assessment and Plan\n This is a 63 year old Portuguese-speaking man with end-stage liver\n disease and stenosed TIPS, recurrent admissions for hepatic\n encephalopathy, now here with abdominal pain and a WBC of 21.3 with a\n neutrophil predominance, lactic acidosis and hepatorenal disease.\n .\n ASCITES Likely related to massive ascites likely hepatorenal\n syndrome. No evidence of SBP given low WBC on diagnostic tap; tap\n appears bloody; most likely coagulopathy, though consistent\n appearance of this finding might suggest hemoperitoneum from another\n process rather than from trauma from tap; CT apparently offers no\n obvious suspect. No sign of perf on CT scan. Surgery evaluating per ED\n request. Possible gastric outlet obstruction seen on CT scan; may\n improve w decrease in ascitic fluid. U/S done, shows partial stenosis\n of the portal vein. No tap at this time due to risk of worsening\n hepatorenal syndrome, however, if worsening hypotension/renal failure,\n may need to tap due to compartment syndrome. Bladder pressure of 24\n yesterday.\n - f/u transplant surgery recs\n - f/u liver recs\n paracentesis of 5L\n - f/u nephrology recs - HD tomorrow\n - albumin today 100g\n - NGT if not tolerating clears, emesis, etc\n - clear liquid diet for now\n .\n LIVER CIRRHOSIS, ETOH, w/ encephalopathy Hepatorenal syndrome worsens\n prognosis. Could have been precipitated by large volume tap on prior\n admission, though pt has tolerated similar (~5L) in the past. Pt has\n been on transplant list. MELD on admission = 41. U/S shows some\n stenosis from TIPS in protal circulation.\n - transplant surgery and liver services following, appreciate recs\n - octreotide and midodrine\n - regular lactulose at home dose\n - continue home rifaximin\n - omeprazole\n - add propranolol once completed HD and blood pressures stable\n - hold diuretics\n .\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) Likely \n hepatorenal syndrome, perhaps large volume tap on last admission;\n vs change in hemodynamics infection; vs compartment syndrome from\n ascites causing pre-renal picture. FeNa on admission 0.6.\n - Cont zosyn\n d/c when cultures negative\n - Follow up on renal recs for HD plans\n - holding metformin - contributing to lactic acidosis\n .\nHYPOTENSION Possibly due to decreased venous return due to abdominal\n pressure vs infection/sepsis vs hypovolemia due to fluid sequestration\n as ascites.\n - start levophed for SBP <80 titrate to MAPs > 65.\n - If patient becomes hypotensive consider tap to decrease\n intra-abdominal pressure\n - zosyn empirically for infection, consider adding flagyl/vanco if\n appears more toxic.\n .\n\n ALTERED MENTAL STATUS (NOT DELIRIUM) Per family report, patient\n currently appears to have intact mental status, however, appears\n confused at times, with mumbling and groaning on. Possibly due to\n hepatic encephalopathy (NH3 = 66 on admission) vs infection, UTI vs\n SBP, vs acidemia. Remains afebrile\n - Lactulose - titrate to 3 BM per day\n - follow culture results\n - holding metformin\n - trend lactate\n - restraints if needed\n .\n COAGULOPATHY Assoc w liver failure. Got 6U FFP for HD line placement.\n Holding coumadin for now.\n - continue to trend coags\n - give vit K for goal INR <2.\n - consider FFP for procedures\n .\n LACTIC ACIDOSIS Most likely liver failure itself, though\n metformin toxicity in setting of new renal failure may also be\n responsible. Mesenteric ischemia could be culprit; no positive evidence\n for this at this point, but should follow closely.\n - trend lactate\n - hold metformin\n - quaiac stool\n - follow AG\n .\n Leukocytosis Unclear source. Concern for abdominal source but as\n above this is not clear after dx tap and CT abd/pelvis, RLL opacity;\n hard to account for this degree of WBC with this small PNA though\n relative immune suppression of liver/renal failure may diminish\n inflammatory response. High WBC out of proportion to symptoms, with abd\n pain, in pt w multiple hospitalizations, raises special concern for c.\n diff though obvious colitis not seen on CT. Resolved since admission.\n - f/u urine, blood and ascites cultures, c.diff toxin\n - continue empiric gram negative coverage with zosyn per liver's\n request\n - consider adding vanco and flagyl if clinical status is worsening\n - trend with CBC with diff\n .\nHyperkalemia Likely in the setting of renal disease at admission, has\n resolved from 6.5 to 5.6. Currently stable at 5.0.\n - Check lytes q12h\n - Check EKG if K+ increases\n .\n LACTIC ACIDOSIS Most likely liver failure itself, though\n metformin toxicity in setting of new renal failure may also be\n responsible. Mesenteric ischemia could be culprit; no positive evidence\n for this at this point, but should follow closely.\n - trend lactate\n - hold metformin\n - quaiac stool\n - follow AG\n .\n DIABETES Holding oral antihyperglycemics based on low blood sugar in\n ED today. ISS alone for now. Has had more issues with high blood sugar\n than low in the past.\n - cont. ISS\n .\nACCESS\n - if requires further pressors place central line - IJ with ultrasound\n ICU Care\n Nutrition:\n Comments: clear diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 11:27 PM\n Arterial Line - 12:15 PM\n 18 Gauge - 12:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2119-08-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590216, "text": "63 yr old Porteguese speaking male with end stage liver, stenosed TIPS.\n recurrent encephalopathy presents with leukocytosis, abd pain, and new\n renal failure with lactic acidosis and hyerkalemia. Tx to MICU for\n acute HD (new HD for him)\n Paracentesis done on , ~5l removed, ascetic fluid turbid Albumen\n 100gm IV ordered for during paracentesis\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Paracentesis\n Action:\n Abd remains distended and tense, bladder pressure 18, Receiving\n lactulose, titrating to 3 stools per day, had Large brown liquid stool\n after lactulose. Wife in to visit, translating for pt, states he is not\n confused and is oriented Wife at times when speaking to pt,\n states he is talking about dying\n Response:\n Paracentesis\n Plan:\n Social work consult in am for family support\n Lactulose as ordered, check bladder pressure twice daily.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output slightly improved in this shift 20-40cc/hr.\n Action:\n Monitoring, Plans for HD \n Response:\n Oliguric\n Plan:\n HD in am\n .H/O hypoglycemia\n Assessment:\n Receiving SS coverage\n Action:\n Fs elevated 404 @ midnight received 12 units humalog and monitored BS\n q2h.\n Response:\n Pending\n Plan:\n Insulin as ordered\n Fs qid\n" }, { "category": "Physician ", "chartdate": "2119-08-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 590102, "text": "Chief Complaint: This is a 63 year old Portuguese-speaking man with\n end-stage liver disease and stenosed TIPS, recurrent admissions for\n hepatic encephalopathy, now here with abdominal pain and a WBC of 21.3\n with a neutrophil predominance and hepatorenal syndrome.\n 24 Hour Events:\n Patient hypotensive, started on levophed, quickly weaned (duration 35\n minutes), pressures stable throughout day off pressor\n Arterial line placed\n HD without incidence, 200ml off\n Transfused 1 unit of pRBC without appropriate bump during dialysis\n ARTERIAL LINE - START 12:15 PM\n ULTRASOUND - At 01:30 PM\n ULTRASOUND - At 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:22 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: 36.8\nC (98.3\n HR: 63 (58 - 77) bpm\n BP: 104/44(60) {97/44(0) - 142/101(234)} mmHg\n RR: 16 (14 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.5 kg (admission): 87.2 kg\n Bladder pressure: 20 (20 - 24) mmHg\n Total In:\n 1,647 mL\n 128 mL\n PO:\n 390 mL\n TF:\n IVF:\n 382 mL\n 128 mL\n Blood products:\n 875 mL\n Total out:\n 469 mL\n 38 mL\n Urine:\n 269 mL\n 38 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,178 mL\n 90 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///23/\n Physical Examination\n Patient moaning, interactive despite language barrier\n Labs / Radiology\n 105 K/uL\n 8.7 g/dL\n 206 mg/dL\n 3.5 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 32 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.2 %\n 6.5 K/uL\n [image002.jpg]\n 11:47 PM\n 06:08 AM\n 09:12 AM\n 07:00 PM\n 11:28 PM\n 04:10 AM\n WBC\n 9.8\n 10.2\n 7.6\n 7.4\n 6.5\n Hct\n 24.5\n 24.7\n 24.8\n 26.0\n 26.2\n Plt\n 135\n 110\n 104\n 115\n 105\n Cr\n 7.5\n 4.8\n 5.2\n 2.1\n 3.5\n Glucose\n 99\n 59\n 74\n 175\n 206\n Other labs: PT / PTT / INR:22.2/35.6/2.1, ALT / AST:18/28, Alk Phos / T\n Bili:184/1.8, Differential-Neuts:83.9 %, Lymph:8.7 %, Mono:5.9 %,\n Eos:1.2 %, D-dimer:1656 ng/mL, Fibrinogen:504 mg/dL, Lactic Acid:2.5\n mmol/L, Albumin:3.1 g/dL, LDH:130 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:2.8 mg/dL\n Fluid analysis / Other labs: FDP 0-10\n Fibrinogen 504\n Haptoglobin 98\n Imaging: Liver ultrasound with doppler\n IMPRESSION:\n 1. Large amount of ascites as in prior study.\n 2. No improvement in elevated velocities of TIPS, and possibly\n increased in the mid portion, concerning for stenosis, although patent.\n Please note that the main portal vein and its other major branches are\n not assessed in any\n detail on this study.\n 3. Coarsened architecture liver without evidence of focal lesion.\n Microbiology: C.Diff pending\n Blood culture pending\n Urine culture pending\n Gram stain of ascites - no bacteria\n Ascites culture - prelim no growth\n Assessment and Plan\n This is a 63 year old Portuguese-speaking man with end-stage liver\n disease and stenosed TIPS, recurrent admissions for hepatic\n encephalopathy, now here with abdominal pain and a WBC of 21.3 with a\n neutrophil predominance, lactic acidosis and hepatorenal disease.\n ASCITES\n Likely related to massive ascites likely hepatorenal syndrome. No\n evidence of SBP given low WBC on diagnostic tap; tap appears bloody;\n most likely coagulopathy, though consistent appearance of this\n finding might suggest hemoperitoneum from another process rather than\n from trauma from tap; CT apparently offers no obvious suspect. No sign\n of perf on CT scan. Surgery evaluating per ED request. Possible gastric\n outlet obstruction seen on CT scan; may improve w decrease in ascitic\n fluid. U/S done, shows partial stenosis of the portal vein. No tap at\n this time due to risk of worsening hepatorenal syndrome, however, if\n worsening hypotension/renal failure, may need to tap due to compartment\n syndrome. Bladder pressure of 24 yesterday.\n - f/u transplant surgery recs\n - f/u liver recs\n - f/u nephrology recs\n - NGT if not tolerating clears, emesis, etc\n - clear liquid diet for now\n LIVER CIRRHOSIS, ETOH, w/ encephalopathy\n Hepatorenal syndrome worsens prognosis. Could have been precipitated by\n large volume tap on prior admission, though pt has tolerated similar\n (~5L) in the past. Pt has been on transplant list. MELD on admission =\n 41. U/S shows some stenosis from TIPS in protal circulation.\n - daily MELD labs\n - transplant surgery and liver services following, appreciate recs\n - octreotide and midodrine\n - regular lactulose at home dose\n - continue home rifaximin\n - omeprazole\n - add propranolol once completed HD and blood pressures stable\n - hold diuretics\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely hepatorenal syndrome, perhaps large volume tap on last\n admission; vs change in hemodynamics infection; vs compartment\n syndrome from ascites causing pre-renal picture. FeNa on admission 0.6.\n - Cont zosyn\n - Follow up on renal recs for HD plans\n - holding metformin - contributing to lactic acidosis\nHYPOTENSION\n Possibly due to decreased venous return due to abdominal pressure vs\n infection/sepsis vs hypovolemia due to fluid sequestration as ascites.\n - start levophed for SBP <80 titrate to MAPs > 65.\n - If patient becomes hypotensive consider tap to decrease\n intra-abdominal pressure\n - zosyn empirically for infection, consider adding flagyl/vanco if\n appears more toxic.\n\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Per family report, patient currently appears to have intact mental\n status, however, appears confused at times, with mumbling and groaning\n on. Possibly due to hepatic encephalopathy (NH3 = 66 on admission) vs\n infection, UTI vs SBP, vs acidemia. Remains afebrile\n - Lactulose 60mg PO TID - titrate to 3 BM per day\n - follow culture results\n - holding metformin\n - trend lactate\n - restraints if needed\n COAGULOPATHY\n Assoc w liver failure. Got 6U FFP for HD line placement. Holding\n coumadin for now.\n - continue to trend coags\n - give vit K for goal INR <2.\n - consider FFP for procedures\n LACTIC ACIDOSIS\n Most likely liver failure itself, though metformin toxicity in\n setting of new renal failure may also be responsible. Mesenteric\n ischemia could be culprit; no positive evidence for this at this point,\n but should follow closely.\n - trend lactate\n - hold metformin\n - quaiac stool\n - follow AG\n Leukocytosis\n Unclear source. Concern for abdominal source but as above this is not\n clear after dx tap and CT abd/pelvis, RLL opacity; hard to account for\n this degree of WBC with this small PNA though relative immune\n suppression of liver/renal failure may diminish inflammatory response.\n High WBC out of proportion to symptoms, with abd pain, in pt w multiple\n hospitalizations, raises special concern for c. diff though obvious\n colitis not seen on CT. Resolved since admission.\n - f/u urine, blood and ascites cultures, c.diff toxin\n - continue empiric gram negative coverage with zosyn per liver's\n request\n - consider adding vanco and flagyl if clinical status is worsening\n - trend with CBC with diff\nHyperkalemia\n Likely in the setting of renal disease at admission, has resolved from\n 6.5 to 5.6. Currently stable at 5.0.\n - Check lytes q12h\n - Check EKG if K+ increases\n LACTIC ACIDOSIS\n Most likely liver failure itself, though metformin toxicity in\n setting of new renal failure may also be responsible. Mesenteric\n ischemia could be culprit; no positive evidence for this at this point,\n but should follow closely.\n - trend lactate\n - hold metformin\n - quaiac stool\n - follow AG\n DIABETES\n Holding oral antihyperglycemics based on low blood sugar in ED today.\n ISS alone for now. Has had more issues with high blood sugar than low\n in the past.\n - cont. ISS\nACCESS\n - if requires further pressors place central line - IJ with ultrasound\n ICU Care\n Nutrition:\n Comments: clear diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 11:27 PM\n Arterial Line - 12:15 PM\n 18 Gauge - 12:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2119-08-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 590104, "text": "Chief Complaint: This is a 63 year old Portuguese-speaking man with\n end-stage liver disease and stenosed TIPS, recurrent admissions for\n hepatic encephalopathy, now here with abdominal pain and a WBC of 21.3\n with a neutrophil predominance and hepatorenal syndrome.\n 24 Hour Events:\n Patient hypotensive, started on levophed, quickly weaned (duration 35\n minutes), pressures stable throughout day off pressor\n Arterial line placed\n HD without incidence, 200ml off\n Transfused 1 unit of pRBC without appropriate bump during dialysis\n ARTERIAL LINE - START 12:15 PM\n ULTRASOUND - At 01:30 PM\n ULTRASOUND - At 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:22 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: 36.8\nC (98.3\n HR: 63 (58 - 77) bpm\n BP: 104/44(60) {97/44(0) - 142/101(234)} mmHg\n RR: 16 (14 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.5 kg (admission): 87.2 kg\n Bladder pressure: 20 (20 - 24) mmHg\n Total In:\n 1,647 mL\n 128 mL\n PO:\n 390 mL\n TF:\n IVF:\n 382 mL\n 128 mL\n Blood products:\n 875 mL\n Total out:\n 469 mL\n 38 mL\n Urine:\n 269 mL\n 38 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,178 mL\n 90 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///23/\n Physical Examination\n Patient moaning, interactive despite language barrier\n Bradycardic to 50\ns, S1, S2 normal, II/VI systolic murmur\n Inspiratory crackles at lung bases, diminished breath sounds at bases,\n without wheeze or rub\n Distended abdomen, diffusely tender, prominent bulging umbilicus, no\n bowel sounds appreciated\n Lower ext edema, warm ext\n Positive for asterixis\n Labs / Radiology\n 105 K/uL\n 8.7 g/dL\n 206 mg/dL\n 3.5 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 32 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.2 %\n 6.5 K/uL\n [image002.jpg]\n 11:47 PM\n 06:08 AM\n 09:12 AM\n 07:00 PM\n 11:28 PM\n 04:10 AM\n WBC\n 9.8\n 10.2\n 7.6\n 7.4\n 6.5\n Hct\n 24.5\n 24.7\n 24.8\n 26.0\n 26.2\n Plt\n 135\n 110\n 104\n 115\n 105\n Cr\n 7.5\n 4.8\n 5.2\n 2.1\n 3.5\n Glucose\n 99\n 59\n 74\n 175\n 206\n Other labs: PT / PTT / INR:22.2/35.6/2.1, ALT / AST:18/28, Alk Phos / T\n Bili:184/1.8, Differential-Neuts:83.9 %, Lymph:8.7 %, Mono:5.9 %,\n Eos:1.2 %, D-dimer:1656 ng/mL, Fibrinogen:504 mg/dL, Lactic Acid:2.5\n mmol/L, Albumin:3.1 g/dL, LDH:130 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:2.8 mg/dL\n Fluid analysis / Other labs: FDP 0-10\n Fibrinogen 504\n Haptoglobin 98\n Imaging: Liver ultrasound with doppler\n IMPRESSION:\n 1. Large amount of ascites as in prior study.\n 2. No improvement in elevated velocities of TIPS, and possibly\n increased in the mid portion, concerning for stenosis, although patent.\n Please note that the main portal vein and its other major branches are\n not assessed in any\n detail on this study.\n 3. Coarsened architecture liver without evidence of focal lesion.\n Microbiology: C.Diff pending\n Blood culture pending\n Urine culture pending\n Gram stain of ascites - no bacteria\n Ascites culture - prelim no growth\n Assessment and Plan\n This is a 63 year old Portuguese-speaking man with end-stage liver\n disease and stenosed TIPS, recurrent admissions for hepatic\n encephalopathy, now here with abdominal pain and a WBC of 21.3 with a\n neutrophil predominance, lactic acidosis and hepatorenal disease.\n ASCITES\n Likely related to massive ascites likely hepatorenal syndrome. No\n evidence of SBP given low WBC on diagnostic tap; tap appears bloody;\n most likely coagulopathy, though consistent appearance of this\n finding might suggest hemoperitoneum from another process rather than\n from trauma from tap; CT apparently offers no obvious suspect. No sign\n of perf on CT scan. Surgery evaluating per ED request. Possible gastric\n outlet obstruction seen on CT scan; may improve w decrease in ascitic\n fluid. U/S done, shows partial stenosis of the portal vein. No tap at\n this time due to risk of worsening hepatorenal syndrome, however, if\n worsening hypotension/renal failure, may need to tap due to compartment\n syndrome. Bladder pressure of 24 yesterday.\n - f/u transplant surgery recs\n - f/u liver recs\n - f/u nephrology recs\n - NGT if not tolerating clears, emesis, etc\n - clear liquid diet for now\n LIVER CIRRHOSIS, ETOH, w/ encephalopathy\n Hepatorenal syndrome worsens prognosis. Could have been precipitated by\n large volume tap on prior admission, though pt has tolerated similar\n (~5L) in the past. Pt has been on transplant list. MELD on admission =\n 41. U/S shows some stenosis from TIPS in protal circulation.\n - daily MELD labs\n - transplant surgery and liver services following, appreciate recs\n - octreotide and midodrine\n - regular lactulose at home dose\n - continue home rifaximin\n - omeprazole\n - add propranolol once completed HD and blood pressures stable\n - hold diuretics\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Likely hepatorenal syndrome, perhaps large volume tap on last\n admission; vs change in hemodynamics infection; vs compartment\n syndrome from ascites causing pre-renal picture. FeNa on admission 0.6.\n - Cont zosyn\n - Follow up on renal recs for HD plans\n - holding metformin - contributing to lactic acidosis\nHYPOTENSION\n Possibly due to decreased venous return due to abdominal pressure vs\n infection/sepsis vs hypovolemia due to fluid sequestration as ascites.\n - start levophed for SBP <80 titrate to MAPs > 65.\n - If patient becomes hypotensive consider tap to decrease\n intra-abdominal pressure\n - zosyn empirically for infection, consider adding flagyl/vanco if\n appears more toxic.\n\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Per family report, patient currently appears to have intact mental\n status, however, appears confused at times, with mumbling and groaning\n on. Possibly due to hepatic encephalopathy (NH3 = 66 on admission) vs\n infection, UTI vs SBP, vs acidemia. Remains afebrile\n - Lactulose 60mg PO TID - titrate to 3 BM per day\n - follow culture results\n - holding metformin\n - trend lactate\n - restraints if needed\n COAGULOPATHY\n Assoc w liver failure. Got 6U FFP for HD line placement. Holding\n coumadin for now.\n - continue to trend coags\n - give vit K for goal INR <2.\n - consider FFP for procedures\n LACTIC ACIDOSIS\n Most likely liver failure itself, though metformin toxicity in\n setting of new renal failure may also be responsible. Mesenteric\n ischemia could be culprit; no positive evidence for this at this point,\n but should follow closely.\n - trend lactate\n - hold metformin\n - quaiac stool\n - follow AG\n Leukocytosis\n Unclear source. Concern for abdominal source but as above this is not\n clear after dx tap and CT abd/pelvis, RLL opacity; hard to account for\n this degree of WBC with this small PNA though relative immune\n suppression of liver/renal failure may diminish inflammatory response.\n High WBC out of proportion to symptoms, with abd pain, in pt w multiple\n hospitalizations, raises special concern for c. diff though obvious\n colitis not seen on CT. Resolved since admission.\n - f/u urine, blood and ascites cultures, c.diff toxin\n - continue empiric gram negative coverage with zosyn per liver's\n request\n - consider adding vanco and flagyl if clinical status is worsening\n - trend with CBC with diff\nHyperkalemia\n Likely in the setting of renal disease at admission, has resolved from\n 6.5 to 5.6. Currently stable at 5.0.\n - Check lytes q12h\n - Check EKG if K+ increases\n LACTIC ACIDOSIS\n Most likely liver failure itself, though metformin toxicity in\n setting of new renal failure may also be responsible. Mesenteric\n ischemia could be culprit; no positive evidence for this at this point,\n but should follow closely.\n - trend lactate\n - hold metformin\n - quaiac stool\n - follow AG\n DIABETES\n Holding oral antihyperglycemics based on low blood sugar in ED today.\n ISS alone for now. Has had more issues with high blood sugar than low\n in the past.\n - cont. ISS\nACCESS\n - if requires further pressors place central line - IJ with ultrasound\n ICU Care\n Nutrition:\n Comments: clear diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 11:27 PM\n Arterial Line - 12:15 PM\n 18 Gauge - 12:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2119-08-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590116, "text": "Hypotension (not Shock)\n Assessment:\n Action:\n Bp 80\ns-115/, Bp dips down to 80\ns/ while asleep, plan to not treat\n unless SBP <80/\n Response:\n Plan:\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hypoglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2119-08-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 590117, "text": "Chief Complaint: liver failure, hepatorenal syndrome, 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 24 Hour Events:\n ARTERIAL LINE - START 12:15 PM\n ULTRASOUND - At 01:30 PM\n ULTRASOUND - At 04:00 PM\n Transient Levophed\n Higher dose Midorine and Octreotide\n HD tolerated - only 200 ml negative - given 1 u PRBCs\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:59 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: 36.8\nC (98.2\n HR: 62 (50 - 77) bpm\n BP: 83/38(50) {83/37(0) - 142/101(234)} mmHg\n RR: 17 (14 - 23) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.5 kg (admission): 87.2 kg\n Bladder pressure: 20 (20 - 20) mmHg\n Total In:\n 1,647 mL\n 265 mL\n PO:\n 390 mL\n 120 mL\n TF:\n IVF:\n 382 mL\n 145 mL\n Blood products:\n 875 mL\n Total out:\n 469 mL\n 43 mL\n Urine:\n 269 mL\n 43 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,178 mL\n 222 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///23/\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 105 K/uL\n 206 mg/dL\n 3.5 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 32 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.2 %\n 6.5 K/uL\n [image002.jpg]\n 11:47 PM\n 06:08 AM\n 09:12 AM\n 07:00 PM\n 11:28 PM\n 04:10 AM\n WBC\n 9.8\n 10.2\n 7.6\n 7.4\n 6.5\n Hct\n 24.5\n 24.7\n 24.8\n 26.0\n 26.2\n Plt\n 135\n 110\n 104\n 115\n 105\n Cr\n 7.5\n 4.8\n 5.2\n 2.1\n 3.5\n Glucose\n 99\n 59\n 74\n 175\n 206\n Other labs: PT / PTT / INR:22.2/35.6/2.1, ALT / AST:18/28, Alk Phos / T\n Bili:184/1.8, Differential-Neuts:83.9 %, Lymph:8.7 %, Mono:5.9 %,\n Eos:1.2 %, D-dimer:1656 ng/mL, Fibrinogen:504 mg/dL, Lactic Acid:2.5\n mmol/L, Albumin:3.1 g/dL, LDH:130 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O ASCITES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n .H/O HEPATIC ENCEPHALOPATHY\n .H/O RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O HYPOGLYCEMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:27 PM\n Arterial Line - 12:15 PM\n 18 Gauge - 12:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2119-08-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 590118, "text": "Chief Complaint: liver failure, hepatorenal syndrome, 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 24 Hour Events:\n ARTERIAL LINE - START 12:15 PM\n ULTRASOUND - At 01:30 PM\n ULTRASOUND - At 04:00 PM\n Transient Levophed\n Higher dose Midorine and Octreotide\n HD tolerated - only 200 ml negative - given 1 u PRBCs\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:59 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: 36.8\nC (98.2\n HR: 62 (50 - 77) bpm\n BP: 83/38(50) {83/37(0) - 142/101(234)} mmHg\n RR: 17 (14 - 23) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.5 kg (admission): 87.2 kg\n Bladder pressure: 20 (20 - 20) mmHg\n Total In:\n 1,647 mL\n 265 mL\n PO:\n 390 mL\n 120 mL\n TF:\n IVF:\n 382 mL\n 145 mL\n Blood products:\n 875 mL\n Total out:\n 469 mL\n 43 mL\n Urine:\n 269 mL\n 43 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,178 mL\n 222 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///23/\n Physical Examination\n Gen: lying in bed, complains of abd pain\n HEENT: op clear\n CV: RR\n Ches: scattrered rales with ext wheezes\n Abd: massive distension, absent bowel sounds, tense ascites\n Ex: trace edema\n Neuro: alert and answering questions\n Labs / Radiology\n 8.7 g/dL\n 105 K/uL\n 206 mg/dL\n 3.5 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 32 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.2 %\n 6.5 K/uL\n [image002.jpg]\n 11:47 PM\n 06:08 AM\n 09:12 AM\n 07:00 PM\n 11:28 PM\n 04:10 AM\n WBC\n 9.8\n 10.2\n 7.6\n 7.4\n 6.5\n Hct\n 24.5\n 24.7\n 24.8\n 26.0\n 26.2\n Plt\n 135\n 110\n 104\n 115\n 105\n Cr\n 7.5\n 4.8\n 5.2\n 2.1\n 3.5\n Glucose\n 99\n 59\n 74\n 175\n 206\n Other labs: PT / PTT / INR:22.2/35.6/2.1, ALT / AST:18/28, Alk Phos / T\n Bili:184/1.8, Differential-Neuts:83.9 %, Lymph:8.7 %, Mono:5.9 %,\n Eos:1.2 %, D-dimer:1656 ng/mL, Fibrinogen:504 mg/dL, Lactic Acid:2.5\n mmol/L, Albumin:3.1 g/dL, LDH:130 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O ASCITES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n .H/O HEPATIC ENCEPHALOPATHY\n .H/O RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O HYPOGLYCEMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:27 PM\n Arterial Line - 12:15 PM\n 18 Gauge - 12:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2119-08-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 590132, "text": "Chief Complaint: liver failure, hepatorenal syndrome, 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 24 Hour Events:\n ARTERIAL LINE - START 12:15 PM\n ULTRASOUND - At 01:30 PM\n ULTRASOUND - At 04:00 PM\n Transient Levophed\n Higher dose Midorine and Octreotide\n HD tolerated - only 200 ml negative - given 1 u PRBCs\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Octreotide, Midodrine, 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 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: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.2\n HR: 62 (50 - 77) bpm\n BP: 83/38(50) {83/37(0) - 142/101(234)} mmHg\n RR: 17 (14 - 23) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.5 kg (admission): 87.2 kg\n Bladder pressure: 20 (20 - 20) mmHg\n Total In:\n 1,647 mL\n 265 mL\n PO:\n 390 mL\n 120 mL\n TF:\n IVF:\n 382 mL\n 145 mL\n Blood products:\n 875 mL\n Total out:\n 469 mL\n 43 mL\n Urine:\n 269 mL\n 43 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,178 mL\n 222 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///23/\n Physical Examination\n Gen: lying in bed, complains of abd pain\n HEENT: op clear\n CV: RR\n Ches: scattered rales with ext wheezes\n Abd: massive distension, absent bowel sounds, tense ascites\n Ex: trace edema\n Neuro: alert and answering questions\n Labs / Radiology\n 8.7 g/dL\n 105 K/uL\n 206 mg/dL\n 3.5 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 32 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.2 %\n 6.5 K/uL\n [image002.jpg]\n 11:47 PM\n 06:08 AM\n 09:12 AM\n 07:00 PM\n 11:28 PM\n 04:10 AM\n WBC\n 9.8\n 10.2\n 7.6\n 7.4\n 6.5\n Hct\n 24.5\n 24.7\n 24.8\n 26.0\n 26.2\n Plt\n 135\n 110\n 104\n 115\n 105\n Cr\n 7.5\n 4.8\n 5.2\n 2.1\n 3.5\n Glucose\n 99\n 59\n 74\n 175\n 206\n Other labs: PT / PTT / INR:22.2/35.6/2.1, ALT / AST:18/28, Alk Phos / T\n Bili:184/1.8, Differential-Neuts:83.9 %, Lymph:8.7 %, Mono:5.9 %,\n Eos:1.2 %, D-dimer:1656 ng/mL, Fibrinogen:504 mg/dL, Lactic Acid:2.5\n mmol/L, Albumin:3.1 g/dL, LDH:130 IU/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:2.8 mg/dL\n US: persistent TIPS stenosis, large ascites\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O ASCITES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n .H/O HEPATIC ENCEPHALOPATHY\n .H/O RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O HYPOGLYCEMIA\n 1. Acute Renal Failure: DDX pre renal versus evolving hepatorenal\n he also has a bladder pressure of 24- held off on repeat tap\n yesterday but will tap today. Plan for HD tomorrow. Watch lytes and\n renally dose all meds. Try a 1 mg/kg albumin challenge today\n 2. Hypotension: has been more stable\n Aline 20 pts higher. When\n sleeps drops MAP to 55-60 but otherwise OK. Check CVP. Anticipate\n potential fluid shifts and hypotension with tap and will support with\n pressors as needed\n 3. ESLD: MELD is high at 41 with HRS concerning, liver team\n following. Consult transplant surgery following and onogin work up for\n listing.\n 4. Acidosis: lactic- DDX is poor forward flow versus metformin\n induced in setting of liver failure with poor clearance. Resolving.\n Holding metformin, had HD, we will continue to follow\n 5. Leukocytosis: pan culture, will maintain on Zosyn as we await\n data\n 6. DM: continue to check FS closely since was so hypoglycemic on\n arrival\n but now hyperglycemic\n Remaining issues as per Housestaff.\n ICU Care\n Nutrition: clears\n Glycemic Control:\n Lines: Dialysis Catheter - 11:27 PM\n Arterial Line - 12:15 PM\n 18 Gauge - 12:30 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: with pt and wife\n status: Full code\n Disposition :ICU\n Total time spent: 45\n" }, { "category": "Nursing", "chartdate": "2119-08-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 589949, "text": "Pt is a 63y/o gentleman recently discharged from where he had\n been admitted for hypocalcemia, mental status changes, Did have TIPS\n for esophageal bleeding, paracentisis for ascites. Had been home with\n his wife when she noticed over the past two days and increase in\n lethargy and loss of appetite. She brought him to EW where he was found\n to have abnormal labs\n.Lacate 9.1, BUN 86 creat 7.6, wbc 21.3, glucose\n was 15, given amp of D50 and repeat fs was 13, placed on D5W infusion\n at 100cc/hr, Had abd.CT scan showing limited 2.2 ascites and lack of\n contrast\nmarked distention of the stomach, and prox duodenum ?gartric\n outlet obstruction of unclear etiology, new since , large\n ascites, Octreotide infusion started . Admit to MICU for closer\n monitoring.\n" }, { "category": "ECG", "chartdate": "2119-08-16 00:00:00.000", "description": "Report", "row_id": 199117, "text": "Normal sinus rhythm, rate 138. Left axis deviation. Non-specific\nrepolarization changes. Compared to the previous tracing of \nnormal sinus rhythm has given way to sinus tachycardia and the ventricular\nrate is virtually doubled. Also, the axis is now leftward.\n\n" }, { "category": "ECG", "chartdate": "2119-08-04 00:00:00.000", "description": "Report", "row_id": 199118, "text": "Sinus rhythm. Non-specific intraventricular conduction delay. Compared to the\nprevious tracing of the Q-T interval is normal.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1093384, "text": " 3:50 PM\n CHEST (PA & LAT) Clip # \n Reason: altered mental status\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ? altered mental status\n REASON FOR THIS EXAMINATION:\n altered mental status\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status.\n\n COMPARISON: .\n\n FRONTAL AND LATERAL VIEWS, CHEST: There is left lower lobe opacity, new since\n the prior study, may reflect atelectasis and/or pneumonia. There is mild\n bibasilar atelectasis. There is no pulmonary edema. There is aortic arch\n calcification. Heart size is normal. Hilar contours are unremarkable. There\n is thoracic kyphotic deformity limiting evaluation on the lateral view. There\n is multilevel degenerative disease, stable. There is also DJD in the vertebral\n column.\n\n IMPRESSION: Left lower lobe opacity may reflect atelectasis and/or pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-04 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1093385, "text": " 3:50 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: eval for obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with abd pain\n REASON FOR THIS EXAMINATION:\n eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain. Evaluate for obstruction.\n\n COMPARISON: CT abdomen, .\n\n SUPINE AND UPRIGHT VIEWS, ABDOMEN: This is extremely limited study due to\n patient's body habitus and underpenetration. A TIPS stent is noted in the\n right upper quadrant. There is extensive ascites, centrally displacing the\n bowel loops. There is no pneumoperitoneum or pneumotosis. However, the\n diaphragms are not completely included in the field of view.\n\n\n IMPRESSION:\n 1. No definite evidence of obstruction.\n 2. Ascites\n\n" }, { "category": "Radiology", "chartdate": "2119-08-05 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1093502, "text": " 12:37 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \n Reason: eval portal system, eval for occlusion of portal system, TIP\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ESLD, s/p TIPS and revision\n REASON FOR THIS EXAMINATION:\n eval portal system, eval for occlusion of portal system, TIPS, etc; eval portal\n flow\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SAT 2:59 PM\n Interval increase in mid-TIPS velocity concerning for continued TIPS stenosis\n (now approx 300 cm/sec).\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 63-year-old male with history of end-stage liver disease, after\n TIPS.\n\n COMPARISON: Previous abdominal Doppler studies and .\n\n ABDOMINAL HEPATIC DOPPLER ULTRASOUND: There is again a large amount of\n ascites. The liver demonstrates coarsened architecture without focal lesion.\n The gallbladder is not well evaluated on the current study. There is no\n intrahepatic biliary ductal dilatation.\n\n A patent TIPS is identified. With velocities of 112 cm/sec, 236 - 300 cm/sec,\n and 160 cm/sec in the proximal, mid, and distal portions respectively. This\n is similar to velocities compared to the prior study, at which time the\n proximal, mid, and distal portions demonstrated velocities of 128 cm/sec, 222\n cm/sec, and 198 cm/sec. However, the mid-TIPS velocity may be slightly\n increased.\n\n The main portal vein is patent, with antegrade flow and a velocity of 57\n cm/sec. A previosly noted filling defect in the main portal vein is not\n visualized, but the portal vein itself was not really assessed. Except for\n the TIPS shunt, its major branches were not really assessed either.\n\n IMPRESSION:\n\n 1. Large amount of ascites as in prior study.\n\n 2. No improvement in elevated velocities of TIPS, and possibly increased in\n the mid portion, concerning for stenosis, although patent. Please note that\n the main portal vein and its other major branches are not assessed in any\n detail on this study.\n\n 3. Coarsened architecture liver without evidence of focal lesion.\n\n (Over)\n\n 12:37 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \n Reason: eval portal system, eval for occlusion of portal system, TIP\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2119-08-05 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1093503, "text": ", MED MICU 12:37 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \n Reason: eval portal system, eval for occlusion of portal system, TIP\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ESLD, s/p TIPS and revision\n REASON FOR THIS EXAMINATION:\n eval portal system, eval for occlusion of portal system, TIPS, etc; eval portal\n flow\n ______________________________________________________________________________\n PFI REPORT\n Interval increase in mid-TIPS velocity concerning for continued TIPS stenosis\n (now approx 300 cm/sec).\n\n" }, { "category": "Radiology", "chartdate": "2119-08-04 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1093388, "text": " 4:20 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: abd pain, elevated lactate, eval for free air or intrabd pat\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with abd pain, new renal failure, elevaed Lactate\n REASON FOR THIS EXAMINATION:\n abd pain, elevated lactate, eval for free air or intrabd pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SHfd FRI 5:12 PM\n Limited ascites and lack of contrast.\n Marked distention of the stomach and prox duodenum. ? gastric outlet\n obstruction of unclear etiology, new since .\n Large ascites, Cirrhosis\n left 2-3 mm nonobstructive renal calc\n No definite wall thickening or pneumatosis or portal venous gas to suggest\n bowel ischemia.\n appendix partially seen\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Abdominal pain. Elevated lactate.\n\n COMPARISON: CT abdomen and pelvis from .\n\n TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained\n without administration of IV contrast. Coronal and sagittal reformatted\n images were obtained. IV contrast was not administered due to elevated\n creatinine, which was discussed with the ordering physician.\n\n FINDINGS:\n\n CT ABDOMEN WITHOUT CONTRAST: The lung bases demonstrate atelectatic changes\n within the left lower lobe, new since prior exam. The heart is upper limit of\n normal in size. There is no pericardial effusion. There is marked amount of\n intra-abdominal ascites, increased since prior exam. There is no\n pneumoperitoneum. The liver demonstrates nodular contour and is cirrhotic. A\n TIPS stent is identified. The gallbladder is collapsed and limiting\n evaluation. Focal high density, likely post surgical or calcification seen\n within the inferior aspect of the right lobe of the liver, image #28, series\n 2. The spleen, adrenals appear unremarkable on this noncontrast study. The\n abdominal aorta and iliac vessels demonstrate mild atherosclerotic\n calcifications. The stomach is markedly distended with fluid and food\n contents. Change in caliber is noted at the he level of the first to second\n portion of the duodenum. The loops of small bowel and large bowel are\n collapsed, however, there is no evidence of bowel wall thickening. No\n pneumatosis is seen. There is no portal venous gas. No free air.\n\n There is 2-3 mm nonobstructive left renal stone, image #42.\n\n PELVIC CT WITHOUT CONTRAST: The urinary bladder contains a Foley catheter.\n The prostate gland and seminal vesicles are grossly unremarkable. The\n visualized rectosigmoid colon is collapsed. There is extension of ascites\n (Over)\n\n 4:20 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: abd pain, elevated lactate, eval for free air or intrabd pat\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n fluid into an umbilical hernia and into a right inguinal hernia. The appendix\n is partially visualized, suboptimally evaluated due to intra-abdominal\n ascites.\n\n OSSEOUS STRUCTURES: Evaluation of the osseous structures demonstrates no\n evidence of acute displaced fracture. Degenerative changes are noted.\n\n IMPRESSION:\n\n 1. Markedly increased intraabdominal ascites. Liver cirrhosis.\n\n 2. Marked stomach distention with transition in caliber at the first to\n second portion of the duodenum, concerning for gastric outlet obstruction of\n unclear etiology.\n\n 3. -mm non-obstructing left renal stone.\n\n 4. No CT evidence of bowel ischemia with no evidence of wall thickening,\n pneumatosis, or portal venous air. No free air.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1093446, "text": " 11:35 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval new line\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with R IJ placed\n REASON FOR THIS EXAMINATION:\n eval new line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old man with right internal jugular catheter is placed.\n\n COMPARISON: .\n\n SUPINE CHEST X-RAY PERFORMED AT 23:55: There is new right internal jugular\n catheter with its tip at the superior vena cava. There is no sign of\n pneumothorax. Cardiac silhouette is similar to the previous study, is\n unremarkable. The aortic knob is calcified with the sign of atherosclerotic\n disease. There is increase in the retrocardiac left lower lobe opacity as\n compared to the previous study with increase in the left pleural effusion\n which is currently moderate. Also noted is TIPS at the right upper quadrant\n of abdomen.\n\n IMPRESSION:\n 1. New central venous line at the right internal jugular vein. No\n pneumothorax.\n 2. Increase in the retrocardiac left lower lobe opacity with small increase\n in the left pleural effusion.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-16 00:00:00.000", "description": "P DUPLEX DOPP ABD/PEL PORT", "row_id": 1095078, "text": " 2:18 PM\n DUPLEX DOPP ABD/PEL PORT Clip # \n Reason: please eval for new acute process and doppler for patency of\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with etoh cirrhosis and ams. please eval for new acute process\n and doppler for patency of vessel\n REASON FOR THIS EXAMINATION:\n please eval for new acute process and doppler for patency of vessel\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRCi WED 5:20 PM\n PFI: Patent TIPS shunt with normal velocities and waveforms. Large amount of\n intra-abdominal ascites.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Liver and gallbladder abdominal ultrasound. Grayscale and Doppler\n evaluation.\n\n INDICATION: Alcoholic cirrhosis with altered mental status worsening. Please\n valuate for TIPS patency.\n\n COMPARISON: Abdominal TIPS evaluation .\n\n GRAYSCALE IMAGING: There is a large amount of intra-abdominal ascites. The\n liver is coarsened, nodular and echogenic consistent with known cirrhosis. No\n definite focal mass lesions identified within the liver. The gallbladder\n again contains several tiny polyps without intraluminal stone or luminal\n dilatation. There is no intra- or extra-hepatic biliary ductal dilatation.\n Moderate splenomegaly is again demonstrated with the spleen measuring at least\n 16.5 cm.\n\n DOPPLER EVALUATION: The main portal vein is patent with normal hepatopetal\n flow at a rate of approximately 30 cm/sec. Flow within the TIPS is normal in\n direction and fully patent with wall-to-wall flow. TIPS vascular velocities\n range from 72 cm/sec proximally with 174 cm/sec mid and 75 cm/sec distally\n which is little changed since prior study. There is normal respiratory\n variation within the TIPS shunt.\n\n CONCLUSION: Patent TIPS shunt with normal velocities and waveforms, little\n changed since recent comparison. Shrunken cirrhotic liver with large amount\n of intra-abdominal ascites.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-16 00:00:00.000", "description": "P DUPLEX DOPP ABD/PEL PORT", "row_id": 1095079, "text": ", P. MED FA10 2:18 PM\n DUPLEX DOPP ABD/PEL PORT Clip # \n Reason: please eval for new acute process and doppler for patency of\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with etoh cirrhosis and ams. please eval for new acute process\n and doppler for patency of vessel\n REASON FOR THIS EXAMINATION:\n please eval for new acute process and doppler for patency of vessel\n ______________________________________________________________________________\n PFI REPORT\n PFI: Patent TIPS shunt with normal velocities and waveforms. Large amount of\n intra-abdominal ascites.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-24 00:00:00.000", "description": "REMOVE TUNNELED CENTRAL W/O PORT", "row_id": 1096265, "text": " 9:42 AM\n DIALYSIS REMOVE Clip # \n Reason: Patient no longer requiring HD, please remove tunneled dialy\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ********************************* CPT Codes ********************************\n * REMOVE TUNNELED CENTRAL W/O PO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with , pt on Coumadin, stopped yesterday, INR 1.8\n REASON FOR THIS EXAMINATION:\n Patient no longer requiring HD, please remove tunneled dialysis line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 63-year-old male with end-stage liver disease on\n Coumadin, stopped yesterday. With creatinine trending down, no longer\n requiring hemodialysis. For removal of tunneled dialysis line.\n\n CLINICIANS: The removal was performed by Dr. supervision by Dr.\n .\n\n FINDINGS: Pre-existing tunneled left internal jugular dialysis line was\n noted. The skin was prepped using a chloraprep stick. Thereafter, under\n sterile conditions, a suture removal kit was used to remove the tunneled left\n internal jugular central venous catheter. Pressure was held at site of\n venopuncture until local hemostasis was achieved. The tunnel exit site was\n covered with a dry sterile dressing. The patient tolerated the removal well\n without complications.\n\n IMPRESSION: Uncomplicated removal of left tunneled internal jugular\n hemodialysis catheter.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1094995, "text": " 8:04 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for intracranial pathology.\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ESLD, altered mental status. Also has pituitary mass.\n REASON FOR THIS EXAMINATION:\n assess for intracranial pathology.\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): OXZa WED 1:16 PM\n PFI: Images degraded by patient's motion however no evidence for acute\n intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old male with end-stage liver disease and altered mental\n status. Patient has known pituitary mass.\n\n TECHNIQUE: Multidetector helical CT scan of the head was obtained without the\n administration of contrast. The initial acquisition was degraded by patient\n motion despite the administration of Haldol, and repeat images were obtained,\n without improvement.\n\n COMPARISON: CT head dated , and .\n\n FINDINGS: There is no evidence of acute hemorrhage, edema, mass effect or\n recent infarction. The -white matter differentiation is preserved. There\n is slight prominence of the sulci and to a lesser extent the ventricles,\n reflecting atrophy, some of which may relate to liver disease (or its causes).\n A previously noted lesion in the region of the pituitary gland measures 12 x\n 11 mm (3a:10) on this examination. The lesion is heterogeneous and it is\n unclear on this examination if this represents a discrete mass; however,\n several \"components\" are of CSF density, similar to the suprasellar cistern.\n This exam suggests there is scalloping of the adjacent tuberculum sellae, and\n this lesion may represent an arachnoid cyst. There is bilateral maxillary\n mucosal thickening. No osseous abnormality is identified.\n\n IMPRESSION:\n 1. No evidence for acute intracranial process.\n 2. Previously noted lesion in the sella, region of the pituitary gland,\n incompletely characterized on this examination. In comparison to several prior\n examinations, this lesion, an incidental finding, is unchanged in size. While\n dedicated MRI of the sella may help further characterization, it should only\n be obtained if warranted on clinical grounds.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1094996, "text": ", H. MED FA10 8:04 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for intracranial pathology.\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ESLD, altered mental status. Also has pituitary mass.\n REASON FOR THIS EXAMINATION:\n assess for intracranial pathology.\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n PFI REPORT\n PFI: Images degraded by patient's motion however no evidence for acute\n intracranial process.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1095247, "text": " 1:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Confirm NGT placement.\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new NGT.\n REASON FOR THIS EXAMINATION:\n Confirm NGT placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New NG tube placement.\n\n Comparison is made to the prior of .\n\n FINDINGS: The distal tip of NG tube projects at the expected location of the\n stomach. The remainder of the study including the location of left CV line,\n cardiomediastinal silhouette and hilar contours are unchanged. There are low\n lung volumes bilaterally. Atelectatic changes at the bases are unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1095024, "text": " 10:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for PNA\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with etoh cirrhosis and ams. please eval for PNA\n REASON FOR THIS EXAMINATION:\n please eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with ethanol cirrhosis and\n altered mental status.\n\n Portable AP chest radiograph was compared to .\n\n The lung volumes are significantly lower probably due to suboptimal\n inspiratory effort. The double-lumen dialysis catheter tip is at the level of\n the proximal right atrium. The bibasal atelectases have progressed since the\n prior study again most likely due to lower lung volumes. There is small\n amount of left pleural effusion. There is no pneumothorax.\n\n The low lung volumes decrease the sensitivity of this study for diagnosing of\n new pneumonia but note is made that the left basal opacity is persistent at\n least since and , although slightly\n improved compared to . Clinical correlation is recommended with\n further radiologic followup.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-18 00:00:00.000", "description": "P ABDOMEN (SUPINE & ERECT) PORT", "row_id": 1095475, "text": " 4:56 PM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: ? Intraabdominal process, ? ileus\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with hx cirrhosis with ascites,? abdominal compartment syndrome\n with worsening renal function, leukocytosis, residuals on tube feeds\n REASON FOR THIS EXAMINATION:\n ? Intraabdominal process, ? ileus\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis and ascites, to evaluate for ileus.\n\n FINDINGS: In comparison with study of , there is again some dilatation of\n loops of both large and small air-filled bowel, consistent with the clinical\n impression of adynamic ileus. Separation of bowel loops is consistent with\n ascites. Scattered radiation related to the body habitus of the patient\n greatly obscures detail.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-08 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1093886, "text": " 8:47 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: please assess patency of portal vein and it's branches with\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ESLD, TIPS, hx of portal vein thrombus\n REASON FOR THIS EXAMINATION:\n please assess patency of portal vein and it's branches with doppler.\n ______________________________________________________________________________\n FINAL REPORT\n LIVER DOPPLER\n\n CLINICAL INDICATION: End-stage liver disease, status post TIPS shunt and\n history of portal vein thrombosis.\n\n COMPARISON STUDY: .\n\n Once again the liver is small and nodular in architecture with a large volume\n of perihepatic ascites. No discrete focal liver lesions are identified. The\n gallbladder shows numerous polyps but no stones and there is no bile duct\n dilatation.\n\n Color flow and pulse Doppler assessment was performed. The main portal vein\n is patent with forward flow and a velocity of 46 cm/sec. The TIPS shunt is\n fully patent with wall-to-wall flow and velocities ranging from 85 cm/sec\n proximally to 147 cm/sec distally. There is normal respiratory variation\n within the TIPS shunt.\n\n The anterior right portal vein is patent but forward in direction rather than\n reversed towards the TIPS shunt. This is unchanged from the prior study. The\n left portal vein is visualized but there is essentially no detectable flow in\n the left portal vein. This was not technically visualized on the last study.\n\n CONCLUSION: Patent TIPS shunt with normal velocities and waveforms. Left\n portal vein is visualized and no flow is detected suggesting a left portal\n vein thrombosis. Main portal vein is fully patent with normal direction and\n normal velocity flow.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-11 00:00:00.000", "description": "TUNNELED W/O PORT", "row_id": 1094397, "text": " 12:00 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: please place tunnelled HD cath\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with etoh cirrhosis, now HD dependent. please place tunnelled\n HD cath\n REASON FOR THIS EXAMINATION:\n please place tunnelled HD cath\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc FRI 3:34 PM\n Uncomplicated image-guided placement of left internal jugular tunneled\n hemodialysis catheter with tip in right atrium. The line is ready to use.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 63-year-old male with alcoholic cirrhosis, now\n hemodialysis dependent. For placement of a tunneled hemodialysis catheter,\n with prior right internal jugular temporary dialysis catheter.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. \n . Dr. , the attending radiologist, was present and\n supervising throughout.\n\n PROCEDURE: Placement of tunneled left internal jugular hemodialysis double-\n lumen 23-cm catheter.\n\n PROCEDURE AND FINDINGS: After the risks, benefits, and alternatives of the\n procedure were explained to the patient, written informed consent was\n obtained. A preprocedure timeout was performed documenting the nature of the\n procedure and patient identifiers x3. Initial son interrogation of\n the right and left internal jugular veins with thrombus demonstrated in the\n right internal jugular vein. The patient was then placed in the supine\n position on the angiographic table and the left neck and shoulder were prepped\n and draped in the usual sterile fashion. Next, a micropuncture needle was used\n to obtain access to the left internal jugular vein under ultrasound guidance\n after local anesthesia was established with approximately 5 cc of 1% buffered\n lidocaine. Hard copy images were obtained for the medical record. Next, a\n 0.018 nitinol wire was passed through the needle into the SVC. A skin was\n made over the needle, which was then removed. A micropuncture sheath was then\n placed over the wire. After appropriate length measurements were made, the\n wire and inner introducer were then removed. Next, wire was passed\n through the sheath and into the right atrium. The proposed tunnel tract site\n was then anesthetized using 1% lidocaine with epinephrine approximately 4 cm\n below the left clavicle. A skin was made. The catheter, cut to size,\n measuring 23 cm, was then brought into the excision and brought out at the\n puncture site using a tunneling device. Next, the tract was dilated and peel-\n away sheath catheter was placed over the wire. The wire and introducer were\n then removed. Next, a double- lumen hemodialysis catheter was placed through\n (Over)\n\n 12:00 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: please place tunnelled HD cath\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the peel-away sheath and positioned with its tip at the level of the right\n atrium under fluoroscopic guidance. Peel-away sheath was then removed. The\n catheter was aspirated, flushed at both ports. 2-0 Vicryl simple suture was\n used to close the puncture site. A silk suture was used to secure the\n catheter in place. Sterile dressing was applied.\n\n After the catheter was secured with sterile dressing, the patient was brought\n out of the interventional suite, and the temporary right internal jugular\n catheter was removed with patient in sitting position, with no immediate post-\n removal complications.\n\n IMPRESSION:\n 1. Uncomplicated placement of left-sided tunneled double-lumen 23-cm\n hemodialysis catheter with tip within the right atrium with catheter ready to\n use.\n 2. Uncomplicated removal of temporary right internal jugular catheter.\n\n 3. Thrombus in the right internal jugular vein.\n\n These results were discussed with at 4:45PM on .\n\n" }, { "category": "Radiology", "chartdate": "2119-08-11 00:00:00.000", "description": "TUNNELED W/O PORT", "row_id": 1094398, "text": ", H. MED FA10 12:00 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: please place tunnelled HD cath\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with etoh cirrhosis, now HD dependent. please place tunnelled\n HD cath\n REASON FOR THIS EXAMINATION:\n please place tunnelled HD cath\n ______________________________________________________________________________\n PFI REPORT\n Uncomplicated image-guided placement of left internal jugular tunneled\n hemodialysis catheter with tip in right atrium. The line is ready to use.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1095394, "text": " 10:06 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy, concern for new infection\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: Rule out pneumonia.\n\n Findings: The left hemodialysis catheter is unchanged with its tip in the\n right atrium. NG tube passes into the stomach and out of view. Low lung\n volumes with bilateral lower lobe atelectasis are stable. Lungs are otherwise\n clear, cardiomediastinal silhouette is unchanged. A TIPS stent is\n unchanged.\n\n IMPRESSION:\n\n Stable bilateral lower lobe atelectasis associated with low lung volumes. No\n new consolidation or pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1094274, "text": " 2:26 PM\n CHEST (PA & LAT) Clip # \n Reason: Please eval for improvement of LLL opacity\n Admitting Diagnosis: ASCITES, HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with EtOH cirrhosis, previous opacity on LLL. Please eval for\n improvement\n REASON FOR THIS EXAMINATION:\n Please eval for improvement of LLL opacity\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old man with alcohol cirrhosis, previous opacity on the\n left lower lobe. Please evaluate for improvement.\n\n TECHNIQUE: PA and lateral chest x-ray.\n\n COMPARISON: Portable chest x-ray from .\n\n FINDINGS: Unchanged left pleural effusion and left lower lobe opacity,\n consistent with atelectasis. Small unchanged right pleural effusion. The\n cardiomediastinal silhouette and hila are normal. No pneumothorax. Unchanged\n right central line with its tip ending at the mid SVC.\n\n IMPRESSION: Unchanged left lower lobe atelectasis and left pleural effusion.\n Small right pleural effusion.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2126-08-28 00:00:00.000", "description": "FLUOR GUID PLCT/REPLCT/REMOVE", "row_id": 879395, "text": " 7:53 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place IR PICC, has failed bedside attempt\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man admitted with urosepsis from multidrug resistant E coli\n requiring IV meropenem for extended course\n REASON FOR THIS EXAMINATION:\n please place IR PICC, has failed bedside attempt\n ______________________________________________________________________________\n FINAL REPORT\n\n\n INDICATION: Urosepsis, needs IV antibiotics.\n\n PROCEDURE: The procedure was performed by Drs. and with Dr.\n , the Attending Radiologist, being present and supervising. The left\n upper arm was prepped in a sterile fashion. Since no suitable superficial\n veins were visible, ultrasound was used for localization of a suitable vein.\n The basilic vein was patent and compressible. After local anesthesia with 2\n mL of 1% lidocaine, the basilic vein was entered under ultrasonographic\n guidance with a 21-gauge needle. Hard copy ultrasound images were obtained,\n documenting patent vein before and after establishing an access. A 0.018\n guidewire was advanced under fluoroscopy into the superior vena cava. Based\n on the markers on the guidewire, it was determined that a length of 30 cm\n would be suitable. The PICC line was trimmed to length and advanced over a 4-\n French introducer sheath under fluoroscopic guidance into the superior vena\n cava. The sheath was removed. The catheter was flushed. A final spot chest\n radiographic image demonstrates tip in the superior vena cava. The line is\n ready for use. A StatLock was applied and the line was heplocked.\n\n IMPRESSION: Successful placement of a 30 cm total length PICC line with tip\n in the superior vena cava, ready for use.\n\n\n\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2126-08-24 00:00:00.000", "description": "Report", "row_id": 196344, "text": "Atrial fibrillation with a rapid ventricular response. Non-specific ST-T wave\nflattening. Compared to the previous tracing of no diagnostic interim\nchange.\n\n" }, { "category": "ECG", "chartdate": "2126-08-23 00:00:00.000", "description": "Report", "row_id": 196345, "text": "Atrial fibrillation with a mean ventricular response, rate 81. Left axis\ndeviation. Left anterior fascicular block. Diffuse non-diagnostic\nrepolarization abnormalities. Compared to the previous tracing of no\ndefinite change.\n\n" }, { "category": "ECG", "chartdate": "2126-08-21 00:00:00.000", "description": "Report", "row_id": 196346, "text": "Atrial fibrillation with a mean ventricular response, rate 97. Compared to the\nprevious tracing of no major change.\n\n" } ]

[ { "category": "Echo", "chartdate": "2141-12-20 00:00:00.000", "description": "Report", "row_id": 79093, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Murmur. Coronary artery disease.\nHeight: (in) 66\nWeight (lb): 163\nBSA (m2): 1.84 m2\nBP (mm Hg): 124/62\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 10:15\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: Moderately dilated RA. Normal interatrial\nseptum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Normal regional LV\nsystolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated ascending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Mild AS (AoVA 1.2-1.9cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. No MS. Eccentric MR\njet. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. No\natrial septal defect is seen by 2D or color Doppler. There is mild symmetric\nleft ventricular hypertrophy. The left ventricular cavity size is normal.\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. The ascending aorta is mildly dilated. There are\nthree aortic valve leaflets. The aortic valve leaflets are moderately\nthickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+)\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nAn eccentric, posteriorly directed jet of mild to moderate (+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is mild pulmonary artery systolic hypertension. There is an anterior\nspace which most likely represents a fat pad.\n\n\n" }, { "category": "Nursing", "chartdate": "2141-12-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 551443, "text": "87 yo women admitted to OSH on with chest pain r/i for NSTEMI.\n Transferred to on . Roto and stenting to RCA. To 3 post\n procedure. Last pm pt lost IV access. Multiple attempts to place Triple\n lumen. Placed in L fem. In am pt became hypotensive with hct\n drop. Pt received 2 units of bld and 1 liter of fluid. CT negative for\n bleed. BP stabilized.\n Atrial fibrillation (Afib)\n Assessment:\n She remains in a-fib with rate varying from 90s to as high as 150s. She\n had been on Lopressor and diltiazem at home, but dilt stopped and\n beta-blocker dose decreased due to hypotension. BP today has been in\n low 100s to 120s. Lungs are clear even with higher heart rate.\n Action:\n Diltiazem was added back at 30mg QID with Lopressor at 25 tid.\n Response:\n Pt remains Hemodynamically stable with bp in 120s.\n Plan:\n Continue to monitor VS. Increase Lopressor and dilt to home doses as\n tolerated.\n Impaired Skin Integrity\n Assessment:\n Pt has total body edema and has been diagnoses with vasculitis, likely\n due to receiving bactrim (allergic to sulfa) at OSH. She has multiple\n weeping areas as well as some necrotic areas that have been biopsied.\n Both arms are edematous and eccymotic. Her R femoral cath site is dry.\n There is small necrotic area lateral to R knee. She has a skin tear on\n the lower R shin. She has small open area on L lower leg. There are\n some pettchiae areas on L upper thigh, that are weeping. She has yeasty\n looking rash under L breast. Heels mildly reddened.\n Action:\n All open areas were washed with wound cleanser and dried. Aquacel was\n applied to all weeping areas and they were covered with DSD and secured\n with kerlix. No tape to skin. Dsgs to be done daily or when wet. All\n skin folds cleansed and criticade clear applied under L breast and also\n to groin area. Skin well lubed with aloe-vesta moisture barrier. Heels\n kept elevated on pillows.\n Response:\n Plan:\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-12-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 551449, "text": "PMH: TIAs, A-fib, Hypothyroid. HTN. husband diet ~1yr\n ago. Melanoma.\n 87 yo women admitted to OSH on with chest pain r/i for NSTEMI.\n Transferred to on . Roto and stenting to RCA. To 3 post\n procedure. Last pm pt lost IV access. Multiple attempts to place Triple\n lumen. Placed in L fem. In am pt became hypotensive with hct\n drop. Pt received 2 units of bld and 1 liter of fluid. CT negative for\n bleed. BP stabilized.\n Atrial fibrillation (Afib)\n Assessment:\n She remains in a-fib with rate varying from 90s to as high as 150s. She\n had been on Lopressor and diltiazem at home, but dilt stopped and\n beta-blocker dose decreased due to hypotension. BP today has been in\n low 100s to 120s. Lungs are clear even with higher heart rate.\n Action:\n Diltiazem was added back at 30mg QID with Lopressor at 25 tid. Lasix\n has not yet been added.\n Response:\n Pt remains Hemodynamically stable with bp in 120s.\n Plan:\n Continue to monitor VS. Increase Lopressor and dilt to home doses as\n tolerated. Of note, pt had been on coumadin, but will probably not be\n restarted due to fall risk.\n Impaired Skin Integrity\n Assessment:\n Pt has total body edema and has been diagnoses with vasculitis, likely\n due to receiving bactrim (allergic to sulfa) at OSH. She has multiple\n weeping areas as well as some necrotic areas that have been biopsied.\n Both arms are edematous and eccymotic. Her R femoral cath site is dry.\n There is small necrotic area lateral to R knee. She has a skin tear on\n the lower R shin. She has small open area on L lower leg. There are\n some pettchiae areas on L upper thigh, that are weeping. She has yeasty\n looking rash under L breast. Heels mildly reddened.\n Action:\n All open areas were washed with wound cleanser and dried. Aquacel was\n applied to all weeping areas and they were covered with DSD and secured\n with kerlix. No tape to skin. Dsgs to be done daily or when wet. All\n skin folds cleansed and criticade clear applied under L breast and also\n to groin area. Skin well lubed with aloe-vesta moisture barrier. Heels\n kept elevated on pillows. Pt has started on prednisone for vasculitis.\n Pt is assisted in changing position\n Response:\n Edema seems to be decreasing as does to degree of weeping. Heels no\n longer reddened. No increase in yeast rash.\n Plan:\n Continue with excellent skin care. Give prednisone as given. Monitor\n for maceration of weeping areas and change position frequently.\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n Pt received total of 2U PRBCs. Lowest crit was 23.3. Early it\n ws 30.9 and at noon it ws 29.6. CT was negative for RP bleed. Today\n urine output dropped to 10-25ccc/hr with bp on the low side, though\n stable.\n Action:\n With crit stable 1liter NS given for poor urine output over 2 hrs. Will\n be in at 1800.\n Response:\n Urine output has increased. Will continue to monitor crits with one due\n ~. Urine output has increased to 100cc after bolus began.\n Plan:\n Draw hematocrit this evening. Keep careful I & O. Monitor for signs of\n further bleeding.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt RI for NSTEMI and had rotobladder to RCA. Peak troponin .9. Pt\n has been pain free. D/P pulses palpable and PT dopplerable. Groin site\n dry.\n Action:\n Monitor groin site for oozing and check pulses. Pt continues on plavix\n for RCA stent.\n Response:\n No further pain.\n Plan:\n Continue as above.\n" }, { "category": "Nursing", "chartdate": "2141-12-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 551439, "text": "87 yo women admitted to OSH on with chest pain r/i for NSTEMI.\n Transferred to on . Roto and stenting to RCA. To 3 post\n procedure. Last pm pt lost IV access. Multiple attempts to place Triple\n lumen. Placed in L fem. In am pt became hypotensive with hct drop.\n Pt received 2 units of bld and 1 liter of fluid. CT negative for\n bleed. BP stabilized.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Radiology", "chartdate": "2141-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1055023, "text": " 8:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate?\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with chest pressure this am and sob\n REASON FOR THIS EXAMINATION:\n infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest pressure this morning and shortness of breath.\n\n FINDINGS: No previous images. The cardiac silhouette is mildly enlarged in\n this patient with a dual-channel pacemaker device in place. Pulmonary vessels\n are essentially within normal limits and there is no definite pleural effusion\n or acute pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-12-27 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1056673, "text": " 8:57 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC line placement IR guided.\n Admitting Diagnosis: CHEST PAIN\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with extremely poor access. Pt has femoral line in place\n currently and will require prolonged hospitalization\n REASON FOR THIS EXAMINATION:\n PICC line placement IR guided.\n ______________________________________________________________________________\n WET READ: AGLc WED 10:16 AM\n Uncomplicated ultrasound and fluoroscopically guided single lumen PICC line\n placement via the left basilic venous approach. Final internal length is 42\n cm, with the tip positioned in SVC. The line is ready for use.\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: 87 year old female requiring prolonged IV access needed for\n medications (metastatic breast cancer, now with NSTEMI and likely vasculitis).\n Pt now only with femoral line in place.\n\n RADIOLOGIST: Dr. and performed the procedure under the\n supervision of attending physician . .\n\n TECHNIQUE: The procedure was explained to the patient and timeout was\n performed to confirm patient identity and procedure to be performed.\n\n Using sterile technique and local anesthesia, the left basilic vein was\n punctured under direct ultrasound guidance using a micropuncture set.\n Ultrasound images obtained before and immediately after establishing\n intravenous access are saved onto PACS. A peel-away sheath was then placed\n over a guidewire and a single-lumen PICC line measuring 42 cm in length was\n then placed through the peel-away sheath under fluoroscopic guidance, with its\n tip positioned in the lower SVC. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest. The peel-away sheath and guidewire were\n then removed. The catheter was secured to the skin, flushed, and a sterile\n 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 internal\n length is 42 cm, with the tip positioned in SVC. The line is ready for use.\n (Over)\n\n 8:57 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC line placement IR guided.\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2141-12-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1056095, "text": " 7:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrates or edema\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with metasatic breast ca, hypotensive this AM, has NSTEMI and\n likely vasculitis; mew oxygen requirement\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates or edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New oxygen requirement, question infiltrate, edema. Metastatic\n breast CA, hypotension, and STEMI and likely vasculitis.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n There is mild hyperinflation. There is moderate cardiomegaly. The aorta is\n calcified and minimally unfolded. A right-sided dual-lead pacemaker is\n present, lead tips over right atrium and right ventricle. No CHF. Minimal\n blunting left costophrenic angle, without other evidence of effusion. Some\n increased retrocardiac density, with obscuration of the medial portion of the\n left hemidiaphragm, unchanged compared with . Biapical pleural\n thickening also unchanged. Osteopenia and degenerative changes of the\n thoracic spine noted.\n\n IMPRESSION:\n\n Compared with , I doubt significant interval change. No CHF. No new\n infiltrate or increase in effusion. Some increased retrocardiac density,\n consistent with left lower lobe collapse and/or consolidation and small left\n effusion are stable.\n\n\n" }, { "category": "Nursing", "chartdate": "2141-12-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551315, "text": "87 yo F with history of AF, hypertension who presented intially with\n NSTEMI and chest pain, s/p delayed cath with 2 vessel disease.\n Atrial fibrillation (Afib)\n Assessment:\n Tele 80\ns-130\ns. SBP > 100.\n Action:\n Lopressor 25mg TID restarted.\n Response:\n No change in rate.\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n L groin is C&D. No evidence of hematoma. Distal pulses by Doppler. Hct\n 23-\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-12-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551316, "text": "87 yo F with history of AF, hypertension who presented intially with\n NSTEMI and chest pain, s/p delayed cath with 2 vessel disease.\n Atrial fibrillation (Afib)\n Assessment:\n Tele 80\ns-130\ns. SBP > 100.\n Action:\n Lopressor 25mg TID restarted.\n Response:\n No change in rate.\n Plan:\n Titrate meds as tolerated.\n Impaired Skin Integrity\n Assessment:\n Pt with generalized anasarca. Heels reddened but blanch able. LE with\n skin tear on R calf.\n Action:\n Adaptic applied to r lower leg with DSD. L lower extremity oozing\n serous fliud. Covered with DSD and softsorb.\n Response:\n ? vasculitis\n Plan:\n Pt restarted on Prednisone daily. Biopsy pending.\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n L groin is C&D. No evidence of hematoma. Distal pulses by Doppler. Hct\n 23- 31.\n Action:\n Pt received 2 units of bld and 1liter of NS.\n Response:\n Hct ^\nd to 31. pt denies any groin pain.\n Plan:\n Serial hcts. Triple lumen to remain in place.\n" }, { "category": "Physician ", "chartdate": "2141-12-24 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 551400, "text": "TITLE: Cardiology Physician Note\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: \n -hct of 23, transfusion of 2 units pRBCs, hct then 30.2\n -derm consult skin lesions, likely vasculitis, bx taken\n -started prednisone 40mg (was on 30mg until admission)\n -CRP 11.2, ESR 6, RF 8\n -CXR for AM to oxygen requirement\n -monitoring hct\n Medications\n Unchanged\n Physical Exam\n BP: 106 / 69 mmHg\n HR: 118 bpm\n Tmax C last 24 hours: 36.6 C\n Tmax F last 24 hours: 97.8 F\n T current C: 36.6 C\n T current F: 97.8 F\n O2 sat: 95 %\n Previous day:\n Intake: 1,453 mL\n Output: 710 mL\n Fluid balance: 743 mL\n Today:\n Output: 140 mL\n Fluid balance: -140 mL\n VS: 106/69, 100, 98%\n Eyes: (Conjunctiva and lids: Abnormal, small lesion on lid)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: Abnormal)\n Neck: (Jugular veins: Not visible)\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Effort: WNL), (Auscultation: WNL)\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL), (Murmur / Rub: Present 2/6 systolic murmur at RUSB, LLSB, Apex,\n also diastolic murmur at RUSB)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: pulses ok, site of cath, No\n bruit), (Left femoral artery: hematoma fem line, No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Dorsalis pedis\n artery: Right: dopplerable, Left: dopplerable), (Edema: Right: 1+,\n Left: 1+)\n Skin: (Abnormal, Multiple areas of small erythematous macules on chest,\n necrotic are on right calf approx 1 cm in diameter, smaller lesion on\n right second toe)\n Labs\n 164\n 10.9\n 123\n 1.1\n 27\n 4.6\n 13\n 105\n 141\n 30.9\n 5.5\n [image002.jpg]\n 09:57 AM\n 12:20 PM\n 06:13 PM\n 04:27 AM\n WBC\n 7.6\n 5.5\n Hgb\n 11.2\n 10.9\n Hct (Serum)\n 31.5\n 30.2\n 30.9\n Plt\n 156\n 164\n INR\n 1.5\n 1.2\n PTT\n 33.1\n 33.4\n Na+\n 141\n K + (Serum)\n 4.2\n 4.6\n Cl\n 105\n HCO3\n 27\n BUN\n 13\n Creatinine\n 1.1\n Glucose\n 123\n CK\n 42\n Troponin T\n 0.40\n ABG: / / / 27 / Values as of 04:27 AM\n Ca 7.9\n Trp, CK - 0.04, 42\n Assessment and Plan\n ASSESSMENT AND PLAN\n 87F w h of AF, hypertension who presented intially with NSTEMI and\n chest pain, s/p delayed cath with 2 vessel disease.\n .\n # NSTEMI: Now s/p cardiac catherization. Troponin peak 0.9. No sig\n change in LV function.\n - Continue statin, beta blocker, plavix, aspirin.\n - Repeat CKs,\n - ECG\n .\n # Hypotension/hct drop: Likely seconary to bleeding into left thigh.\n Now stable hct and no longer hypotensive.\n - serial hct\n - s/p 2 U PRBC\n .\n # PUMP: no acute signs of chf, normal EF. have diastolic\n dysfunction as previously had volume overload on last hospitalization\n requiring lasix. Will watch for signs of fluid overload and restart\n outpatient diuretics (will have to use ethocrinic acid as sulfa\n allergy)\n - monitor i/o\n .\n # RHYTHM: AF, previously with RVR. Will restart metoprolol and\n titrate up as BP tolerates, will add diltiazem as needed, but will need\n to restart prior to discharge. No coumadin for now, high risk give\n age, previously with TIA. Will need to discuss risks with family at\n d/c\n .\n # SKIN RASH/NECROTIC AREAS: The patient has several areas of rash,\n ecrosis. Derm consult concerned for vasculitis as well as drug LCV.\n Will hold sulfa meds, abx as possible.\n - await skin bx\n - appreciate derm consult\n - avoid sulfas\n - restart prednisone\n .\n # Temporal arteritis/vasculitis: as above skin lesions concerning for\n vasculitis. Will restart prednisone 40 mg, await ,ANCA, ESR,CRP,\n etc in evaluation. Likely need to consult rheum on monday.\n - prednisone\n - await labs\n # Hypothyroidism: will continue levothyroxine.\n # COPD: unclear if true history as not initially noted in admission\n note, no signs of dyspnea, will wean o2 as tolerates. On steroids for\n vasculitis, thus unlikely to have COPD exacerbation\n # GERD: continue PPI\n # FEN: euvolemic, replete lytes (will recheck potassium), advance diet\n as tolerates\n .\n FEN:\n ACCESS: PIV's\n PROPHYLAXIS: hep sc, pantoprazole\n -Pain managment with\n -Bowel regimen\n CODE: Presumed full\n DISPO: CCU for now, anticipate tx until tomorrow\n" }, { "category": "Physician ", "chartdate": "2141-12-24 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 551405, "text": "Cardiology Physician Note\n History of Present Illness\n Events / History of present illness: \n -hct of 23, transfusion of 2 units pRBCs, hct then 30.2\n -derm consult skin lesions, likely vasculitis, bx taken\n -started prednisone 40mg (was on 30mg until admission)\n -CRP 11.2, ESR 6, RF 8\n -CXR for AM to oxygen requirement\n -monitoring hct\n Medications\n Unchanged\n Physical Exam\n BP: 106 / 69 mmHg\n HR: 118 bpm\n Tmax C last 24 hours: 36.6 C\n Tmax F last 24 hours: 97.8 F\n T current C: 36.6 C\n T current F: 97.8 F\n O2 sat: 95 %\n Previous day:\n Intake: 1,453 mL\n Output: 710 mL\n Fluid balance: 743 mL\n Today:\n Output: 140 mL\n Fluid balance: -140 mL\n VS: 106/69, 100, 18, 98%\n Eyes: (Conjunctiva and lids: Abnormal, small lesion on lid)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: Abnormal)\n Neck: (Jugular veins: Not visible)\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Effort: WNL), (Auscultation: WNL)\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL), (Murmur / Rub: Present 2/6 systolic murmur at RUSB, LLSB, Apex,\n also diastolic murmur at RUSB)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: pulses ok, site of cath, No\n bruit), (Left femoral artery: hematoma fem line, No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Dorsalis pedis\n artery: Right: dopplerable, Left: dopplerable), (Edema: Right: 1+,\n Left: 1+)\n Skin: (Abnormal, Multiple areas of small erythematous macules on chest,\n necrotic are on right calf approx 1 cm in diameter, smaller lesion on\n right second toe)\n Labs\n 164\n 10.9\n 123\n 1.1\n 27\n 4.6\n 13\n 105\n 141\n 30.9\n 5.5\n [image002.jpg]\n 09:57 AM\n 12:20 PM\n 06:13 PM\n 04:27 AM\n WBC\n 7.6\n 5.5\n Hgb\n 11.2\n 10.9\n Hct (Serum)\n 31.5\n 30.2\n 30.9\n Plt\n 156\n 164\n INR\n 1.5\n 1.2\n PTT\n 33.1\n 33.4\n Na+\n 141\n K + (Serum)\n 4.2\n 4.6\n Cl\n 105\n HCO3\n 27\n BUN\n 13\n Creatinine\n 1.1\n Glucose\n 123\n CK\n 42\n Troponin T\n 0.40\n ABG: / / / 27 / Values as of 04:27 AM\n Ca 7.9\n Trp, CK - 0.04, 42\n Assessment and Plan\n ASSESSMENT AND PLAN\n 87F w AFib, HTN who presented intially with NSTEMI and chest pain, s/p\n delayed cath with 2 vessel disease.\n .\n # NSTEMI: Now s/p cardiac catherization. Troponin peak 0.9,\n downtrending. No sig change in LV function.\n - Continue statin, beta blocker, plavix, aspirin\n - ECG\n .\n # Hypotension/hct drop: Likely secondary to bleeding into left thigh vs\n suddenly stopped steroids. Now stable Hct ~30 s/p 2 U PRBC and no\n longer hypotensive (SBP in 100s).\n - serial hct (q8h)\n - restarted steroids\n .\n # PUMP: no acute signs of CHF, normal EF. have diastolic\n dysfunction as previously had volume overload on last hospitalization\n requiring lasix. Will watch for signs of fluid overload and restart\n outpatient diuretics (will have to use ethacrynic acid as sulfa\n allergy)\n - monitor i/o\n .\n # RHYTHM: AF, previously with RVR. No coumadin for now, high risk give\n age, previously with TIA. Will need to discuss risks with family at\n d/c\n - restart diltiazem 30mg PO QID for rate control\n - continued metoprolol 25mg TID\n .\n # SKIN RASH/NECROTIC AREAS: The patient has several areas of rash,\n necrosis. Derm consult concerned for vasculitis as well as drug LCV.\n Will hold sulfa meds, abx as possible.\n - await skin bx\n - appreciate derm consult\n - avoid sulfas (lasix!)\n - restarted prednisone\n - daily LFTs and CBC/Diff\n .\n # Temporal arteritis/vasculitis: as above skin lesions concerning for\n vasculitis. Restarted prednisone 40 mg, await ,ANCA, ESR,CRP, etc\n in evaluation. Likely need to consult rheum on monday.\n - prednisone\n - await labs\n # Hypothyroidism: will continue levothyroxine.\n # COPD: unclear if true history as not initially noted in admission\n note, no signs of dyspnea, will wean o2 as tolerates. On steroids for\n vasculitis, thus unlikely to have COPD exacerbation.\n # GERD: continue PPI\n # FEN: euvolemic, replete lytes (will recheck potassium), advance diet\n as tolerates\n .\n FEN: cardiac diet\n ACCESS: PIV's , L femoral line\n PROPHYLAXIS: hep sc, pantoprazole\n -Bowel regimen\n CODE: Presumed full\n DISPO: possible call-out today pending Hct\n" }, { "category": "Physician ", "chartdate": "2141-12-24 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 551407, "text": "Cardiology Physician Note\n History of Present Illness\n Events / History of present illness: \n -hct of 23, transfusion of 2 units pRBCs, hct then 30.2\n -derm consult skin lesions, likely vasculitis, bx taken\n -started prednisone 40mg (was on 30mg until admission)\n -CRP 11.2, ESR 6, RF 8\n -CXR for AM to oxygen requirement\n -monitoring hct\n Medications\n Unchanged\n Physical Exam\n BP: 106 / 69 mmHg\n HR: 118 bpm\n Tmax C last 24 hours: 36.6 C\n Tmax F last 24 hours: 97.8 F\n T current C: 36.6 C\n T current F: 97.8 F\n O2 sat: 95 %\n Previous day:\n Intake: 1,453 mL\n Output: 710 mL\n Fluid balance: 743 mL\n Today:\n Output: 140 mL\n Fluid balance: -140 mL\n VS: 106/69, 100, 18, 98%\n Eyes: (Conjunctiva and lids: Abnormal, small lesion on lid)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: Abnormal)\n Neck: (Jugular veins: Not visible)\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Effort: WNL), (Auscultation: WNL)\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL), (Murmur / Rub: Present 2/6 systolic murmur at RUSB, LLSB, Apex,\n also diastolic murmur at RUSB)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: pulses ok, site of cath, No\n bruit), (Left femoral artery: hematoma fem line, No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Dorsalis pedis\n artery: Right: dopplerable, Left: dopplerable), (Edema: Right: 1+,\n Left: 1+)\n Skin: (Abnormal, Multiple areas of small erythematous macules on chest,\n necrotic are on right calf approx 1 cm in diameter, smaller lesion on\n right second toe)\n Labs\n 164\n 10.9\n 123\n 1.1\n 27\n 4.6\n 13\n 105\n 141\n 30.9\n 5.5\n [image002.jpg]\n 09:57 AM\n 12:20 PM\n 06:13 PM\n 04:27 AM\n WBC\n 7.6\n 5.5\n Hgb\n 11.2\n 10.9\n Hct (Serum)\n 31.5\n 30.2\n 30.9\n Plt\n 156\n 164\n INR\n 1.5\n 1.2\n PTT\n 33.1\n 33.4\n Na+\n 141\n K + (Serum)\n 4.2\n 4.6\n Cl\n 105\n HCO3\n 27\n BUN\n 13\n Creatinine\n 1.1\n Glucose\n 123\n CK\n 42\n Troponin T\n 0.40\n ABG: / / / 27 / Values as of 04:27 AM\n Ca 7.9\n Trp, CK - 0.04, 42\n Assessment and Plan\n ASSESSMENT AND PLAN\n 87F w AFib, HTN who presented intially with NSTEMI and chest pain, s/p\n delayed cath with 2 vessel disease.\n .\n # NSTEMI: Now s/p cardiac catherization. Troponin peak 0.9,\n downtrending. No sig change in LV function.\n - Continue statin, beta blocker, plavix, aspirin\n - ECG\n .\n # Hypotension/hct drop: Likely secondary to bleeding into left thigh vs\n suddenly stopped steroids. Now stable Hct ~30 s/p 2 U PRBC and no\n longer hypotensive (SBP in 100s).\n - serial hct (q8h)\n - restarted steroids\n .\n # PUMP: no acute signs of CHF, normal EF. have diastolic\n dysfunction as previously had volume overload on last hospitalization\n requiring lasix. Will watch for signs of fluid overload and restart\n outpatient diuretics (will have to use ethacrynic acid as sulfa\n allergy)\n - monitor i/o\n .\n # RHYTHM: AF, previously with RVR. No coumadin for now, high risk give\n age, previously with TIA. Will need to discuss risks with family at\n d/c\n - restart diltiazem 30mg PO QID for rate control\n - continued metoprolol 25mg TID\n .\n # SKIN RASH/NECROTIC AREAS: The patient has several areas of rash,\n necrosis. Derm consult concerned for vasculitis as well as drug LCV.\n Will hold sulfa meds, abx as possible.\n - await skin bx\n - appreciate derm consult\n - avoid sulfas (lasix!)\n - restarted prednisone\n - daily LFTs and CBC/Diff\n .\n # Temporal arteritis/vasculitis: as above skin lesions concerning for\n vasculitis. Restarted prednisone 40 mg, await ,ANCA, ESR,CRP, etc\n in evaluation. Likely need to consult rheum on monday.\n - prednisone\n - await labs\n # Hypothyroidism: will continue levothyroxine.\n # COPD: unclear if true history as not initially noted in admission\n note, no signs of dyspnea, will wean o2 as tolerates. On steroids for\n vasculitis, thus unlikely to have COPD exacerbation.\n # GERD: continue PPI\n # FEN: euvolemic, replete lytes (will recheck potassium), advance diet\n as tolerates\n .\n FEN: cardiac diet\n ACCESS: PIV's , L femoral line\n PROPHYLAXIS: hep sc, pantoprazole\n -Bowel regimen\n CODE: Presumed full\n DISPO: possible call-out today pending Hct\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Total time spent on patient care: 30 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 10:39 ------\n" }, { "category": "Nursing", "chartdate": "2141-12-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551291, "text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-12-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551292, "text": "87 yo F with history of AF, hypertension who presented intially with\n NSTEMI and chest pain, s/p delayed cath with 2 vessel disease.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-12-23 00:00:00.000", "description": "Cardiology Comprehensive Physician Note", "row_id": 551296, "text": "Date of service: \n Initial visit, Cardiology service: CCU\n Presenting complaint: Chest pain, (Other: hypotension)\n History of present illness: Ms is an 87 yo F with a history\n of atrial fibrillation and hypertension who initially presented to an\n outside hospital with chest pain. There the AF treated with diltiazem\n 5 mg IV. Her nursing home called EMS where she was found by EMS to\n have AF with RVR and transferred to on . The report\n from the nursing home describes the patient with severe crushing\n substernal chest pain with a HR of 120. Given troponin leak at \n , the patient was transferred to for cardiac evaluation.\n .\n The patient arrived to the floor and was found to have ankle edema, but\n otherwise asymptomatic. Given the patient's elevated INR, cardiac\n catherization was deferred from to . The cardiac catherization\n showed severe 2 vessel CAD with a heavily calcified RCA. A rota and\n BMS was placed to the RCA. However, post cardiac cath on at 9 PM,\n the patient was triggered for nursing conern, no IV access. Tiggered\n later on for hypotension.\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. S/he denies recent fevers, chills or rigors. S/he denies\n exertional buttock or calf pain. All of the other review of systems\n were negative.\n .\n Of note, per ER records she had been on abx and steroids for 3 wks for\n a PNA (starting ). She has been on 40mg predniosone from to\n , and then was changed to 30mg PO prednisone. Also, her lasix dose\n was recently changed increased to 40 for 3 days ( to\n ). Amiodarone was stopped due to pulm fibrosis concern.\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 In the ED, initial vitals were 116/55, 106, 16, 100% RA.\n Past medical history: Atrial Fibrillation- s/p cardioversion\n amio dc/d on , now on atenolol and cardizem\n TIA\n hypothyroid\n HTN\n depression\n melanoma\n ? History of syncope\n Temporal arteritis hx\n s/p appendectomy\n s/p hysterectomy\n CAD Risk Factors\n CAD Risk Factors Present\n Hypertension\n CAD Risk Factors Absent\n Diabetes mellitus, Dyslipidemia, Family Hx of CAD, Family Hx of sudden\n cardiac death\n (Tobacco: No)\n Cardiovascular Procedural History\n PCI: Most recent: \n There is no history of:\n CABG\n Pacemaker / ICD\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Amiodarone\n Pulmonary Toxic\n Current medications: KCL SR 40 mEq a day\n calcium 500 mg TID\n vitamin D 400 International Units twice a day,\n Coumadin 2 mg a day,\n nitroglycerin 0.4 mg q5 minutes sublingual p.r.n.,\n Tylenol 650 every 6 hours as needed,\n multivitamin 1 tab daily\n Prilosec 20 mg a day\n vitamin B12 1,000 mcg a day\n Synthroid 125 mcg daily\n Cardizem CD 360 daily\n Ensure 1 can 3 times a day between meals\n Lasix 40 mg a day\n DuoNebs q.4 hours p.r.n.,\n digoxin 0.125 mcg a day\n coated aspirin 81 mg a day,\n Toprol XL 150 mg daily.\n Benzonatate 100 mg \n Meclizine 25 mg Q8 hr prn\n Prednisone 30mg Qday\n bisacodyl 10mg supp PRN daily\n milk of mag 30ml PRN\n robatussin 100mg/5ml Q4H PRN\n Fleets enema PRN\n Bactrim DS x 1 week, thru \n Cardiovascular ROS\n Cardiovascular ROS Signs and Symptoms Present\n Edema, TIA / CVA\n Cardiovascular ROS Signs and Symptoms Absent\n Murmur, Rheumatic fever, Chest pain, SOB, DOE, PND, Orthopnea,\n Palpitations, Syncope, Presyncope, Lightheadedness, Pulmonary embolism,\n DVT, Claudication, Exertional buttock pain, Exertional calf pain\n Review of Systems\n Organ system ROS abnormal\n Integumentary, Neurological\n Signs and symptoms present\n Joint pains, Myalgias\n Organ system ROS normal\n Constitutional, Eyes, ENT, Respiratory, Gastrointestinal, Endocrine,\n Hematology / Lymphatic, Genitourinary, Musculoskeletal, Psychiatric,\n Allergy / Immune\n Signs and symptoms absent\n Recent fevers, Chills, Rigors, Cough, Hemoptysis, Black / red stool,\n Bleeding during surgery\n ROS Details: Rash initially with sulfa, also ongoing right leg necrotic\n area that is approx 1-2 weeks in duration, new necrotic area on toe\n Social History\n Marital status: widowed\n Children: 4\n (Alcohol: No), (Recreational drug use: No)\n Family history: Non-contributory\n Social history details: Lives at healthcare since fall in\n . Otherwise lives at home.\n -Tobacco history: none\n -ETOH: rare\n -Illicit drugs: none\n Physical Exam\n Date and time of exam: , 12:00\n General appearance: alert and oriented, complainint of back pain\n Vital signs: t 96.5 105 124/62 100% 2L\n Height: 66 Inch, 168 cm\n Eyes: (Conjunctiva and lids: Abnormal, small lesion on lid)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: Abnormal)\n Neck: (Jugular veins: Not visible)\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Effort: WNL), (Auscultation: WNL)\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL), (Murmur / Rub: Present 2/6 systolic murmur at RUSB, LLSB, Apex,\n also diastolic murmur at RUSB)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: pulses ok, site of cath, No\n bruit), (Left femoral artery: hematoma fem line, No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Dorsalis pedis\n artery: Right: dopplerable, Left: dopplerable), (Edema: Right: 1+,\n Left: 1+)\n Skin: (Abnormal, Multiple areas of small erythematous macules on chest,\n necrotic are on right calf approx 1 cm in diameter, smaller lesion on\n right second toe)\n Labs\n 156\n 11.2\n 31.5\n 7.6\n [image002.jpg]\n 09:57 AM\n 12:20 PM\n WBC\n 7.6\n Hgb\n 11.2\n Hct (Serum)\n 31.5\n Plt\n 156\n INR\n 1.5\n PTT\n 33.1\n Tests\n ECG: Initial studies showed HR 91, in AF, TWI/STD in I, II, V4-V6,\n serial repeat ECGs showed variable ST depressions in above pattern with\n both atrial fibrillation and occasional a flutter.\n Echocardiogram: The left atrium is mildly dilated. The right\n atrium is moderately dilated. No atrial septal defect is seen by 2D or\n color Doppler. There is mild symmetric left ventricular hypertrophy.\n The left ventricular cavity size is normal. Regional left ventricular\n wall motion is normal. Overall left ventricular systolic function is\n normal (LVEF>55%). Right ventricular chamber size and free wall motion\n are normal. The ascending aorta is mildly dilated. There are three\n aortic valve leaflets. The aortic valve leaflets are moderately\n thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild\n (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\n thickened. An eccentric, posteriorly directed jet of mild to moderate\n (+) mitral regurgitation is seen. The tricuspid valve leaflets are\n mildly thickened. There is mild pulmonary artery systolic hypertension.\n There is an anterior space which most likely represents a fat pad.\n Cardiac Cath: (Date: ), FINAL DIAGNOSIS:\n 1. 2 vessel coronary artery disease.\n 2. Normal ventricular function.\n 3. Unsccessful attempt to cross the LCX CTO.\n 4. Successful rotablation, PTC and stenting of the RCA.\n .\n Assessment and Plan\n ASSESSMENT AND PLAN 87 yo F with history of AF, hypertension who\n presented intially with NSTEMI and chest pain, s/p delayed cath with 2\n vessel disease.\n .\n # NSTEMI: Now s/p cardiac catherization. Troponin peak 0.9. No sig\n change in LV function.\n - Continue statin, beta blocker, plavix, aspirin.\n - Repeat CKs,\n - ECG\n .\n # Hypotension/hct drop: Likely seconary to bleeding into left thigh.\n Now stable hct and no longer hypotensive.\n - serial hct\n - s/p 2 U PRBC\n .\n # Pump: no acute signs of chf, normal EF. have diastolic\n dysfunction as previously had volume overload on last hospitalization\n requiring lasix. Will watch for signs of fluid overload and restart\n outpatient diuretics (will have to use ethocrinic acid as sulfa\n allergy)\n - monitor i/o\n .\n # RHYTHM: AF, previously with RVR. Will restart metoprolol and\n titrate up as BP tolerates, will add diltiazem as needed, but will need\n to restart prior to discharge. No coumadin for now, high risk give\n age, previously with TIA. Will need to discuss risks with family at\n d/c\n .\n # Skin rash/ necrotic areas: The patient has several areas of rash,\n ecrosis. Derm consult concerned for vasculitis as well as drug LCV.\n Will hold sulfa meds, abx as possible.\n - await skin bx\n - appreciate derm consult\n - avoid sulfas\n - restart prednisone\n .\n # Temporal arteritis/vasculitis: as above skin lesions concerning for\n vasculitis. Will restart prednisone 40 mg, await ,ANCA, ESR,CRP,\n etc in evaluation. Likely need to consult rheum on monday.\n - prednisone\n - await labs\n .\n FEN:\n ACCESS: PIV's\n PROPHYLAXIS: hep sc, pantoprazole\n -Pain managment with\n -Bowel regimen\n CODE: Presumed full\n DISPO: CCU for now, anticipate tx until tomorrow\n" }, { "category": "Physician ", "chartdate": "2141-12-23 00:00:00.000", "description": "Cardiology Comprehensive Physician Note", "row_id": 551297, "text": "Date of service: \n Initial visit, Cardiology service: CCU\n Presenting complaint: Chest pain, (Other: hypotension)\n History of present illness: Ms is an 87 yo F with a history\n of atrial fibrillation and hypertension who initially presented to an\n outside hospital with chest pain. There the AF treated with diltiazem\n 5 mg IV. Her nursing home called EMS where she was found by EMS to\n have AF with RVR and transferred to on . The report\n from the nursing home describes the patient with severe crushing\n substernal chest pain with a HR of 120. Given troponin leak at \n , the patient was transferred to for cardiac evaluation.\n .\n The patient arrived to the floor and was found to have ankle edema, but\n otherwise asymptomatic. Given the patient's elevated INR, cardiac\n catherization was deferred from to . The cardiac catherization\n showed severe 2 vessel CAD with a heavily calcified RCA. A rota and\n BMS was placed to the RCA. However, post cardiac cath on at 9 PM,\n the patient was triggered for nursing conern, no IV access. Tiggered\n later on for hypotension.\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. S/he denies recent fevers, chills or rigors. S/he denies\n exertional buttock or calf pain. All of the other review of systems\n were negative.\n .\n Of note, per ER records she had been on abx and steroids for 3 wks for\n a PNA (starting ). She has been on 40mg predniosone from to\n , and then was changed to 30mg PO prednisone. Also, her lasix dose\n was recently changed increased to 40 for 3 days ( to\n ). Amiodarone was stopped due to pulm fibrosis concern.\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 In the ED, initial vitals were 116/55, 106, 16, 100% RA.\n Past medical history: Atrial Fibrillation- s/p cardioversion\n amio dc/d on , now on atenolol and cardizem\n TIA\n hypothyroid\n HTN\n depression\n melanoma\n ? History of syncope\n Temporal arteritis hx\n s/p appendectomy\n s/p hysterectomy\n CAD Risk Factors\n CAD Risk Factors Present\n Hypertension\n CAD Risk Factors Absent\n Diabetes mellitus, Dyslipidemia, Family Hx of CAD, Family Hx of sudden\n cardiac death\n (Tobacco: No)\n Cardiovascular Procedural History\n PCI: Most recent: \n There is no history of:\n CABG\n Pacemaker / ICD\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Amiodarone\n Pulmonary Toxic\n Current medications: KCL SR 40 mEq a day\n calcium 500 mg TID\n vitamin D 400 International Units twice a day,\n Coumadin 2 mg a day,\n nitroglycerin 0.4 mg q5 minutes sublingual p.r.n.,\n Tylenol 650 every 6 hours as needed,\n multivitamin 1 tab daily\n Prilosec 20 mg a day\n vitamin B12 1,000 mcg a day\n Synthroid 125 mcg daily\n Cardizem CD 360 daily\n Ensure 1 can 3 times a day between meals\n Lasix 40 mg a day\n DuoNebs q.4 hours p.r.n.,\n digoxin 0.125 mcg a day\n coated aspirin 81 mg a day,\n Toprol XL 150 mg daily.\n Benzonatate 100 mg \n Meclizine 25 mg Q8 hr prn\n Prednisone 30mg Qday\n bisacodyl 10mg supp PRN daily\n milk of mag 30ml PRN\n robatussin 100mg/5ml Q4H PRN\n Fleets enema PRN\n Bactrim DS x 1 week, thru \n Cardiovascular ROS\n Cardiovascular ROS Signs and Symptoms Present\n Edema, TIA / CVA\n Cardiovascular ROS Signs and Symptoms Absent\n Murmur, Rheumatic fever, Chest pain, SOB, DOE, PND, Orthopnea,\n Palpitations, Syncope, Presyncope, Lightheadedness, Pulmonary embolism,\n DVT, Claudication, Exertional buttock pain, Exertional calf pain\n Review of Systems\n Organ system ROS abnormal\n Integumentary, Neurological\n Signs and symptoms present\n Joint pains, Myalgias\n Organ system ROS normal\n Constitutional, Eyes, ENT, Respiratory, Gastrointestinal, Endocrine,\n Hematology / Lymphatic, Genitourinary, Musculoskeletal, Psychiatric,\n Allergy / Immune\n Signs and symptoms absent\n Recent fevers, Chills, Rigors, Cough, Hemoptysis, Black / red stool,\n Bleeding during surgery\n ROS Details: Rash initially with sulfa, also ongoing right leg necrotic\n area that is approx 1-2 weeks in duration, new necrotic area on toe\n Social History\n Marital status: widowed\n Children: 4\n (Alcohol: No), (Recreational drug use: No)\n Family history: Non-contributory\n Social history details: Lives at healthcare since fall in\n . Otherwise lives at home.\n -Tobacco history: none\n -ETOH: rare\n -Illicit drugs: none\n Physical Exam\n Date and time of exam: , 12:00\n General appearance: alert and oriented, complainint of back pain\n Vital signs: t 96.5 105 124/62 100% 2L\n Height: 66 Inch, 168 cm\n Eyes: (Conjunctiva and lids: Abnormal, small lesion on lid)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: Abnormal)\n Neck: (Jugular veins: Not visible)\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Effort: WNL), (Auscultation: WNL)\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL), (Murmur / Rub: Present 2/6 systolic murmur at RUSB, LLSB, Apex,\n also diastolic murmur at RUSB)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: pulses ok, site of cath, No\n bruit), (Left femoral artery: hematoma fem line, No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Dorsalis pedis\n artery: Right: dopplerable, Left: dopplerable), (Edema: Right: 1+,\n Left: 1+)\n Skin: (Abnormal, Multiple areas of small erythematous macules on chest,\n necrotic are on right calf approx 1 cm in diameter, smaller lesion on\n right second toe)\n Labs\n 156\n 11.2\n 31.5\n 7.6\n [image002.jpg]\n 09:57 AM\n 12:20 PM\n WBC\n 7.6\n Hgb\n 11.2\n Hct (Serum)\n 31.5\n Plt\n 156\n INR\n 1.5\n PTT\n 33.1\n Tests\n ECG: Initial studies showed HR 91, in AF, TWI/STD in I, II, V4-V6,\n serial repeat ECGs showed variable ST depressions in above pattern with\n both atrial fibrillation and occasional a flutter.\n Echocardiogram: The left atrium is mildly dilated. The right\n atrium is moderately dilated. No atrial septal defect is seen by 2D or\n color Doppler. There is mild symmetric left ventricular hypertrophy.\n The left ventricular cavity size is normal. Regional left ventricular\n wall motion is normal. Overall left ventricular systolic function is\n normal (LVEF>55%). Right ventricular chamber size and free wall motion\n are normal. The ascending aorta is mildly dilated. There are three\n aortic valve leaflets. The aortic valve leaflets are moderately\n thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild\n (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\n thickened. An eccentric, posteriorly directed jet of mild to moderate\n (+) mitral regurgitation is seen. The tricuspid valve leaflets are\n mildly thickened. There is mild pulmonary artery systolic hypertension.\n There is an anterior space which most likely represents a fat pad.\n Cardiac Cath: (Date: ), FINAL DIAGNOSIS:\n 1. 2 vessel coronary artery disease.\n 2. Normal ventricular function.\n 3. Unsccessful attempt to cross the LCX CTO.\n 4. Successful rotablation, PTC and stenting of the RCA.\n .\n Assessment and Plan\n ASSESSMENT AND PLAN 87 yo F with history of AF, hypertension who\n presented intially with NSTEMI and chest pain, s/p delayed cath with 2\n vessel disease.\n .\n # NSTEMI: Now s/p cardiac catherization. Troponin peak 0.9. No sig\n change in LV function.\n - Continue statin, beta blocker, plavix, aspirin.\n - Repeat CKs,\n - ECG\n .\n # Hypotension/hct drop: Likely seconary to bleeding into left thigh.\n Now stable hct and no longer hypotensive.\n - serial hct\n - s/p 2 U PRBC\n .\n # Pump: no acute signs of chf, normal EF. have diastolic\n dysfunction as previously had volume overload on last hospitalization\n requiring lasix. Will watch for signs of fluid overload and restart\n outpatient diuretics (will have to use ethocrinic acid as sulfa\n allergy)\n - monitor i/o\n .\n # RHYTHM: AF, previously with RVR. Will restart metoprolol and\n titrate up as BP tolerates, will add diltiazem as needed, but will need\n to restart prior to discharge. No coumadin for now, high risk give\n age, previously with TIA. Will need to discuss risks with family at\n d/c\n .\n # Skin rash/ necrotic areas: The patient has several areas of rash,\n ecrosis. Derm consult concerned for vasculitis as well as drug LCV.\n Will hold sulfa meds, abx as possible.\n - await skin bx\n - appreciate derm consult\n - avoid sulfas\n - restart prednisone\n .\n # Temporal arteritis/vasculitis: as above skin lesions concerning for\n vasculitis. Will restart prednisone 40 mg, await ,ANCA, ESR,CRP,\n etc in evaluation. Likely need to consult rheum on monday.\n - prednisone\n - await labs\n .\n FEN:\n ACCESS: PIV's\n PROPHYLAXIS: hep sc, pantoprazole\n -Pain managment with\n -Bowel regimen\n CODE: Presumed full\n DISPO: CCU for now, anticipate tx until tomorrow\n ------ Protected Section ------\n # Hypothyroidism: will continue home meds\n # COPD: unclear if true history as not initially noted in admission\n note, no signs of dyspnea, will wean o2 as tolerates. On steroids for\n vasculitis, thus unlikely to have COPD exacerbation\n # GERD: continue PPI\n # FEN: euvolemic, replete lytes (will recheck potassium), advance diet\n as tolerates\n ------ Protected Section Addendum Entered By: , MD\n on: 17:38 ------\n" }, { "category": "Nursing", "chartdate": "2141-12-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551365, "text": "87 yo F with history of AF, hypertension who presented intially with\n NSTEMI and chest pain, s/p delayed cath with 2 vessel disease.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in controlled afib\n Action:\n Pt tolerating Lopressor 25mg tid.\n Response:\n Tolerating afib. SBP > 90s\n Plan:\n Consider long term anticoagulation of filter.\n Impaired Skin Integrity\n Assessment:\n Pt with generalized anasarca. Heels reddened but blanch. LE with skin\n bandaged w/ cling\n Action:\n Kling leg DSD intact. Softsorb applied to RLE, both legs elevated on\n pillow.\n Response:\n ? vasculitis ? due to drug reaction.\n Plan:\n Pt restarted on Prednisone daily. Biopsy pending\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n Right groin dressing D+I.\n Action:\n No bleeding from left groin . TLC in place.\n Response:\n Hct remain s > 30\n Plan:\n Monitor HCT.\n" }, { "category": "Nursing", "chartdate": "2141-12-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551366, "text": "87 yo F with history of AF, hypertension who presented intially with\n NSTEMI and chest pain, s/p delayed cath with 2 vessel disease. Roto and\n BMS to\n Atrial fibrillation (Afib)\n Assessment:\n Remains in controlled afib\n Action:\n Pt tolerating Lopressor 25mg tid.\n Response:\n Tolerating afib. SBP > 90s\n Plan:\n Consider long term anticoagulation of filter.\n Impaired Skin Integrity\n Assessment:\n Pt with generalized anasarca. Heels reddened but blanch. LE with skin\n bandaged w/ cling\n Action:\n Kling leg DSD intact. Softsorb applied to RLE, both legs elevated on\n pillow.\n Response:\n ? vasculitis ? due to drug reaction.\n Plan:\n Pt restarted on Prednisone daily. Biopsy pending\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n Right groin dressing D+I.\n Action:\n No bleeding from left groin . TLC in place.\n Response:\n Hct remain s > 30\n Plan:\n Monitor HCT.\n" }, { "category": "Nursing", "chartdate": "2141-12-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551369, "text": "87 yo F with history of AF, hypertension who presented intially with\n NSTEMI and chest pain, s/p delayed cath with 2 vessel disease. Roto and\n BMS to RCA. Signif blood loss. Left groin ooz. CT neg. transfused w/\n 2ux of PRBCs and 1liter of fluid.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in controlled afib\n Action:\n Pt tolerating Lopressor 25mg tid.\n Response:\n Tolerating afib. SBP > 90s\n Plan:\n Consider long term anticoagulation of filter.\n Impaired Skin Integrity\n Assessment:\n Pt with generalized anasarca. Heels reddened but blanch. LE with skin\n bandaged w/ cling\n Action:\n Kling leg DSD intact. Softsorb applied to RLE, both legs elevated on\n pillow.\n Response:\n ? vasculitis ? due to drug reaction.\n Plan:\n Pt restarted on Prednisone daily. Biopsy pending\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n Right groin dressing D+I.\n Action:\n No bleeding from left groin . TLC in place.\n Response:\n Hct remain s > 30. u/o down. Pt possibly uvolemic.\n Plan:\n Monitor HCT. Monitor groin for bleeding.\n" }, { "category": "Physician ", "chartdate": "2141-12-23 00:00:00.000", "description": "Cardiology Comprehensive Physician Note", "row_id": 551289, "text": "Date of service: \n Initial visit, Cardiology service: CCU\n Presenting complaint: Chest pain, (Other: hypotension)\n History of present illness: Ms is an 87 yo F with a history\n of atrial fibrillation and hypertension who initially presented to an\n outside hospital with chest pain. There the AF treated with diltiazem\n 5 mg IV. Her nursing home called EMS where she was found by EMS to\n have AF with RVR and transferred to on . The report\n from the nursing home describes the patient with severe crushing\n substernal chest pain with a HR of 120. Given troponin leak at \n , the patient was transferred to for cardiac evaluation.\n .\n The patient arrived to the floor and was found to have ankle edema, but\n otherwise asymptomatic. Given the patient's elevated INR, cardiac\n catherization was deferred from to . The cardiac catherization\n showed severe 2 vessel CAD with a heavily calcified RCA. A rota and\n BMS was placed to the RCA. However, post cardiac cath on at 9 PM,\n the patient was triggered for nursing conern, no IV access. Tiggered\n later on for hypotension.\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. S/he denies recent fevers, chills or rigors. S/he denies\n exertional buttock or calf pain. All of the other review of systems\n were negative.\n .\n Of note, per ER records she had been on abx and steroids for 3 wks for\n a PNA (starting ). She has been on 40mg predniosone from to\n , and then was changed to 30mg PO prednisone. Also, her lasix dose\n was recently changed increased to 40 for 3 days ( to\n ). Amiodarone was stopped due to pulm fibrosis concern.\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 In the ED, initial vitals were 116/55, 106, 16, 100% RA.\n Past medical history: Atrial Fibrillation- s/p cardioversion\n amio dc/d on , now on atenolol and cardizem\n TIA\n hypothyroid\n HTN\n depression\n melanoma\n ? History of syncope\n Temporal arteritis hx\n s/p appendectomy\n s/p hysterectomy\n CAD Risk Factors\n CAD Risk Factors Present\n Hypertension\n CAD Risk Factors Absent\n Diabetes mellitus, Dyslipidemia, Family Hx of CAD, Family Hx of sudden\n cardiac death\n (Tobacco: No)\n Cardiovascular Procedural History\n PCI: Most recent: \n There is no history of:\n CABG\n Pacemaker / ICD\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Amiodarone\n Pulmonary Toxic\n Current medications: KCL SR 40 mEq a day\n calcium 500 mg TID\n vitamin D 400 International Units twice a day,\n Coumadin 2 mg a day,\n nitroglycerin 0.4 mg q5 minutes sublingual p.r.n.,\n Tylenol 650 every 6 hours as needed,\n multivitamin 1 tab daily\n Prilosec 20 mg a day\n vitamin B12 1,000 mcg a day\n Synthroid 125 mcg daily\n Cardizem CD 360 daily\n Ensure 1 can 3 times a day between meals\n Lasix 40 mg a day\n DuoNebs q.4 hours p.r.n.,\n digoxin 0.125 mcg a day\n coated aspirin 81 mg a day,\n Toprol XL 150 mg daily.\n Benzonatate 100 mg \n Meclizine 25 mg Q8 hr prn\n Prednisone 30mg Qday\n bisacodyl 10mg supp PRN daily\n milk of mag 30ml PRN\n robatussin 100mg/5ml Q4H PRN\n Fleets enema PRN\n Bactrim DS x 1 week, thru \n Cardiovascular ROS\n Cardiovascular ROS Signs and Symptoms Present\n Edema, TIA / CVA\n Cardiovascular ROS Signs and Symptoms Absent\n Murmur, Rheumatic fever, Chest pain, SOB, DOE, PND, Orthopnea,\n Palpitations, Syncope, Presyncope, Lightheadedness, Pulmonary embolism,\n DVT, Claudication, Exertional buttock pain, Exertional calf pain\n Review of Systems\n Organ system ROS abnormal\n Integumentary, Neurological\n Signs and symptoms present\n Joint pains, Myalgias\n Organ system ROS normal\n Constitutional, Eyes, ENT, Respiratory, Gastrointestinal, Endocrine,\n Hematology / Lymphatic, Genitourinary, Musculoskeletal, Psychiatric,\n Allergy / Immune\n Signs and symptoms absent\n Recent fevers, Chills, Rigors, Cough, Hemoptysis, Black / red stool,\n Bleeding during surgery\n ROS Details: Rash initially with sulfa, also ongoing right leg necrotic\n area that is approx 1-2 weeks in duration, new necrotic area on toe\n Social History\n Marital status: widowed\n Children: 4\n (Alcohol: No), (Recreational drug use: No)\n Family history: Non-contributory\n Social history details: Lives at healthcare since fall in\n . Otherwise lives at home.\n -Tobacco history: none\n -ETOH: rare\n -Illicit drugs: none\n Physical Exam\n Date and time of exam: , 12:00\n General appearance: alert and oriented, complainint of back pain\n Vital signs: per R.N.\n Height: 66 Inch, 168 cm\n Eyes: (Conjunctiva and lids: Abnormal, small lesion on lid)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: Abnormal)\n Neck: (Jugular veins: Not visible)\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Effort: WNL), (Auscultation: WNL)\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL), (Murmur / Rub: Present)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: pulses ok, site of cath, No\n bruit), (Left femoral artery: hematoma fem line, No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Dorsalis pedis\n artery: Right: dopplerable, Left: dopplerable), (Edema: Right: 1+,\n Left: 1+)\n Skin: (Abnormal, Multiple areas of small erythematous macules on chest,\n necrotic are on right calf approx 1 cm in diameter, smaller lesion on\n right second toe)\n Labs\n 156\n 11.2\n 31.5\n 7.6\n [image002.jpg]\n 09:57 AM\n 12:20 PM\n WBC\n 7.6\n Hgb\n 11.2\n Hct (Serum)\n 31.5\n Plt\n 156\n INR\n 1.5\n PTT\n 33.1\n Tests\n ECG: Initial studies showed HR 91, in AF, TWI/STD in I, II, V4-V6,\n serial repeat ECGs showed variable ST depressions in above pattern with\n both atrial fibrillation and occasional a flutter.\n Echocardiogram: The left atrium is mildly dilated. The right\n atrium is moderately dilated. No atrial septal defect is seen by 2D or\n color Doppler. There is mild symmetric left ventricular hypertrophy.\n The left ventricular cavity size is normal. Regional left ventricular\n wall motion is normal. Overall left ventricular systolic function is\n normal (LVEF>55%). Right ventricular chamber size and free wall motion\n are normal. The ascending aorta is mildly dilated. There are three\n aortic valve leaflets. The aortic valve leaflets are moderately\n thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild\n (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\n thickened. An eccentric, posteriorly directed jet of mild to moderate\n (+) mitral regurgitation is seen. The tricuspid valve leaflets are\n mildly thickened. There is mild pulmonary artery systolic hypertension.\n There is an anterior space which most likely represents a fat pad.\n Cardiac Cath: (Date: ), FINAL DIAGNOSIS:\n 1. 2 vessel coronary artery disease.\n 2. Normal ventricular function.\n 3. Unsccessful attempt to cross the LCX CTO.\n 4. Successful rotablation, PTC and stenting of the RCA.\n .\n Assessment and Plan\n ASSESSMENT AND PLAN 87 yo F with history of AF, hypertension who\n presented intially with NSTEMI and chest pain, s/p delayed cath with 2\n vessel disease.\n .\n # NSTEMI: Now s/p cardiac catherization. Troponin peak 0.9. No sig\n change in LV function.\n - Continue statin, beta blocker, plavix, aspirin.\n .\n # Hypotension/hct drop: Likely seconary to bleeding into left thigh.\n Now stable hct and no longer hypotensive.\n - serial hct\n - s/p 2 U PRBC\n .\n # Pump: no acute signs of chf, normal EF. have diastolic\n dysfunction as previously had volume overload on last hospitalization\n requiring lasix. Will watch for signs of fluid overload and restart\n outpatient diuretics (will have to use ethocrinic acid as sulfa\n allergy)\n .\n # RHYTHM: AF, previously with RVR. Will restart metoprolol and\n titrate up as BP tolerates\n .\n # Skin rash/ necrotic areas: The patient has several areas of rash,\n ecrosis. Derm consult concerned for vasculitis as well as drug LCV.\n Will hold sulfa meds, abx as possible.\n - await skin bx\n - appreciate derm consult\n - avoid sulfas\n - restart prednisone\n .\n # Temporal arteritis/vasculitis: as above skin lesions concerning for\n vasculitis. Will restart prednisone 40 mg, await ,ANCA, ESR,CRP,\n etc in evaluation. Likely need to consult rheum on monday.\n - prednisone\n - await labs\n .\n FEN:\n ACCESS: PIV's\n PROPHYLAXIS: hep sc, pantoprazole\n -Pain managment with\n -Bowel regimen\n CODE: Presumed full\n DISPO: CCU for now, anticipate tx until tomorrow\n" }, { "category": "Physician ", "chartdate": "2141-12-24 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 551354, "text": "TITLE: Cardiology Physician Note\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: \n -hct of 23, transfusion of 2 units pRBCs, hct then 30.2\n -derm consult skin lesions, likely vasculitis, bx taken\n -started prednisone 40mg (was on 30mg until admission)\n -CRP 11.2, ESR 6, RF 8\n -CXR for AM to oxygen requirement\n -monitoring hct\n Medications\n Unchanged\n Physical Exam\n BP: 106 / 69 mmHg\n HR: 118 bpm\n Tmax C last 24 hours: 36.6 C\n Tmax F last 24 hours: 97.8 F\n T current C: 36.6 C\n T current F: 97.8 F\n O2 sat: 95 %\n Previous day:\n Intake: 1,453 mL\n Output: 710 mL\n Fluid balance: 743 mL\n Today:\n Output: 140 mL\n Fluid balance: -140 mL\n Eyes: (Conjunctiva and lids: Abnormal, small lesion on lid)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: Abnormal)\n Neck: (Jugular veins: Not visible)\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Effort: WNL), (Auscultation: WNL)\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL), (Murmur / Rub: Present 2/6 systolic murmur at RUSB, LLSB, Apex,\n also diastolic murmur at RUSB)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: pulses ok, site of cath, No\n bruit), (Left femoral artery: hematoma fem line, No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Dorsalis pedis\n artery: Right: dopplerable, Left: dopplerable), (Edema: Right: 1+,\n Left: 1+)\n Skin: (Abnormal, Multiple areas of small erythematous macules on chest,\n necrotic are on right calf approx 1 cm in diameter, smaller lesion on\n right second toe)\n Labs\n 164\n 10.9\n 123\n 1.1\n 27\n 4.6\n 13\n 105\n 141\n 30.9\n 5.5\n [image002.jpg]\n 09:57 AM\n 12:20 PM\n 06:13 PM\n 04:27 AM\n WBC\n 7.6\n 5.5\n Hgb\n 11.2\n 10.9\n Hct (Serum)\n 31.5\n 30.2\n 30.9\n Plt\n 156\n 164\n INR\n 1.5\n 1.2\n PTT\n 33.1\n 33.4\n Na+\n 141\n K + (Serum)\n 4.2\n 4.6\n Cl\n 105\n HCO3\n 27\n BUN\n 13\n Creatinine\n 1.1\n Glucose\n 123\n CK\n 42\n Troponin T\n 0.40\n ABG: / / / 27 / Values as of 04:27 AM\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n HEMORRHAGE/HEMATOMA, PROCEDURE-RELATED (E.G., CATH, PACEMAKER, ICD\n BLEED)\n IMPAIRED SKIN INTEGRITY\n ASSESSMENT AND PLAN 87 yo F with history of AF, hypertension who\n presented intially with NSTEMI and chest pain, s/p delayed cath with 2\n vessel disease.\n .\n # NSTEMI: Now s/p cardiac catherization. Troponin peak 0.9. No sig\n change in LV function.\n - Continue statin, beta blocker, plavix, aspirin.\n - Repeat CKs,\n - ECG\n .\n # Hypotension/hct drop: Likely seconary to bleeding into left thigh.\n Now stable hct and no longer hypotensive.\n - serial hct\n - s/p 2 U PRBC\n .\n # Pump: no acute signs of chf, normal EF. have diastolic\n dysfunction as previously had volume overload on last hospitalization\n requiring lasix. Will watch for signs of fluid overload and restart\n outpatient diuretics (will have to use ethocrinic acid as sulfa\n allergy)\n - monitor i/o\n .\n # RHYTHM: AF, previously with RVR. Will restart metoprolol and\n titrate up as BP tolerates, will add diltiazem as needed, but will need\n to restart prior to discharge. No coumadin for now, high risk give\n age, previously with TIA. Will need to discuss risks with family at\n d/c\n .\n # Skin rash/ necrotic areas: The patient has several areas of rash,\n ecrosis. Derm consult concerned for vasculitis as well as drug LCV.\n Will hold sulfa meds, abx as possible.\n - await skin bx\n - appreciate derm consult\n - avoid sulfas\n - restart prednisone\n .\n # Temporal arteritis/vasculitis: as above skin lesions concerning for\n vasculitis. Will restart prednisone 40 mg, await ,ANCA, ESR,CRP,\n etc in evaluation. Likely need to consult rheum on monday.\n - prednisone\n - await labs\n # Hypothyroidism: will continue home meds\n # COPD: unclear if true history as not initially noted in admission\n note, no signs of dyspnea, will wean o2 as tolerates. On steroids for\n vasculitis, thus unlikely to have COPD exacerbation\n # GERD: continue PPI\n # FEN: euvolemic, replete lytes (will recheck potassium), advance diet\n as tolerates\n .\n FEN:\n ACCESS: PIV's\n PROPHYLAXIS: hep sc, pantoprazole\n -Pain managment with\n -Bowel regimen\n CODE: Presumed full\n DISPO: CCU for now, anticipate tx until tomorrow\n" }, { "category": "Nursing", "chartdate": "2141-12-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551358, "text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-12-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551360, "text": "87 yo F with history of AF, hypertension who presented intially with\n NSTEMI and chest pain, s/p delayed cath with 2 vessel disease.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in controlled afib\n Action:\n Pt tolerating Lopressor 25mg tid.\n Response:\n Tol afib\n Plan:\n Consider long term anticoagulation of filter.\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-12-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 551476, "text": "PMH: TIAs, A-fib, Hypothyroid. HTN. husband diet ~1yr\n ago. Melanoma.\n 87 yo women admitted to OSH on with chest pain r/i for NSTEMI.\n Transferred to on . Roto and stenting to RCA. To 3 post\n procedure. Last pm pt lost IV access. Multiple attempts to place Triple\n lumen. Placed in L fem. In am pt became hypotensive with hct\n drop. Pt received 2 units of bld and 1 liter of fluid. CT negative for\n bleed. BP stabilized.\n Atrial fibrillation (Afib)\n Assessment:\n She remains in a-fib with rate varying from 90s to as high as 150s. She\n had been on Lopressor and diltiazem at home, but dilt stopped and\n beta-blocker dose decreased due to hypotension. BP today has been in\n low 100s to 120s. Lungs are clear even with higher heart rate.\n Action:\n Diltiazem was added back at 30mg QID with Lopressor at 25 tid. Lasix\n has not yet been added.\n Response:\n Pt remains Hemodynamically stable with bp in 120s.\n Plan:\n Continue to monitor VS. Increase Lopressor and dilt to home doses as\n tolerated. Of note, pt had been on coumadin, but will probably not be\n restarted due to fall risk.\n Impaired Skin Integrity\n Assessment:\n Pt has total body edema and has been diagnoses with vasculitis, likely\n due to receiving bactrim (allergic to sulfa) at OSH. She has multiple\n weeping areas as well as some necrotic areas that have been biopsied.\n Both arms are edematous and eccymotic. Her R femoral cath site is dry.\n There is small necrotic area lateral to R knee. She has a skin tear on\n the lower R shin. She has small open area on L lower leg. There are\n some pettchiae areas on L upper thigh, that are weeping. She has yeasty\n looking rash under L breast. Heels mildly reddened.\n Action:\n All open areas were washed with wound cleanser and dried. Aquacel was\n applied to all weeping areas and they were covered with DSD and secured\n with kerlix. No tape to skin. Dsgs to be done daily or when wet. All\n skin folds cleansed and criticade clear applied under L breast and also\n to groin area. Skin well lubed with aloe-vesta moisture barrier. Heels\n kept elevated on pillows. Pt has started on prednisone for vasculitis.\n Pt is assisted in changing position\n Response:\n Edema seems to be decreasing as does to degree of weeping. Heels no\n longer reddened. No increase in yeast rash.\n Plan:\n Continue with excellent skin care. Give prednisone as given. Monitor\n for maceration of weeping areas and change position frequently.\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n Pt received total of 2U PRBCs. Lowest crit was 23.3. Early it\n ws 30.9 and at noon it ws 29.6. CT was negative for RP bleed. Today\n urine output dropped to 10-25ccc/hr with bp on the low side, though\n stable.\n Action:\n With crit stable 1liter NS given for poor urine output over 2 hrs. Will\n be in at 1800.\n Response:\n Urine output has increased. Will continue to monitor crits with one due\n ~. Urine output has increased to 100cc after bolus began.\n Plan:\n Draw hematocrit this evening. Keep careful I & O. Monitor for signs of\n further bleeding.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt RI for NSTEMI and had rotobladder to RCA. Peak troponin .9. Pt\n has been pain free. D/P pulses palpable and PT dopplerable. Groin site\n dry.\n Action:\n Monitor groin site for oozing and check pulses. Pt continues on plavix\n for RCA stent.\n Response:\n No further pain.\n Plan:\n Continue as above.\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n CHEST PAIN\n Code status:\n Height:\n 66 Inch\n Admission weight:\n 79.2 kg\n Daily weight:\n Allergies/Reactions:\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Amiodarone\n Pulmonary Toxic\n Precautions: Contact\n PMH:\n CV-PMH: Arrhythmias, Hypertension\n Additional history: TIA\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:127\n D:45\n Temperature:\n 97\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,520 mL\n 24h total out:\n 539 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:27 AM\n Potassium:\n 4.6 mEq/L\n 04:27 AM\n Chloride:\n 105 mEq/L\n 04:27 AM\n CO2:\n 27 mEq/L\n 04:27 AM\n BUN:\n 13 mg/dL\n 04:27 AM\n Creatinine:\n 1.1 mg/dL\n 04:27 AM\n Glucose:\n 123 mg/dL\n 04:27 AM\n Hematocrit:\n 29.6 %\n 12:50 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: yellow band x2 right hand\n Transferred from: ccu F625\n Transferred to: F325\n Date & time of Transfer: ,21:05\n" }, { "category": "Radiology", "chartdate": "2141-12-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1055964, "text": " 12:31 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? bleed\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with AMS, nasea, h/a post-cath on heparin and integrillin\n REASON FOR THIS EXAMINATION:\n ? bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AGLc SAT 3:20 AM\n no acute intracranial hemorrhage seen. small vessel ischemic disease, with\n old right basal ganglia lacunar infarct. fluid in sphenoid sinuses and\n inspissated secretions in ethmoid aircells. if concern remains for acute\n infarction, recommend MR for more sensitive eval.\n WET READ VERSION #1 AGLc SAT 3:04 AM\n no acute intracranial hemorrhage seen. small vessel ischemic disease, with\n old right basal ganglia lacunar infarct. fluid in sphenoid sinuses and\n inspissated secretions in ethmoid aircells.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87-year-old female with altered mental status, nausea, and headache\n after catheterization. The patient is on heparin and Integrilin. Here to\n evaluate for evidence of intracranial hemorrhage.\n\n TECHNIQUE: MDCT axial imaging was performed through the brain without\n administration of IV contrast.\n\n NON-CONTRAST HEAD CT: There is no evidence of acute intracranial hemorrhage,\n mass effect, hydrocephalus, or of large vascular territory infarction.\n Moderately extensive periventricular and subcortical white matter hypodensity,\n which include the left insular external capsule, likely relate to chronic\n small vessel ischemic disease. Proportionate sulcal and ventricular\n prominence is consistent with age-related involutional change. Rounded\n hypodensity in the right basal ganglia likely represents an old lacunar\n infarct. Vascular calcifications are noted along the cavernous carotid and\n intracranial vertebral arteries. The soft tissues appear intact. The patient\n has had prior right lens replacement. Fluid is seen layering in the sphenoid\n sinuses, and inspissated secretions are noted within a few right-sided ethmoid\n air cells. Minimal mucosal thickening is also noted along the left maxillary\n sinus, which is incompletely visualized. The mastoid air cells are well\n aerated.\n\n IMPRESSION:\n 1. No evidence of acute intracranial hemorrhage seen.\n 2. Fluid in the sphenoid sinuses with inspissated secretions in the ethmoid\n air cells.\n 3. Evidence of chronic small vessel ischemic disease, with right basal\n ganglia lacunar infarct.\n\n\n (Over)\n\n 12:31 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? bleed\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2141-12-23 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1056006, "text": " 9:24 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please eval for RP bleed and femoral hematoma\n Admitting Diagnosis: CHEST PAIN\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with A-fib, CAD, s/p cath. Pt with hematoma on left fem after\n CVL placement. cath was performed on right groin. Pt with Hct drop,\n hypotension, and abd/back pain.\n REASON FOR THIS EXAMINATION:\n please eval for RP bleed and femoral hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GWp SAT 11:36 AM\n No RP hematoma; asymm in L inner thigh musculature raises possibility of bleed\n into muscle/hematoma GWlms\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Query retroperitoneal bleed and femoral hematoma.\n\n COMPARISON: None available.\n\n TECHNIQUE: Multiple MDCT-axial images were obtained from the base of the\n lungs through the distal thighs without the administration of intravenous\n contrast or enteric contrast. Sagittal and coronal reformations were derived.\n\n FINDINGS:\n\n CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: In the visualized chest there\n are bilateral pleural effusions left greater than right with relaxation and\n dependent atelectasis. There is no pneumothorax. The visualized portion of\n the heart appears normal excepting for dense calcification of the left\n anterior descending, circumflex and right coronary arteries. Pacemaker wires\n are seen in their expected locations. The aorta is densely calcified.\n\n In the abdomen contrast is seen in the gallbladder, kidneys, collecting system\n and bladder preumable from an earlier contrast study. On the left a small\n renal hypodensity is too small to characterize. The spleen, right adrenal and\n abdominal loops of bowel appear normal. There is a 7mm left adrenal nodule\n (-4) consistent with an adenoma. The pancreas is slightly atrophic. There is\n dense splenic artery calcification. A hypodensity in the right lobe of the\n liver is likely a benign cyst. Incidental note is made of a splenule. There is\n no abdominal free fluid, free air or pathologic lymphadenopathy.\n\n CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: Pelvic loops of bowel appear\n normal. There are dense vascular calcifications. The decompressed bladder\n contains a Foley and appears normal. There is no pathologic lymphadenopathy,\n free air or free fluid.\n\n MUSCULOSKELETAL: In the left inner thigh musculature the adductor muscle\n bellies appear enlarged (301B, 36) suggesting hemorrhage into these muscles.\n There is no suspicious lytic or blastic lesion but degenerative changes are\n (Over)\n\n 9:24 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please eval for RP bleed and femoral hematoma\n Admitting Diagnosis: CHEST PAIN\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n seen at multiple levels throughout the spine. Compression of L4 is age\n indeterminate.\n\n IMPRESSION:\n 1. Left inner thigh hematoma. No evidence of retroperitoneal bleed.\n\n 2. Significant coronary artery calcification.\n\n 3. Age-indeterminate compression fracture of L4; in the right clinical\n context further imaging such as edema-sensitive MR .\n\n 4. Left adrenal adenoma.\n\n 5. Left pleural effusion and atelectasis.\n\n\n" }, { "category": "ECG", "chartdate": "2141-12-26 00:00:00.000", "description": "Report", "row_id": 189735, "text": "Atrial fibrillation. Diffuse non-specific ST-T wave abnormalities. Since the\nprevious tracing of there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2141-12-25 00:00:00.000", "description": "Report", "row_id": 189736, "text": "Atrial fibrillation\nInferior/lateral ST-T changes\nSince previous tracing of , demand ventricular pacing not seen\n\n" }, { "category": "ECG", "chartdate": "2141-12-22 00:00:00.000", "description": "Report", "row_id": 189737, "text": "Atrial fibrillation with ventricular premature beats. Poor R wave progression.\nNon-specific ST-T wave changes - consider ischemia. Compared to the previous\ntracing of ventricular premature beats are new and the T wave\ninversions in leads V4-V6 are more prominent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2141-12-22 00:00:00.000", "description": "Report", "row_id": 189738, "text": "Atrial fibrillation. Inferolateral ST-T wave changes suggest myocardial\nischemia. Compared to the previous tracing of the inferior ST-T wave\nchanges are more pronounced. Clinical correlation is suggeted.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2141-12-19 00:00:00.000", "description": "Report", "row_id": 189739, "text": "Atrial fibrillation\nDelayed R wave progression with late precordial QRS transition\nDiffuse ST-T wave abnormalities\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of the same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2141-12-19 00:00:00.000", "description": "Report", "row_id": 189740, "text": "Atrial fibrillation\nDelayed R wave progression with late precordial QRS transition\nDiffuse ST-T wave abnormalities\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2141-12-18 00:00:00.000", "description": "Report", "row_id": 189741, "text": "Atrial fibrillation with a probable ventricular paced beat\nDelayed R wave progression with late precordial QRS transition\nDiffuse ST-T wave abnormalities\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of the same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2141-12-18 00:00:00.000", "description": "Report", "row_id": 189742, "text": "Atrial fibrillation\nDelayed R wave progression with late precordial QRS transition\nDiffuse ST-T wave abnormalities\nThese findings are nonspecific but clinical correlation is suggested\nNo previous tracing available for comparison\n\n" } ]